无消化道症状的食道和胃重复癌1例报告

患者，男，72岁，因头昏，乏力2年，加重10天入院。2年前患者因口干、头昏、乏力，体重下降5kg，无发热、多汗、多食、易饥饿，院外查空腹血糖7．8mmol／L，诊断糖尿病，间断口服降糖药（具体不详）2月，偶查空腹血糖5～8mmol／L，症状好转，自行停药，无特殊不适，未再监测血糖。10天前无诱因头昏、乏力加重、纳差、恶心、轻微咳嗽、少许白色黏液痰，无呕吐、冒酸、发热，无尿路刺激症状，大便正常，院外查空腹血糖5．4mmol／L，以糖尿病收入院。病史中无心累、气紧、双下肢浮肿、吞咽不适，无黑大便。既往史：30年前因胆囊结石行胆囊切除术。2年前发现血压高，最高160／95mmHg，曾服罗布麻，未测血压。无烟、酒等不良嗜好。家族史无特殊。查体：无特殊。入院后查血、尿、大便常规，肝、肾功能，隐血试验，胸片，彩超，ECG，Holter，均正常。入院诊断：①颈椎骨质增生，椎基底动脉供血不足；②肺部感染；③前列腺增生，尿路感染；④胆总管结石；     

饮酒与剧烈运动致肌溶解1例

1 病例 患者QYG，男，34岁，某公司副总经理。以反复全身肌肉酸痛，乏力，尿色加深一月余就诊。患者有经常性饮酒的习惯；近三月来，参加健身运动，每日运动1～2小时，较剧烈。近一月余来反复感全身肌肉酸痛，乏力，尿稍减少，尿色加深，有时如茶水，体重下降。无发热、畏寒、鼻塞、清涕、咳嗽、胸痛、腹痛、尿频尿急伴随，自认为系运动疲劳综合征，未在意，仍继续健身运动与经常性饮酒。     

多饮、多尿、乏力、厌食1个月腹泻、肢瘫、心悸、气短1周（病案讨论见本期第74页）

1 病历摘要 患者，女，30岁，干部。主因“多饮、多尿、乏力、厌食1个月余，腹泻、肢瘫、心悸、气短1周”，门诊以“尿崩症”收住兰州大学第一医院内分泌科。患者于1个月前因工作调动劳累，出现失眠、咽喉部疼痛，在厂卫生所以“上感”肌注“青霉素”80万u，每日2次，共3天，咽痛症状未见明显缓解，并出现口渴、多饮、多尿，1周后上述症状加重，日饮水8L，排尿量约7．5L，出现肢软无力、恶心、非喷射性呕吐，呕吐物为胃内容物，厌食，不能正常工作。     

获得性血友病B针灸后出血1例报告

患者，女，65岁，因颈、腰、臀剧痛8小时急诊入院。入院前10小时因颈、腰、腿痛在外院接受普通针刺（毫针）治疗。既往高血压病史10年，颈、腰痛数年，未作治疗。顺产1子1女，已停经，既往月经量较大，无手术史。2月前因服用非甾体类药物后出现全身多处紫癜，停药后消退，无其他过敏史。入院查体：痛苦面容，面色萎黄，呻呤不止，全身大汗、湿冷，强迫左侧卧位，不能平卧、坐起及站立。心肺腹部无异常，脊柱叩痛，颈、腰、背肌痉挛、轻微肿胀，压痛敏感。右臀部肿胀，张力高，压痛敏感。     

头痛、发热、呕吐12小时,全身紫癜5小时

患者女，54岁，因头痛、发热、呕吐12小时，全身紫癜5小时于2004年3月20日入院。患者于昨晚6时许，急骤起病，寒战、发热、头痛、全身酸痛无力，体温39℃。患者当时无抽搐、昏迷、呕吐、腹痛、流鼻涕及咳嗽等症状。到村卫生所就诊，给予退热剂、补液等治疗，具体药名不详。当晚12时左右全身不适加重，出冷汗、四肢末梢发凉、呼吸急促、口唇轻度发绀、烦躁不安，并呕吐1次，呕吐物为胃内容物，非喷射性，当时发现全身皮肤点片状紫癜，测血压50／40mmHg，     

持续高热、腹泻和皮疹16天

1病历摘要 患者，女，80岁，2003年5月6日下午因受凉而发热达39．5℃，伴头晕、鼻塞、流涕，无咽痛、咳嗽，无尿频、尿急、尿痛，无腰痛，无四肢关节疼痛，人院前曾予头孢菌素、林可霉素、氧氟沙星等治疗，体温未降，且出现皮疹，无明显瘙痒；在外院查血常规及胸片正常，因用药后体温不降，后加用地塞米松及丙种球蛋白，体温可降至37．5℃，但很快又复升.     

代谢综合征的中医治疗

近年来，随着社会经济的发展，生活方式、饮食结构的改变（高蛋白、高脂肪、高热量、低纤维），导致代谢综合征的发生率越来越高，严重影响了人们的身心健康。中医并无代谢综合征这一病名，但根据其形体肥胖，口甘口黏，多食易饥，头晕，困倦乏力，胸脘痞闷，大便不爽，舌苔腻，脉滑或弦或濡之证候，可归属于中医的“脾瘅”、“湿阻”、“肥胖”、“消渴”、“眩晕”、“胸痹”、     

浆膜腔积液常规检测嗜酸性粒细胞增高的肺腺癌1例

1 临床资料 患者，老年男性，79岁，胸痛2周，呈钝痛，伴轻微咳嗽咳痰，咳白色泡沫痰，无发热、咳血、乏力，无头昏、心慌、胸闷、腹痛，盗汗明显。     

胎儿小肠扭转并闭锁超声表现一例

孕妇22岁，孕1产0，孕34周。夫妇身体健康，孕期无用药史，无感染史。超声检查提示：单活胎，双顶径8．6cm，头围28．6cm，股骨长6．5cm，肱骨长5．5cm，腹围29．0cm，胎儿颅内结构、脊柱、胸腔、心肺、肝、肾、膀胱、四肢未见异常；胎儿胃泡增大，约5．1cm×2．4cm，幽门管增宽，与扩张的十二指肠贯通，中腹部小肠扩张，纵、横切面显示为多个大小不等、形态各异的囊性结构，最大内径1．8cm，囊腔内见密集的细小点状回声（图1），实时扫查见各囊腔相互连通，形态、大小随肠管蠕动发生变化，部分管腔蠕动及逆蠕动明显，结肠未见扩张，未见腹水；羊水深6．6cm，浑浊，胎盘位于前壁。超声提示：（1）宫内晚孕、单活胎；（2）胎儿腹围增大，胃、十二指肠及中腹部小肠连续性扩张，符合机械性肠梗阻表现，考虑小肠闭锁可能性大；（3）羊水浑浊。     

误诊为尿路感染的儿童卵巢畸胎瘤1例报告

1病例患儿，女，9岁，因反复发作尿频、尿急、尿痛三年余，再发十余天予2007年1月21日入院，患儿于三年前无明显诱因出现尿频、尿急、尿痛，为阵发性刺痛，尿道口无流脓，无畏寒、发热，无腹痛、腰痛，颜面、下肢无水肿，经抗炎治疗后症状消失；此后反复发作，34次／年，均予抗炎治疗后好转，十余天前症状再发，为进一步诊治以“尿路感染”收入院。起病以来神清、精神好，食纳可，睡眠佳，大便正常。     

NEWS AND INNOVATIONS

Representative Frank R. Wolf, Chairman of the U.S. House of Representatives Subcommittee on Commerce, Justice, State, and the Judiciary, Committee on Appropriations; and Representative James C. Greenwood, Chairman of the Subcommittee on Oversight and Investigations, Committee on Energy and Commerce, requested that the U.S. Government Accounting Office (GAO) investigate OxyContin Abuse and Diversion. The GAO is the audit, evaluation and investigative arm of Congress. On December 23, 2003, the GAO submitted a 57 page report to the Representatives describing the outcomes of the investigation.

The full report includes appendices that describe the scope and methodology of the investigation, summaries of FDA changes to the original approved OxyContin label, databases used to monitor abuse and diversion of OxyContin and oxycodone, and comments from the FDA and DEA. This special report is an abstract of the GAO report and includes the conclusions and recommendations for action form the full report.     

Experiences of AIDS-dedicated nurses in alleviating the stress of AIDS caregiving

From the beginning of the AIDS epidemic, there have been individuals dedicated to the care of patients with AIDS. However, there has been little research regarding their perceptions and experiences of AIDS caregiving and the strategies they use to alleviate the stress and promote their willingness to care. Based on the experiences of 12 nurses at one hospital, who had chosen to work on an AIDS-dedicated unit, this exploratory study, conducted in 1998, explored the following: the physical, emotional or spiritual risks and stresses associated with AIDS caregiving; factors that provide resistance to the stresses of AIDS caregiving and promote a willingness to care; and strategies recommended by AIDS-dedicated nurses in caring for patients with AIDS. The data reveal important themes related to the physical stress of AIDS caregiving, specifically being aware of risks, but not paralysed by fear, and bombardment of the senses. The coping strategies of nurses included taking the risk in their stride, reframing the risk, and protecting oneself. The emotional stress of AIDS caregiving included witnessing suffering, experiencing unresolved grief, accepting diversity, being emotionally connected, distress from the dismantling of the AIDS unit and work demands, and declining team spirit. Coping strategies included balancing personal and professional life, releasing pain, respecting yet controlling feelings, managing demands, and asking for help. Nurses maintained their spiritual perspective. They experienced through AIDS caregiving a greater sense of shared humanity and a new perspective of life. Findings indicate that AIDS-dedicated nurses use many coping strategies. The experiences of these nurses can assist clinicians, educators and administrators in supporting nurses' caregiving and promoting the quality of care offered to patients with AIDS.     

阻生牙拔除术后并发症防治的系统评价／Meta分析的汇总评价

目的对防治阻生牙拔除术后并发症的系统评价／Meta分析进行汇总评价。方法计算机检索PubMed、TheCochraneLibrary、CBM、CNKI和WanFangData,收集防治阻生牙拔除术后并发症的所有系统评价／Meta分析,同时手工检索15种专业期刊并追溯纳入研究的参考文献,检索时限均为从建库至2012年9月30日。由两位研究者按照纳入标准独立筛选文献、提取资料后,采用AMSTAR评价纳入研究质量并采用GRADE系统进行证据质量分级。结果共纳入12个相关系统评价／Meta分析,其中5个涉及干槽症防治,6个涉及肿胀预防,7个涉及疼痛防治,6个涉及张口受限,2个涉及感染预防,3个涉及出血预防,1个为拔牙术后神经损伤的治疗。基于AMSTAR的质量评价结果显示,7个研究质量为轻度限制,5个为中度限制。GRADE系统的质量评价结果显示,2个研究的证据分级为高级,12个为中级,9个为低级,7个为极低级。结论当前防治阻生牙拔除术后并发症的系统评价／Meta分析结果可为临床实践提供一定参考,临床医生应结合实际情况进行循证决策。此外,仍建议开展更多大样本、高质量研究予以证实。     

ICU日记法研究的文献计量学及可视化分析

目的 了解ICU日记在国内外的研究现状与研究趋势,以期为ICU日记的临床应用提供指导性依据。方法 检索Web of Science（WOS）数据库和中国知网（CNKI）中建库至2021年10月15日发表的ICU日记研究相关文献,经CiteSpace文献分析软件对年发文量、国家、机构、关键词、参考文献等进行知识图谱分析。结果 WOS数据库检索出140篇,CNKI检索出29篇,年发文量呈上升的趋势。国际发文前5的国家依次是美国、丹麦、英国、瑞典,澳大利亚,发文最多的机构是丹麦的哥本哈根大学和Rigshospitalet医院;国内发文最多的省份是北京市和湖南省,发文最多的机构是北京协和医学院护理学院和中南大学湘雅护理学院。该领域主要的研究热点为患者ICU记忆重建、患者及亲属心理健康、日记使用体验及康复随访。结论 国内ICU日记研究尚处初级阶段,有待借鉴国外ICU日记研究热点,加强国内与国际合作,完善日记干预模式,为促进我国急危重症患者及家属健康提供思路。     

Mechanisms and markers of carcinogenesis and neoplastic progression

Neoplastic transformation evolves over a period of time involving the progression of the cellular immunophenotype (IP) from normal to hyperplastic to dysplastic, and finally, to fully malignant IPs. Superimposed on these changes is the interaction of the initiated cell with its microenvironment, whereby the neoplastically transformed cells, through the regulation or dysregulation of cytoskeletal, integrin, protease and adhesion molecules, develop a novel manner of relation with their surrounding microenvironment. Studies of the neuroendocrine-immune network revealed that the hormonal and cytokine milieu plays an important role impacting the growth and dedifferentiation capabilities of neoplastic cells. This is further affected by the tumour cells themselves determining the constitution of this hormonal microenvironment, allowing the most aggressive and invasive of neoplastically transformed cell clones to promote their own growth and dissemination. The elucidation of the steps of the progression of cancer from premalignant to metastatic and invasive forms is of utmost importance in the differential diagnosis of neoplasms and in the establishment of more efficacious therapeutic regimens. These regimens will certainly begin to take on a more individualised form. The functional characterisation of various human malignancies as to the neoplastically transformed cells’ IP, the bases of their interaction with tissue stromal elements, and the molecules involved in the humoral microenvironment of the particular stage of tumour will certainly allow for the better diagnosis, staging, prognostication and treatment of cancers in the future. This paper reviews carcinogenesis from nutritional, genetic and molecular, and humoral aspects, and discusses the importance of tumour markers in the diagnosis and therapeutic management of human cancer.     

精神科保护性约束实施及解除专家共识

目的 形成《精神科保护性约束实施及解除专家共识》,规范精神科保护性约束实施及解除的相关内容。方法 运用循证方法,按照证据级别高低,检索、评价和汇总该领域的证据,提取精神科保护性约束实施及解除的推荐建议和研究结论,形成共识初稿,通过2轮专家函询及2次专家论证会,结合专家意见,对初稿进行调整、修改和完善,形成共识终稿。结果 2轮函询专家积极系数均为100%,专家权威程度均为0.90,各指标重要性赋值均数均>3.5分,且变异系数均<0.25,专家肯德尔和谐系数分别为0.146和0.166（均P<0.01）。最终对精神科保护性约束应用人群、前提与原则、目的、评估要点、基本要求、记录表、流程图、实施过程中的干预策略、伦理问题及风险、建议共10个部分的推荐意见达成一致。结论 该共识为精神科保护性约束的实践提供指导依据,可使精神科保护性约束行为更规范。     

The patient's perceived caring needs as a message of suffering

The patient's perceived caring needs as a message of suffering ¶The aim of the study was to arrive at a deeper understanding of the patient's experience of caring needs, that is, of problems, needs and desires, by investigating and explaining how these will be expressed and shaped in the caring relation and to illuminate its implications for caring. The target population consisted of 38 patients in a medical ward and 37 patients in a surgical ward in a central hospital in Western Finland. The patients were interviewed in the wards and asked about perceived caring needs. By means of a hermeneutical process of interpretation a pattern emerged which was interpreted as pictures of themselves and of the nurses. These types of patients fell into three groups: the satisfied, the complaining and satisfied, and the complaining and dissatisfied patients. The types of nurses were divided into the competent and friendly, the competent and contact-creating and the competent and courageous. The patients' caring needs can be interpreted and understood from the standpoint of their experience of suffering, but also in relation to their experience of pleasure and comfort. The most conspicuous caring needs were experiencing confidence in the competence of the nurses, comfort, guidance, dialogue and closeness, which the patients expressed as problems, needs and desires. The patients' caring needs can contain new possibilities of growth and development. The nurse can relieve patients' suffering by promoting their experience of comfort. If the nurses' view of the limits of reality are extended to comprise the existential/spiritual dimension of human beings as well, new possibilities will emerge of interpreting and understanding patients' caring needs as a message of suffering.     

Brief history of quality movement in US healthcare

The current healthcare quality improvement infrastructure is a product of a century long experience of cumulative efforts. It began with an acknowledgement of the role of quality in healthcare, and gradually evolved to encompass the prioritization of quality improvement and the development of systems to monitor, quantify, and incentivize quality improvement in healthcare. We review the origins and the evolution of the US healthcare quality movement, identify existing initiatives specific to musculoskeletal care, outline significant challenges and opportunities, and propose recommendations for the future. Elements noted to be associated with successful healthcare quality improvement efforts include the presence of physician leadership, infrastructural support, and prioritization of healthcare quality within the culture of the organization. Issues that will require continued work include the development of a valid and reliable evidence base, accurate and replicable performance measurement and data collection methods, and development of a standard set of specialty specific performance metrics, with accurate provider attribution, risk adjustment and reporting mechanisms.     

Headache: What Do Children and Mothers Expect From Pediatricians?

(Headache 2010;50:290‐300) Background.— Headache is a frequent occurrence among children and adolescents, and one of the most common causes of medical consultation. While serious conditions presenting headache as the chief complaint are not common in the pediatric population, enormous sums are invested to perform very expensive and often unnecessary diagnostic investigations. Pediatricians should adopt a flexible and diversified diagnostic/therapeutic approach and, at the same time, should not forget to take into consideration the demands, expectations, and worries of children and their parents. Objective.— The aim of this study was to assess simultaneously children's and mothers' expectations from the pediatric consultation concerning headache, and pediatricians' opinions about said expectations. In addition, we attempted to investigate mothers', children's, and pediatricians' opinions about symptomatic and prophylactic treatment of headache. Method.— A total of 100 young headache sufferers, 50 were male and 50 were female, from 10 to 16 years of age, were enrolled in this study. Two diversified, self‐administered, ad hoc questionnaires about their expectations from the pediatric treatment of headache and about symptomatic and prophylactic treatment were delivered to each patient and their mother, to which they responded separately. A third self‐administered questionnaire was delivered to a sample of 50 pediatricians. Results.— Our study showed that children and their mothers sometimes have different expectations about the consultation of the pediatrician and of the headache specialist. Frequency of pain was the main reason for pediatric consultation for 70% of mothers, whereas only 2% of them (as opposed to what pediatricians believed) consulted the pediatrician because they were worried about a tumor. Moreover, a high percentage of children and mothers expected from the pediatric consultation to be reassured that it is not a serious illness and to find out the causes of headache (60% and 47%, and 45% and 62%, respectively). A total of 26% of children wanted to know the progression of headache in the future, but only 3% of mothers shared the same demand. With regard to their expectations, pediatricians agree only in part with children and their mothers. On the contrary, the majority of children (68%), mothers (49%), and pediatricians (90%) agree that a symptomatic treatment was necessary in the presence of a severe pain. In addition, 61% of children, 37% of mothers, and 74% of pediatricians believed that a prophylactic treatment was necessary when the pain is severe and long‐lasting. Conclusion.— Pediatricians sometimes do not consider sufficiently children's and mothers' wishes and expectations and, consequently, could limit the outcome of their diagnostic‐therapeutic approach. This is particularly important because, in the developmental age, an accurate recognition of patients' and parents' expectations represents an essential requirement for a favorable outcome of the consultation.     

玛咖对果蝇和小鼠繁殖能力与睡眠的影响

【目的】研究玛咖对果蝇和雄性小鼠性能力、繁殖能力以及睡眠的影响。【方法】用含有玛咖粉末（01．％,02．％）的培养基培养果蝇,检测玛咖对果蝇交配数以及羽化成虫数量的影响。进一步用玛咖混悬溶液按01．g／kg剂量和02．g／kg剂量给成年雄鼠连续灌胃15d,通过检测小鼠精液品质、观察其睾丸和附睾的组织学变化,并记录其子代生育情况,以评价小鼠的生殖力。通过直接睡眠动物数、戊巴比妥钠协同睡眠潜伏期、延长戊巴比妥钠睡眠时间以及戊巴比妥钠阈下剂量协同催眠动物数等指标来检测不同剂量组（01．g／kg ,02．g／kg和04．g／kg）玛咖对小鼠睡眠的影响。【结果】实验结果表明玛卡能显著提高果蝇的性交配率以及生殖率,增加并能明显增强小鼠睾丸的发育、提高精液品质,也能提升生育率和平均窝仔数以及子代平均体重和存活率。睡眠实验表明,玛咖不会引起实验动物直接睡眠,但能延长戊巴比妥钠诱导的睡眠时间,缩短其入睡潜伏期;在戊巴比妥钠阈下剂量催眠实验中能明显增加睡眠动物数。【结论】玛咖在不同的动物模型上都能提高雄性动物的性能力,增加其繁殖能力;并能改善动物睡眠。