我国护理学硕士研究生核心知识体系的研究

目的探讨所有研究方向的护理学硕士研究生都必须学习和具备的知识,以尝试构建我国护理学硕士研究生教育的核心知识体系。方法采用德尔菲专家函询法。在查阅文献和半结构访谈的基础上,形成分为2种培养类型(科学学位、专业学位),包含5个维度(高级护理实践、教育、管理、科研、专业发展)、82个核心知识备选条目的问卷。58名从事护理教育、临床管理的专家参加函询,按照5分级Likert标度法进行评价选择。结果经2轮函询后形成专家一致性意见,问卷回复率分别为91.4%和87%。有37项和47项知识分别成为科学学位和专业学位硕士研究生的核心知识,其4分以上(重要和很重要)的选择率均在80%以上。两种培养类型的研究生均应具备科研、专业发展、临床实践、教育和管理的相关知识,科学学位研究生偏重于学习更多教育、科研知识,专业学位研究生则更注重临床实践和管理知识的获取;在专业发展知识方面,侧重点稍有不同。结论两种培养类型的护理学硕士研究生共同的核心知识有32项,科学学位护理学硕士研究生的核心知识有37项,被纳入专业学位护理学硕士研究生的核心知识有47项。护理学硕士生核心知识的确立为组建护理硕士教育核心课程奠定了合理的基础。     

护理硕士专业学位研究生临床带教老师遴选标准的构建

目的 构建护理硕士专业学位研究生临床带教老师遴选标准。方法 基于国内外文献研究和专家访谈形成函询指标,通过德尔菲法对来自15个省、市的35名护理专家进行2轮函询。结果 2轮函询结束时专家意见趋向一致,专家权威系数为分别为0.821和0.853,肯德尔和谐系数分别为0.225和0.296（P<0.01）。最终形成的护理硕士专业学位研究临床实践带教老师遴选标准包括10项带教资质标准、5项核心能力以及35项核心能力相关评估条目。结论 护理硕士专业学位研究生临床带教老师遴选标准比较全面和富有代表性,可以为合理选择护理硕士专业学位研究生临床带教老师提供参考。     

基于职业发展的护理硕士专业学位课程设置

目的:探讨基于职业发展的护理硕士专业学位研究生的课程设置。方法:采用德尔菲法对30名专家进行两轮函询。结果:围绕护士职业发展设置了3门公共课和职业基础模块、职业发展模块、职业前沿模块组成的17门专业课;临床实践包括护理实习和医疗实习。结论:护理硕士专业学位研究生课程设置应以培养能力为主线,围绕护士职业发展进行,注重临床实践专科技术操作的同时进行临床医疗实习。     

儿科护理硕士专业学位研究生临床师资准入标准及核心能力评价体系的构建

目的:构建儿科护理硕士专业学位研究生临床师资准入标准及核心能力评价体系。方法:通过文献检索、半结构化访谈及研究小组讨论拟定儿科护理硕士专业学位研究生临床师资准入标准及核心能力评价体系初稿，运用德尔菲法进行问卷函询完成指标筛选与修改，采用层次分析法确定指标权重。结果:共进行了2轮专家函询，专家积极系数分别为100.00%和94.44%，专家权威系数为0.89和0.90，专家意见协调系数分别为0.233和0.281(P<0.001)。最终形成的儿科护理硕士专业学位研究生临床师资准入指标包括学历、职称、临床经验、教学经验、发表论文5项，核心能力包括一级指标5项（临床专业能力、临床教学能力、人格修养、护理科研能力、临床管理能力）、二级指标15项及三级指标64项。结论:构建的儿科护理硕士专业学位研究生临床师资准入标准及核心能力评价体系具有科学性和可靠性，可为儿科护理硕士专业学位研究生临床师资的选拔、培养、考核和评价提供依据。     

ICU方向护理硕士专业学位研究生培养方案的构建

目的 构建基于新入职护士培训的ICU方向护理硕士专业学位研究生培养方案,为实现护理硕士专业学位研究生培养与新入职护士培训的并轨奠定基础.方法 通过文献分析法拟定ICU方向护理硕士专业学位研究生培养方案初稿,采用德尔菲法对25名专家进行2轮函询.结果 2轮函询专家积极系数分别为93.3%和89.3%,专家权威系数均为0.91,各项内容变异系数为0.06~0.24.ICU方向护理硕士专业学位研究生培养方案包括课程设置、教学时间安排、临床实践内容3部分.结论 培养方案具有较好的科学性,为护理硕士专业学位研究生教育改革提供新思路.     

护理专业学位硕士研究生临床实践能力指标体系的研究

目的构建我国护理专业学位硕士研究生临床实践能力的指标体系。方法采用Delphi法从全国范围选择45名专家进行两轮函询。结果专家积极性高,两轮函询问卷有效回收率分别为80.00%和91.67%;专家的权威程度系数分别为0.85、0.89;第2轮一级指标和二级指标的协调系数分别为0.284、0.262。最终形成包含6个一级指标,即:临床专科护理能力、教育能力、提供咨询能力、研究能力、临床和专业领导能力和自我管理能力及34个二级指标的护理专业学位硕士研究生临床实践能力指标体系。结论初步确定了护理硕士专业学位研究生临床实践能力的指标体系,为日后形成护理专业学位硕士研究生培养方案提供科学依据。     

护理学硕士研究生核心能力评价指标的初步研究

目的建立适合我国护理学硕士研究生核心能力评价指标体系,为护理教学和评价提供参考依据。方法采用文献回顾法、专家讨论法和德尔菲法初步确定评价指标体系,采用德尔菲法对备选指标进行2轮专家函询。结果经过2轮函询后确定了一级指标5个、二级指标16个及三级指标66个。结论初步建立的护理学硕士研究生核心能力评价指标体系,基本能够合理的评价护理学硕士研究生的能力。     

护理专业学位硕士研究生体外生命支持护理教学方案的构建

目的构建一套科学且符合护理专业学位硕士研究生的体外生命支持护理教学方案,为我国护理专业学位硕士研究生专科化培养方案的制定提供借鉴和参考。方法通过文献回顾及半结构式访谈初步形成教学方案,2018年7—12月,运用德尔菲法对26名专家进行2轮问卷函询。结果2轮函询后形成5条一级指标(培养目标)、22条二级指标(培养目标)、77条三级指标(培养内容)、2条培养方式及时间的护理硕士专业学位研究生体外生命支持护理教学方案,专家积极系数、专家权威程度、专家意见集中程度及专家意见协调程度均较好。结论基于德尔菲法构建的护理专业学位硕士研究生体外生命支持护理教学方案,具有较高的科学性和可靠性。     

基于Delphi法的护理硕士专业学位研究生理论课程设置研究

目的：依据护理硕士专业学位研究生核心能力指标体系和专科护士核心能力指标体系,确定护理硕士专业学位研究生理论课程设置方案,提高护理硕士专业学位研究生的培养质量。方法在查阅文献、小组讨论的基础上初步构建护理硕士专业学位研究生理论课程,采用Delphi法对指标进行评价筛选。结果经过2轮咨询后,各专家意见趋于一致。2轮咨询有效问卷回收率分别为92%、94%;专家权威系数分别为0.825、0.875;指标变异系数为0.059～0.225;指标的协调系数为0.26（P<0.01）。最终确定由公共学位课程、专业必修学位课程、专业选修课程、学术活动4个部分组成的理论课程。结论护理硕士专业学位研究生理论课程设置构建合理,可为提升护理硕士专业学位研究生的核心能力和培养质量奠定基础,加快护理专科化发展进程。     

中医护理硕士专业学位研究生培养模式的构建研究

[目的]构建中医护理专业学位硕士研究生培养模式。[方法]运用Delphi专家函询法构建中医护理硕士专业学位研究生培养模式。[结果]通过2轮专家函询,最终构建的中医护理专业学位硕士研究生培养模式包括培养目标、课程设置、学制学分设置等5个要素。[结论]最终构建的培养模式科学、全面,可操作性强,可为高等院校中医护理专业学位研究生培养方案的制订提供指导和参考。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.