动态血糖监测仪及胰岛素泵临床应用中的持续质量改进

目的 探讨持续质量改进(CQI)对提高患者使用动态血糖监测系统(CGMS)、胰岛素泵(CSII)护理质量的作用.方法 选择2007年4～12月305例糖尿病患者为对照组,按照常规方法在公司业务员指导下,讲授仪器的结构、工作原理和操作步骤,护士现场学习,护士长和骨干护士重点学习全部操作,然后在科室推广应用.以2008年4～12月308例糖尿病患者为观察组,以CQI理论为指导,制订内分泌专科分层次的培训计划,制定各种操作规范并由护士长全程监督控制.结果 改进后护士理论、操作考核成绩比改进前显著提高(均P＜0.01);观察组中使用CSII的患者对护士安装仪器、故障处理和观察巡视的满意度较对照组显著提高(P＜0.05,P＜0.01);观察组使用CGMS者仪器电缆线折断、局部皮肤炎症发生率显著低于对照组(均P＜0.05).结论 持续质量改进有助于护士业务技能的提高,为糖尿病患者的治疗、监测提供保证,提高了护理质量.     

持续质量改进在肾活检护理中的应用

目的探讨肾活检护理中持续质量改进（CQI）的应用效果。方法根据入院时间将422例患者分为对照组（203例）和观察组（219例）,对照组按常规护理。观察组采用CQI模式进行护理,建立专职肾活检小组,评估并分析肾活栓过程中存在的护理问题．制定改进措施并实施。结果观察组患者满意度显著高于对照组（P〈0．01）,患者肾活栓知识知晓率提高（P〈0．01）,肾活检术后肉眼血尿发生率减少。结论肾活检护理中采用CQI,可提高护理质量,减少肾活检术后肉眼血尿的发生率,保证患者安全．体现了以人为本的护理理念。     

整体护理干预对血液透析患者营养状况及透析并发症的影响

目的 改善血液透析患者的饮食营养状况，降低透析并发症。方法 应用护理程序对126例血液透析患者（观察组）实施整体护理干预，与105例实施常规护理的血液透析患者（对照组）比较，观察患者饮食营养状况、透析并发症发生率及患者满意率。结果 观察组饮食控制依从性及血浆白蛋白、血红蛋白均显著高于对照组（P〈0．05，P〈0．01），水负荷过高、血压异常及内瘘闭塞发生率显著低于对照组（P〈0．05，P〈0．01），患者满意率显著高于对照组（P〈0．01）。结论 应用护理程序实施整体护理干预对提高血液透析患者的饮食营养状况、减少并发症、提高其生活质量有积极意义。     

录像反馈式练习法在临床护理技能培训中的应用

目的探讨录像反馈式练习法在临床护理技能培训中的应用效果。方法将101名参加培训的护士随机分成对照组（51名）和观察组（50名）。在培训的练习阶段,对照组按传统方法练习。观察组采用录像反馈式方法练习。结果观察组3项操作（静脉输血、真空静脉采血、输液泵的应用）考核成绩显著高于对照组（P〈0．05,P〈0．01）;其学习积极性、学习主动性、合作能力、观察问题能力、解决问题能力、沟通技巧、操作熟练程度、动作协调性、动作连贯性、动作技巧性、动作美感、动作创新性亦显著高于对照组（P〈0．05,P〈0．01）。结论录像反馈式练习法可显著提高临床护理人员护理技能培训效果,促进其综合素质的提高。     

感动服务在肿瘤患者护理中的应用

目的探讨感动服务用于肿瘤患者的护理效果。方法将400例肿瘤患者按入院时间分为对照组（200例）和观察组（200例）。对照组采用常规护理方法进行护理；观察组在常规护理的基础上提供感动服务，包括更新服务理念，倡导护士行为反思，实现人文护理，开展形式多样的健康教育，开展护理新技术，改进服务流程等。结果观察组患者对护理人员的服务态度、健康教育、治疗及时、解决问题、技术操作满意程度显著优于对照组（均P〈0．01），投诉率显著低于对照组（P〈0．01）。结论感动服务能多方面提高患者对护理服务的满意度，有利于护理质量的持续改进。     

甲状腺手术患者术前访视方法的改进

目的探讨改进甲状腺手术患者术前访视的方法及效果。方法将240例行手术治疗的甲状腺患者随机分为观察组和对照组各120例，对照组按照常规进行术前访视．观察组由巡回护士与病房护士共同进行术前访视、心理干预及放松训练．并于术后回访。结果两组患者入手术室20rain后焦虑评分及收缩压、心率比较．差异有显著性意义（均P〈0．01）；观察组因高度紧张需延迟手术及术中增加麻醉辅助用药者显著低于对照组。患者满意度显著高于对照组（P〈0．05．P〈0．01）。结论改进后的访视方法，能有效缓解甲状腺手术患者的术前焦虑，减少血压、心率的波动，使患者以最佳状态接受手术．提高了患者对手术室护理工作的满意度。     

综合护理干预对精神分裂症患者社会技能及生活质量的影响

目的探讨综合护理干预对精神分裂症惠者社会技能及生活质量的影响。方法将76例精神分裂症患者随机均分为观察组和对照组。两组均常规予利培酮系统治疗，观察组从第3周开始予以为期8周的综合护理干预，内容包括集体健康教育、个体心理护理、生活技能训练、社会技能训练、家庭支持和教育等，随后对两组患者进行为期1年的随访。采用阴性和阳性症状评定量表（PANSS）、住院患者护士观察量表（NOSIE-30）和生活质量量表（QOL-100）进行评估。结果随访结束时，观察组PANSS总分、阳性症状及阴性症状评分显著低于对照组（均P〈0．01）；NOSIE-30总分及总积极因素评分显著高于对照组（均P〈0．01），总消极因素评分显著低于对照组（P〈0．01）；生活质量总分、生活领域、心理领域、独立性领域及社会关系领域评分显著高于对照组（P〈0．05，P〈0．01）。结论综合护理干预不仅有助于改善精神分裂症患者的精神症状和社会技能，而且有助于提高患者的生活质量。     

持续质量改进对纠正血液透析患者高磷血症的作用

目的通过持续质量改进（CQI）的方法纠正血液透析（HD）患者的高磷血症。方法选择60例维持性血液透析患者随访9个月,应用PDCA四步法,即设计（plan）-实施（do）-检验（check）-应用（act）,设计并实施改善患者高磷血症的治疗流程。结果在CQI后,高磷血症患者的平均血磷水平由（2．39±0．56）mmol／L下降至（1．81±0．27）mmol／L（P〈0．01）;血磷≤1．78mmol／L的患者比例从40．O％上升至58．3％（P〈0．05）;钙磷乘积≤55的患者比例从61．7％上升至90．0％（PdO．01）。结论CQI的方法可以显著改善维持性血液透析患者的高磷血症。     

血液灌流辅助抢救急性重度有机磷农药中毒的疗效观察

目的探讨血液灌流（HP）辅助抢救急性重度有机磷农药中毒（ASOPP）疗效。方法根据时间段将ASOPP患者分为观察组（46例）和对照组（20例），两组均常规采用内科抢救治疗方法，观察组在此基础上加用HP治疗。结果观察组治愈率显著高于对照组（P〈0．05），而病死率、并发症发生率及阿托品总用量显著低于对照组（P〈0．01，P〈0．05）；患者昏迷时间、住院时间显著较对照组短（P〈0．01．P〈0．05）。结论系统内科治疗辅助HP，可提高ASOPP患者治愈率，降低病死率及并发症发生率；严密的病情观察及护理是抢救成功的关键。     

实施自我管理教育项目对住院2型糖尿病患者的影响

目的探讨实施自我管理教育项目对2型糖尿病患者健康信念、自我管理行为及糖化血红蛋白的影响。方法将100例住院2型糖尿病患者随机分为对照组与观察组各50例。对照组给予常规健康教育,观察组在此基础上由科室医生、教育护士、营养师、心理咨询师等8名成员组成自我管理教育项目组,对患者进行自我管理教育。两组均随访3个月,分别在干预前、干预后第3个月评估患者的健康信念、自我管理行为和糖化血红蛋白水平。结果观察组干预后健康信念得分显著高于对照组（P〈0．01）;自我管理行为显著优于对照组（P〈0．05）;糖化血红蛋白降低程度较对照组更为显著（P〈0．01）。结论对住院2型糖尿病患者实施自我管理教育项目,能提高其健康信念水平、改善自我管理行为、降低糖化血红蛋白。     

Ⅰ型神经纤维瘤病并发右阴部内动脉出血栓塞治疗1例

患者男，62岁，确诊为“神经纤维瘤病Ⅰ型”40余年。因“右臀部及会阴部疼痛20h入院”，入院前右臀部及会阴部出现包块，包块进行性增大。该患者入院10h后义出现剧烈疼痛，考虑血管再次破裂出血可能，遂行急症DSA榆查及血管栓塞治疗。查体：全身皮肤多处检及1～3cm结节；右臀部及公阴部有约8cm×8cm×6cm大小包块，呈暗红色，且延续至双侧阴囊及阴茎皮下，     

胆囊癌转化治疗模式探索与思考北大核心CSCD

胆囊癌病人预后不佳。如何进一步精确评估手术可行性、提高外科根治性手术比例,是改善胆囊癌治疗效果的关键。以病人是否能从外科手术中获益为标准,可将处于局部进展状态而尚未发生远处转移的胆囊癌病人,进一步细分为临界可切除胆囊癌和局部进展期胆囊癌两种类型,并应对局部进展期胆囊癌开展转化治疗。随着综合治疗手段的进步,有望通过系统性治疗联合外科手术的转化治疗模式,提高此类病人的R0切除率,从而改善预后。     

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??Strategy and controversy of regional lymph node dissection applied to differentiated thyroid carcinoma LI Yin??YANG Zhong-yuan?? LI Qiu-li??et al. Department of Head and Neck Surgery??Sun Yat-sen University Cancer Center??Guangzhou 510060??China
Corresponding author??GUO Zhu-ming??E-mail??guozhm@sysucc.org.cn
Abstract Papillary thyroid carcinoma (PTC) has excellent prognosis. But metastasis to the cervical lymph node usually occurs early. Thyroidectomy and reasonable lymph node dissection are regarded as the best choices for thyroid carcinoma treatment widely. Patients with cN1 require the lymph node dissection. But for patients with cN0, the need of prophylactic central lymph node dissection or prophylactic modified neck dissection remains controversial.     

连续血液净化治疗严重脓毒症免疫炎性反应临床观察

严重脓毒症及其相关的脓毒性休克和多脏器功能障碍综合征是危重病患者死亡的主要原因之一。传统的观点认为,脓毒症是一种过度的炎性反应,但应用针对某种炎性介质的抗炎治疗没有在临床获得预期效果。后期研究又发现,脓毒症免疫功能紊乱中更多的是由于“过度免疫抑制”的参与。     

再谈椎体成形术的适应证、禁忌证及并发症

自1984年法国医生Dera—mond首次应用经皮穿刺向椎体内注射充填骨水泥治疗颈椎侵袭性血管瘤以来，经皮椎体成形术（percutaneous verte—broplasty，PVP）已在临床广泛应用，以后又有经皮椎体后凸成形术（percutaneous kypho—plasty，PKP）的发展与应用。我国在本世纪初应用PVP和PKP以来，亦积累了丰富的临床经验。     

The Role of Peritoneal Scintigraphy in the Detection of Continuous Ambulatory Peritoneal Dialysis Complications

While continuous ambulatory peritoneal dialysis (CAPD) offers several advantages over hemodialysis in patients with end-stage renal disease, several complications have been recognized. The intraperitoneal instillation of dialysate increases intra-abdominal pressure and consequently predisposes the patient to leaks and herniations through defects in the abdominal wall.

The use of an intraperitoneal radiolabeled colloid has been previously described to image entities such as hernias, patent processus vaginalis, abdominal wall, and diaphragmatic leakage. This study shows a simple, non-invasive method of determining the site of dialysate leak and its importance to assist further patient management.

There has been a continuing increase in the number of end stage renal disease patients maintained on chronic peritoneal dialysis (CPD). Many patients choose CPD as their preferred chronic dialysis treatment, though approximately 20% of patients who drop out transfer to hemodialysis annually.¹ Juergensen PH, Rizvi H, Caride VJ, Kliger AS, Finkelstein FO. Value of scintigraphy in chronic peritoneal dialysis patients. Kidney Int 1999; 55: 1111–1119, [INFOTRIEVE], [CSA][Crossref], [PubMed], [Web of Science ®] , [Google Scholar] Although peritonitis remains the major reason for transfer to hemodialysis, other factors such as exit site infections, catheter-related problems, abdominal wall and inguinal hernias, loss of ultrafiltrations, and poor clearance contribute to CPD technique failure.² Finkelstein FO, Sorkin M, Cramton CW, Nolph K. Conference report initiatives peritoneal dialysis: where do we go from here?. Perit Dial Int 1991; 11: 274–278, [INFOTRIEVE], [CSA][PubMed], [Web of Science ®] , [Google Scholar] In order to permit the continuation of long-term therapy with CPD, these complications should be resolved.

Routine laboratory evaluation or physical examination can detect some CPD-related problems; however, some patients require more complicated investigations to evaluate their problems properly.     

膝关节僵直松解术后自控镇痛下的早期治疗

膝关节附近的骨关节损伤、手术及长期制动,导致关节内伸膝装置的广泛粘连、挛缩,临床上常出现膝关节僵直,治疗较为棘手,极大地影响了患者的生活质量。针对上述情况对膝关节僵直患者采用于术松解,并在术后自控镇痛下进行早期治疗,取得了满意效果,现报告如下。     

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??Laparoscopic transcystic bile duct exploration??An analysis of 32 cases FAN Xiong-wei*, YANG Hai-tao, GUO Wei, et al.*Department of General Surgery, Wuzhong People's Hospital Affiliated to Ningxia Medical University, Wuzhong 751100, China
Corresponding author: GUO Wei, E-mail??guoweibfh@163.com
Abstract Objective To investigate the feasibility of laparoscopic transcystic biliary duct exploration (LTCBDE) for the treatment of common bile duct (CBD) stones by using 5 mm conventional choledochoscope in the basic-level hospital. Methods The clinical data and outcomes of 32 cases of gallstone and CBD stones treated by LTCBDE in Wuzhong People's Hospital Affiliated to Ningxia Medical University from June 2015 to April 2016 were analyzed retrospectively. All the cases were diagnosed with gallstone accompanying CBD stones preoperatively by ultrasonography, CT and (or) MRCP. Results The diameter of CBDs were 8 to 15 mm. CT or MRCP showed the diameter of the cystic ducts were more than 3 mm. The number of CBD stones were 1 to 3, and the diameter were 3 to 8 mm. Thirty of 32 cases of LTCBDE were successfully performed with the success rate of 93.8% (30/32). The average operation time was (96.2±32.5) min, and the average postoperative hospital stay was (3.5±2.1) d, and the incidence of complications was 6.3% (2/32). There were 8 cases of large stones during the operation, and the microincision technique was used to complete the stone removal. After 10 to 22 months of out-hospital follow-up, no biliary stricture, residual stones and recurrence were found. Conclusion It is feasible that the LTCBDE using conventional 5 mm choledochoscope can be applied in basic-level hospital when the patients are well selected and the surgeons are well trained. Thus, the technique is worthy to be popularized in the basic-level hospitals.     

复杂性脾切除102例回顾性分析

目的 总结复杂性脾切除的治疗经验。方法 对1998年1月至2008年1月中南大学湘雅医院收治的102例复杂性脾切除病例进行回顾性分析。结果 病人均痊愈出院,无手术死亡及胰漏和胃、结肠损伤。其中29例出现术后并发症：腹腔内出血4例;肺部并发症13例,其中8例左胸腔积液病人有7例合并左膈下脓肿;脾静脉栓塞性静脉炎6例;大量腹水6例。分别经再次手术或保守治疗后痊愈。结论 完善的术前评估,规范的手术操作,正确的脾周粘连的解剖分离及脾蒂的处理,是确保复杂性脾切除安全的关键。     

Involvement of Spinal Cord Nuclear Factor kB Activation in A Rat Model of Persistent,Postoperative Pain Evoked by Skin/Muscle Incision and Retraction （SMIR）

Background： Persistent postoperative pain is common but the pathogenic mechanisms underlying it are under debate. Recent studies have implicated the activation of nuclear factor kappa B （NF-kB） in spinal for development of neuropathic and inflammatory pain. Aims： The aim of the present study was to investigate whether NF-kB also mediates hyperalgesia in persistent postoperative pain and potentially the pathogenesis of postoperative pain, by measuring NF-kB levels and assessing the anti-allodynic effect of NF-r.B inhibition by pyrrolidine dithiocarbamate （PDTC） in rats after skin/muscle incision and retraction （SMIR） injury. Methods： After rats received a SMIR surgery, mechanical allodynia were determined by von Frey filaments, and NF-kB p65 in the spinal cord was quantified to determine the level NF-KB expression at different time points after SMIR by western blotting. The NF-kB inhibitor PDTC was administered intrathecally at day 1 after surgery and then daily for 7 days to determine the role of NF-KB in postoperative pain, Results： A significant increase in level of NF-kB p65 was observed in the spinal cord from day 1 to day 7 after SMIR, Intrathecal injection of PDTC attenuated SMIR-induced mechanical allodynia from day 3 to day 12. Conclusions： SMIR-induced mechanical allodynia can be partially reversed by the NF-kB inhibitor. Our results suggest that NF-r.B activation in spinal cord plays a role in SMIR-induced mechanical allodyuia in rats. Therefore, NF-kB inhibition may be useful but not sufficient for the therapeutic control of postoperative pain,