刍议各类误诊误治的原因及其法律后果

在医疗实践中 ,因误诊误治所引发的诉讼案例呈增加趋势。根据医疗机构和医务人员有无过错 ,误诊误治分为有过错的误诊误治和无过错的误诊误治两类 ,前者又分为故意性误诊误治、责任性误诊误治和技术性误诊误治 ,后者则分为在现有医学技术条件下无法避免的误诊误治和由于患者或第三方原因造成的误诊误治。发生误诊误治后 ,需要结合给患者造成的实际损害、导致误诊误治的原因以及医疗机构事先所作的承诺三种情形 ,综合判断医疗机构和医务人员应承担何种法律后果     

伤害预防与控制专业人员对我国伤害预防领域现况及未来发展的评价

目的对我国伤害预防与控制专业人员在伤害预防领域中所开展工作的现况及对未来工作的规划及其期望进行分析,为推动伤害防控领域的进一步发展提供依据。方法自制统一问卷,以中华预防医学会伤害预防与控制分会及其下属6个学组的全体委员作为调查对象,开展横断面调查,应用描述流行病学方法对资料进行统计分析。结果受访者参与伤害相关工作平均年限为(10.81±5.62)年。“中华预防医学会伤害预防与控制分会的成立”“全国医院伤害监测工作的开展”及“推广应用了伤害的某些干预措施或策略”是伤害防控工作中最重要的三大成就;“经费不足”“政府主管部门不重视”及“疾控单位缺乏伤害预防的专门机构”是伤害防控工作中最主要的三个问题;“提供专门经费开展全国伤害普查工作,加强伤害的干预研究”“伤害的疾病负担分析,提交政府主管部门并向居民公布”和“伤害监测报告定期公布”是伤害防控领域最应加强的三件工作。有74.39%的受访者认为当前我国医学院校急需开设伤害防控课程。结论我国伤害预防与控制领域快速发展,伤害预防与控制工作取得了显著成效,广大伤害专家及防控人员应再接再厉,全面推动伤害预防工作,加强伤害领域的构建与发展,降低伤害的发生率及其造成的疾病和社会经济负担。     

口腔专科手术室护士工作满意度调查及分析

目的探讨口腔专科手术室护士工作满意度及其原因。方法以西安地区口腔医院和口腔专科手术室护士为研究对象,对护士的满意度及不同年资护士满意度差异进行问卷调查,采用量性研究和质性研究相结合的方法进行统计分析。结果口腔专科手术室护士在与共事者（医生、护士）的关系、家庭/工作的平衡、对排班的满意度三个方面满意度最高,在交流/交往机会、福利待遇方面满意度较低。不同年资护士在家庭/工作的平衡、社会或专业上交流/交往机会、福利待遇等方面差异有统计学意义。结论护理管理者根据专科手术室护士满意度因素,采取相应的管理措施,提高手术护理质量,满足护士自我实现的需要。     

MSCT三维重建技术在胸腰椎骨折患者经椎弓根螺钉内固定术中的应用研究

目的：探讨MSCT三维重建技术在胸腰椎骨折患者经椎弓根螺钉内固定术中的应用效果,为手术方案的施行提供置钉指导。方法选择我院2010年2月至2013年2月收治的胸腰椎骨折患者60例,选择32层螺旋CT机（MSCT）建立椎弓根螺钉分析模型,并进行相关数据的测量与对比。结果所有测量指标的椎弓根左右两侧数值对比无明显差异（P＞0.05）。不同节段的测量指标对比有明显差异（P＜0.05）,其中内外夹角、内外弧长、上下夹角、上下弧长、实验钉长、钉道长为逐渐减少的趋势,而螺钉直径、钉尾间距、水平面进钉角（TSA）与矢状面进钉角（SSA）值为逐渐增加的趋势。结论 MSCT三维重建技术应用于胸腰椎骨折患者可指导临床进行个性化经椎弓根螺钉内固定术,为患者的诊断和手术设计提供了一种新的影像解剖学依据。     

A new development in haematological cell counting: the Sysmex NE-8000, automaton for cell count and physical five-part leukocyte differentiation

We compared the results of the Sysmex NE-8000 with those of the Sysmex E-4000 and the Technicon H-6000. Both for the whole blood cell count and the leukocyte differentiation we obtained intra- and inter-assay coefficients of variation fully comparable with those for other cell counters. The carry-over between samples was negligibly small. The linearity range was broad, which implies a universal application in routine haematological analysis. The numerical results from the Sysmex NE-8000 and the Technicon H-6000 corresponded closely, with exception of the mean corpuscular volume and the haematocrit, whereas these parameters showed excellent agreement between the NE-8000 and the E-4000. In the differentiation of leukocytes, the NE-8000 and H-6000 showed good correlation and conformity for lymphocytes, neutrophils and eosinophils; for monocytes and basophils the conformity was poor. We also found a good correlation between the NE-8000 and E-4000 for lymphocytes and neutrophils, whereas the correlation was less for the middle cell ratio and the sum of monocytes, eosinophils and basophils. Furthermore, we compared Receiver Operating Characteristic curves for the different leukocyte subtypes on the NE-8000, the H-6000 and the E-4000, and investigated the flagging frequency in inpatients, outpatients and blood donors.     

新疆地区城镇妇女对HPV感染与宫颈癌相关性的认知和行为干预研究

目的：探讨城镇妇女对HPV感染与宫颈癌相关性的认知情况和行为干预的影响。方法：对在我院妇产科门诊就诊接受宫颈癌筛查的患者同时进行HPV感染与宫颈癌相关性宣传教育,应用自行设计的问卷评估干预效果。结果：干预后患者对HPV感染与宫颈癌相关性知识综合掌握情况和愿意接受宫颈癌筛查的患者明显提高。结论：对就诊患者进行宫颈癌筛查的宣传,重视对HPV感染与宫颈癌相关性的健康教育,可提高城镇妇女对疾病的认识,使患者消除顾虑,建立健康的行为和生活方式,对城镇妇女宫颈癌的防治有着重要意义。     

两种方法清洗消毒简易呼吸器的效果观察

目的探讨两种消毒方法用于简易呼吸器的消毒效果,以便选择最佳的消毒方法。方法选择160个污染程度一致的简易呼吸器,随机分为两组,每组各80个,分别采用手工清洗消毒法和机械清洗消毒法对简易呼吸器进行清洗消毒。比较清洗消毒后气囊球体外表面、内腔面、接口内消毒的合格率。结果机械清洗消毒简易呼吸器各个部位合格率均为100．00％,手工清洗消毒合格率外表面100．00％、内腔面91．25％、接口内93．75％,两种方法清洗消毒后简易呼吸器外表面、接口内合格率比较,均P〉0．05,差异无统计学意义;内腔面合格率比较,P〈0．05,差异具有统计学意义。结论简易呼吸器机械清洗消毒法优于手工清洗消毒法。     

合编医疗单位技术建设双向互动模式的构建与实践

作者结合本单位管辖2个医院、4个疗养院的实际情况，以及承担医疗、疗养、特勤保障等特点，提出并实践了“疗治双向互动、疗疗双向互动、资源双向互动”的“双向互动”技术建设新模式，深化了疗治结合内涵，加快了重点学科建设，促进了人才队伍成长，提高了科研工作能力，在研究探索联勤体制下“多军兵种结合、疗医结合、疗疗结合、医医结合”的技术建设方面进行了有益尝试。     

精神科护士心身症状及其压力应对方式调查

目的探讨心身症状及其应对方式对精神科护士的影响。方法对148名护士进行症状自评量表、生活事件量表、压力应对方式问卷等测试,探讨群体特征、应对方式及生活事件对精神科护士的影响。结果高年资护士存在轻微的心理问题,心身症状主要在饮食睡眠、焦虑、抑郁、躯体化方面表现明显。结论精神科护士各年龄段经历的生活事件、自身症状的影响不同,医院应给予重视,提供良好的生活、工作环境,关爱护士身心健康,使其保持良好的心态,提高工作效率。     

PET-CT同机及异机融合精度的临床验证

目的验证恶性肿瘤患者放疗定位时同时采用的PET-CT与CT在头颈部、胸部、盆腔异机和同机融合的精度,为PET-CT在临床放疗中的应用提供依据。方法综合采用定位标志和解剖结构对患者的PET-CT和定位CT进行自动融合和人工融合,分别比较头颈部、胸部、盆腔同机以及异机融合的精度,并分析三维方向的融合误差。结果在不同的解剖部位,同机融合均明显优于异机融合;在头颈部和盆腔,在X、Y方向摆位重合度高,和同机融合差异不大,Z方向异机融合精度差于同机融合。在胸部和上腹部不论PET-CT同机融合还是PET与CT异机融合,误差均较大,差异有统计学意义,达不到精确放疗靶区勾画的要求。结论在头颈部和盆腔,PET和CT不管是同机还是异机融合,均能达到精确放疗的要求,而在胸部和上腹部PET能够指导靶区勾画,但呼吸动度等原因影响融合精度,图像融合适应精确放疗还需要更多的验证工作和方法。     

应用扩散张量成像技术对急性缺血性卒中机体功能障碍与锥体束损伤程度的相关性研究

目的应用扩散张量成像技术(diffusion tensor imaging,DTI)研究急性缺血性卒中机体功能障碍与锥体束损伤程度的相关性。材料与方法收集急性缺血性脑卒中患者在发病急性期内的常规MRI平扫、扩散加权成像、DTI检查、工作站自动生成各向异性指数(fractional anisotropy,FA)图及ADC图,从中筛选出病变累及单侧基底节区的急性缺血性脑卒中患者16例,分别测量病灶区与大脑对侧相应部位的FA值、ADC值、纤维束数量,并计算出纤维束数量健侧与患侧差值,使用mimics软件对病灶体积进行测量,同时使用美国国立卫生研究院卒中量表(NIH Stroke Scale,NIHSS)、临床医学肌力分级对机体功能障碍程度进行评价。使用统计学方法研究健、患侧纤维束数量、FA值、ADC值的差异;统计出数量差值与病灶体积、NIHSS评分、肌力评分的相关性;统计16例患者出现的所有神经系统阳性表现。通过扩散张量纤维束成像(diffusion tensor tractography,DTT)和3D slicer软件在病变区和健侧对应部位重建,对比观察纤维束的形态变化。结果健、患侧锥体束数量、FA和ADC配对t检验有统计学差异(P<0.05,分别为0.001、0.005、0.001)。纤维束数量差值和病灶体积、肌力分级有显著相关关系(r=0.632,P=0.009;r=-0.554,P=0.026);病灶体积和NIHSS评分有显著正相关关系,差异及相关性有统计学意义(r=0.789,P=0.000)。健、患侧纤维束数量差值和NIHSS评分无相关性(P=0.061),FA值减少程度和ADC减少程度无相关性(P=0.890)。患侧纤维束走形异于健侧,部分患侧纤维束受压、变形、移位、断裂,部分健侧纤维束向患侧延伸。结论急性缺血性脑卒中患者机体功能障碍与锥体束损伤程度有相关性,病灶体积越大,锥体束损伤程度越严重,脑组织损伤程度越重,机体功能障碍程度越明显。     

升降相因在反流性食管炎中的应用

脾胃位于中焦,气机以此为升降之枢纽。气机随脾升而胃降,升降相协调,各脏腑生理功能才能正常发挥。脾胃正常生理功能的运行也有赖于气机的升降,气机的升降失调影响脾胃升降运行,是脾胃系疾病的基本病机,故论治脾胃病常常以恢复气机正常升降为立足点,以升降相因作为脾胃病的治法大要。反流性食管炎作为脾胃病的常见病,其病机为脾胃功能失调,胃气上逆,现大多以降逆和胃为主要治法。但责之根本,其病机仍是以脾胃升降失调为本,故治疗不应只局限与降逆治法,因以升降相因为治法,以恢复脾胃升降之职,使脾健胃顺,气机调达,诸症自除。     

Doctors-nurses integration in paediatric onco-hematology: a cornerstone for quality of care. Report on a three years experience

The rapid evolution of care and the constantly changing needs and expectations of patients and their families require flexibility and re-organisation of the caring and treatment activities. These include the increased need for high-specialised personal competence; communication and interpersonal skills; and a close collaboration and integration between doctors and nurses--the main professional groups in the health care team. An optimal integration is not always and easily achievable and requires personal motivation, active efforts, investments and the development of the effective operative models for providing the integrated high specialised daily care. It is not easy in the busy daily routine to find time, motivation and share common goals. This is why a support for the groups willing to implement projects for improving integration between doctors and nurses was provided through an action-research laboratory. The aims of the multi-step action-research laboratory were the following: to improve the integration of different professionals; to improve the exchange of knowledge and skills; to build the necessary bases for planning and running comprehensive, integrated clinical projects in the field of paediatric haematology-oncology. The ultimate goals of this effort was to improve the quality of the care and cure provided to children with cancer and their families. The project lasted three years, and consisted of yearly residential meetings alternating with experiences conducted in the working environments of the participants. The following steps were planned: Identification of the problem. Participants were asked to analyse the main problems of their units, that could be solved-improved with a better integration/collaboration between doctors and nurses and the main difficulties routinely encountered in working effectively together. Groups were asked to analyse the problem in their own practice, identify the possible solutions, main obstacles, strengths and weaknesses, plan the necessary of activities (short and medium term) for improving the problems. Sharing of projects. The projects were shared and common problems and solutions discussed. Final presentation of the projects with the aim of devising solutions and strategies for consolidation of the eventual changes obtained. Supervision, theoretical support and personalised feed-back from the scientific panel were guaranteed between the meetings and during the planning and implementation phases. Methods, instruments and techniques for improving collaboration and integration were discussed during the yearly meetings (i.e. how to work by objectives; how to plan and co-ordinate multidisciplinary meetings...) with lectures, workgroups, role-playing. Representatives from the 16 wards participated to the project: at least one nurse and one doctor from each centre, in the position to take decisions and implement changes. In spite of common problems related to the workload, difficulties in involving other colleagues, 13 projects were implemented. The need to discuss, plan together, organise interdisciplinary meetings improved the integration and communication between doctors and nurses.     

人工全髋关节置换术中坐骨神经损伤的应用解剖学观察

背景人工全髋关节置换术(THR)是近年来治疗老年人髋关节疾患的首选方法,按Harri's评分优良率为84%.该手术对坐骨神经损伤发生率国内报道为0.46%,国外报道为0.08%～9.70%.目的通过解剖位置的分析探讨THR术中坐骨神经损伤的因素.设计以人体解剖标本为研究对象,单一样本研究.单位湖州师范学院医学院解剖实验室.对象实验于2003-03/05在湖州师范学院医学院解剖实验室完成.正常人体成年骨盆标本56具,男27具,女29具.方法对坐骨神经的来源及走行、坐骨神经与髋臼的关系进行测量分析,并对在THR术中拉钩及螺丝钉固定所致坐骨神经损伤,进行详尽测量分析. 主要观察指标坐骨神经与髋臼的位置关系.结果测出坐骨神经至髋臼底的距离左侧为(6.00±0.85)mm,右侧为(6.00±0.71)mm;坐骨神经至髋臼缘的距离左侧为(13.00±0.75)mm,右侧为(14.00±0.06)mm.坐骨神经在髋臼缘处周径左侧为(32.00±0.28)mm,右侧为(31.00±0.68)mm.髋臼底至坐骨大孔的距离为左侧为(29.00±0.36)mm,右侧为(29.00±0.24)mm.结论确定拉钩及螺丝钉固定在1～3点及5～6点为安全区.在THR术中陈旧髋臼骨折脱位、拉钩的位置不当、螺钉固定髋臼位置不当均可导致医源因素损伤坐骨神经.     

针灸对单纯性肥胖症瘦素和胰岛素抵抗的影响

目的探讨针灸对单纯性肥胖病瘦素和胰岛素抵抗的作用. 方法采用 RT-PCR和 Northern Blot技术测定瘦素受体( OB-R)基因表达水平,放射免疫分析测定血清和下丘脑瘦素( Leptin)和胰岛素( INS)的含量.观察针灸治疗前后单纯性肥胖患者血清瘦素、 INS、脂质水平的变化;还观察针刺治疗前后肥胖大鼠体质量、 Lee's指数、体脂、血清和下丘脑瘦素和 INS的含量以及下丘脑 OB-R基因表达的变化. 结果 单纯性肥胖患者瘦素、 INS、总胆固醇( TC)、三酰甘油( TG)、低密度脂蛋白-胆固醇( LDL-C)的含量均显著高于正常人水平;而高密度脂蛋白-胆固醇( HDL-C)却显著低于正常人水平,针灸治疗后患者瘦素、 INS、 TC、 TG、 LDL-C的含量均明显回降,而 HDL-C含量却明显回升,这种变化与减肥疗效有关.肥胖大鼠体质量、 Lee's指数、体脂及血清瘦素和 INS水平均显著高于正常大鼠,而下丘脑瘦素和 INS水平及 OB-R基因表达水平均明显低于正常大鼠.针刺治疗取得良好减肥疗效的同时,肥胖大鼠血清瘦素和 INS均明显回降,而下丘脑瘦素和 INS水平以及 OB-R基因表达水平却明显升高. 结论 针灸对肥胖机体中枢和外周瘦素和 INS水平的良性调整作用以及促进下丘脑 OB-R基因表达可能是针灸纠正瘦素和胰岛素抵抗以及异常的内分泌代谢的重要机制.     

超声和MRI影像学及影像组学在乳腺癌中的研究进展

乳腺癌是全球女性最常见的恶性肿瘤之一,发病率和致死率居癌症首位,早期诊断和早期治疗可以提高疾病预后效果,降低疾病相关死亡率。超声和MRI影像学是乳腺癌诊疗指南推荐对原发肿瘤评估无创检查方式,随着科技的发展,越来越多的影像学新技术应用于临床实践,乳腺癌检出率和诊断准确率都有了很大提高。人工智能的出现,拓展了影像组学的应用,推动了乳腺癌精准医疗的发展。本文针对超声和MRI影像学及影像组学在乳腺癌临床诊疗中的应用进展进行了综述。      

Methodological bases for prognosis in medicine]

Current status of prognosis in clinical, experimental and prophylactic medicine is delineated with formulation of the purposes and feasibility of therapeutic and preventive realization of the disease onset and run prediction. Literature and first-hand experience provided the basis for grounding medical prognosis theory. Basic points in the theory are the following: utilization in the prognosis of only a complex of the most significant clinical signs of the disease, the patient's record, social and household, ecological and occupational aspects of the patient's life; comparison of the latter with leading pathogenetic mechanisms underlying the emergence and progression of the pathology; consideration of the relationships between dysfunction and morphology of the organs and systems; simultaneous analysis of the aggression factors, systemic reactivity and resistance of tissue; scrutiny of predisposition to pathological reactions. An essential aspect of medical prediction is a valid choice of mathematical methods of analysis and processing of the clinical information.     

控制留置胃管操作流程关键环节的探讨

目的:探讨脑卒中伴吞咽障碍患者留置胃管操作流程关键环节的控制,培训护士操作技能,提高留置胃管一次性成功率和减少不良反应的发生。方法:观察、分析、讨论脑卒中伴吞咽障碍者留置胃管操作流程中的关键环节,比较控制留置胃管操作关键环节培训前后12名护士对48例脑卒中患者留置胃管和置管过程中患者不良反应发生情况。结果:12名护士培训前后留置胃管一次性成功率和置管过程中患者不良反应的发生情况均有显著性差异(P<0.05)。结论:护士掌握留置胃管操作流程关键环节的控制,能显著性提高置管成功率和减少操作过程中患者的不良反应。     

悬吊式非腹腔镜与气腹腹腔镜胆囊切除术护理比较研究

目的探讨悬吊式非腹腔镜与气腹腹腔镜胆囊切除术临床护理特点。方法采用随机对照方法,比较非气腹60例与CO2气腹60例腹腔镜胆囊切除术的手术时间、术后体温、镇痛药使用、尿潴留、胃肠反应、皮下气肿、腹部切口并发症、平均住院时间等方面,并做对比分析。结果气腹组与非气腹组相比较,镇疼药使用、皮下气肿、尿潴留、胃肠反应方面P0.05为2组间差异有统计学意义;手术时间、体温、腹部切口并发症、平均住院时间方面P0.05差异无统计学意义。结论非气腹组胃肠反应、镇疼药使用、尿潴留、皮下气肿方面存在显著优越性,对提高护理工作效率和质量有着重要的意义。悬吊式非腹腔镜胆囊切除术与气腹腹腔镜手术的护理比较有较大优势。     

Troubleshooting non-infectious peritoneal dialysis issues.

Peritoneal dialysis is commonly preformed by patients and their caregivers in the home, in nursing homes, and in both acute and rehabilitation hospitals. The success of the therapy requires that the nurse overseeing the care of the patient on peritoneal dialysis in the acute, sub-acute, and chronic settings has the skills and knowledge to identify specific non-infectious issues, choose an appropriate and effective intervention activity, document the findings and outcomes, and educate the patient to assist in the resolution of the non-infectious issues, and avoid future recurrence. This article reviews the most common non-infectious complications that occur in patients on peritoneal dialysis and discusses an organized clinical process to troubleshoot the issues and achieve the desired clinical outcomes.