医患沟通与知情同意在医疗及病案管理中的作用

《医疗事故处理条例》及《中华人民共和国执业医师法》中明确规定，医疗机构及其医务人员必须向患者履行告知义务。临床医师履行好告知义务是提高医疗质量及病案质量、降低医疗风险、提高医疗安全的基本工作之一，是在依法履行医师的义务。良好的医患关系是医院自身发展的客观需要，多数医疗纠纷的产生与医患沟通不畅有关。知情同意书是医患沟通的桥梁，是患者知情同意在病案管理中的书面体现。     

护士履行告知义务与患者知情同意权的探讨

目的：护士在护理活动中正确履行告知义务，以维护护患双方的合法权益，提高护理质量。方法：加强护士告知的意识和告知能力的培养，具体在患者入院时、治疗护理过程中和出院时履行告知义务。结果：护士在工作中充分地履行告知义务，保障了患者的知情同意权，建立了互相信任、互相理解的护患关系。结论：医护人员的告知义务与患者的知情权在医患关系中是对应的权利义务关系，履行告知义务，对于提高护理质量，减少护患纠纷有着至关重要的意义。     

1例鼻饲过程中病情突变导致护理纠纷引发的思考

通过案例分析,得出告知不详、医护患三者没有进行良好的沟通是引起护理纠纷的原因。提出医务人员依法、及时、有效地收集具有法律效力的证据,使医护患三者之间建立良好的沟通,切实履行告知义务及医患沟通制度,可以有效地预防或减少护理纠纷的发生。     

浅谈医患关系危机管理

探讨医患关系危机，提出突发事件的发生给医患关系带来不可预测的危机；医疗护理质量低下是最严重的医患关系危机；医疗护理记录缺陷是造成危机最致命的因素；重要技术操作未履行告知义务，与病人沟通不到位；服务态度、医疗服务价格的透明度等隐藏着许多不被人们重视的危机。通过对以上危机因素的分析，提出医患关系危机的预防和管理措施。     

三聚氰胺污染奶粉致婴幼儿泌尿系结石筛查概况及医患沟通策略

目的：提高突发公共卫生事件中医患沟通的能力，避免医患纠纷，促进医患和谐。方法：我院2008年9月17日～10月10日共为14882例儿童进行泌尿系结石筛查，筛查工作中我们通过获取可靠病史，尽量减轻患儿家长的冲动情绪，向家长详细告知结石治疗的相关问题，有的放矢做好各类患儿家长的沟通工作。结果：我院经筛查和复查共确定三聚氰胺结石204例，收住院72例。经过积极有效的医患沟通，稳定了筛查儿童家长的冲动情绪，使其积极配合犀院的筛查和诊治工作，避免了矛盾激化。结论：在突发公共卫生事件中，医护人员面临特殊的群体，需做好沟通、告知工作，才能避免医患纠纷，维护社会稳定。     

三聚氰胺污染奶粉致婴幼儿泌尿系结石筛查慨况及医患沟通策略

目的:提高突发公共卫生事件中医惠沟通的能力,避免医患纠纷,促进医患和谐.方法:我院2008年9月17日-10月10日共为14882例儿童进行泌尿系结石筛查,筛查工作中我们通过获取可靠病史,尽量减轻患儿家长的冲动情绪,向家长详细告知结石治疗的相关问题,有的放矢做好各类惠儿家长的沟通工作.结果:我院经筛查和复查共确定三聚氰胺结石204例,收住院72例.经过积极有效的医患沟通,稳定了筛查儿童家长的冲动情绪,使其积极配合医院的筛查和诊治工作,避免了矛盾激化.结论:在突发公共卫生事件中,医护人员面临特殊的群体,需做好沟通、告知工作,才能避免医患纠纷,维护社会稳定.     

ICU医患沟通记录单的设计与应用

目的应用ICU医患沟通记录单,以降低医护患纠纷的发生率。方法将患者住院期间的治疗、护理方案、费用、皮肤情况等告知家属并在医患沟通记录单上签名。结果患者家属对医护工作满意度由95.08%上升至99.13%,投诉率由2.60%下降至0.57%。结论医患沟通记录单的应用有利于提高患者家属的满意度,减少护患纠纷。     

病房实施护理告知的临床实践

护理安全是保证护理质量的前提,有效的护患沟通可以防范护理安全隐患,减少医患纠纷。沟通的实质是院方是否完整地履行了告知义务,患者是否享有知情同意权。沟通交流是非常重要的^[1]。由于护士与患者接触多,因此护士在医疗告知实施过程中承担着十分重要的作用。我院2005年2月-2007年2月对住院患者全面实施了护理告知制度,收到了较好效果,现报道如下。     

病房实施护理告知的临床实践

护理安全是保证护理质量的前提,有效的护患沟通可以防范护理安全隐患,减少医患纠纷.沟通的实质是院方是否完整地履行了告知义务,患者是否享有知情同意权.沟通交流是非常重要的 [1] .由于护士与患者接触多,因此护士在医疗告知实施过程中承担着十分重要的作用.我院2005年2月-21307年2月对住院患者全面实施了护理告知制度,收到了较好效果.现报道如下.     

护士的告知义务与病人的知情同意权

护士的告知义务与病人的知情权是对应的权利义务关系,我国从行政法规及部门规章的高度规定了护士的告知义务,同时赋予了病人知情同意权。护士的告知义务包括入院时的告知、住院期间的告知、出院时的告知。其中住院期间的告知又包括一般生活护理的告知、给药的告知、特殊检查治疗的告知、手术的告知、留取化验标本的告知、治疗费用的告知、健康教育知识的告知等。护士履行告知义务时要随时随地进行,注意选择合适的告知对象,采取多种告知形式,及时记录重要的告知内容,并注意医护间传递信息的一致性,遵循护理伦理学原则。     

Migraine and genetic and acquired vasculopathies

It is remarkable that migraine is a prominent part of the phenotype of several genetic vasculopathies, including cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL), retinal vasculopathy with cerebral leukodystrophy (RVCL) and hereditary infantile hemiparessis, retinal arteriolar tortuosity and leukoencephalopahty (HIHRATL). The mechanisms by which these genetic vasculopathies give rise to migraine are still unclear. Common genetic susceptibility, increased susceptibility to cortical spreading depression (CSD) and vascular endothelial dysfunction are among the possible explanations. The relation between migraine and acquired vasculopathies such as ischaemic stroke and coronary heart disease has long been established, further supporting a role of the (cerebral) blood vessels in migraine. This review focuses on genetic and acquired vasculopathies associated with migraine. We speculate how genetic and acquired vascular mechanisms might be involved in migraine.     

Fibrinogen and fibrin structure and functions

Fibrinogen molecules are comprised of two sets of disulfide-bridged Aalpha-, Bbeta-, and gamma-chains. Each molecule contains two outer D domains connected to a central E domain by a coiled-coil segment. Fibrin is formed after thrombin cleavage of fibrinopeptide A (FPA) from fibrinogen Aalpha-chains, thus initiating fibrin polymerization. Double-stranded fibrils form through end-to-middle domain (D:E) associations, and concomitant lateral fibril associations and branching create a clot network. Fibrin assembly facilitates intermolecular antiparallel C-terminal alignment of gamma-chain pairs, which are then covalently 'cross-linked' by factor XIII ('plasma protransglutaminase') or XIIIa to form 'gamma-dimers'. In addition to its primary role of providing scaffolding for the intravascular thrombus and also accounting for important clot viscoelastic properties, fibrin(ogen) participates in other biologic functions involving unique binding sites, some of which become exposed as a consequence of fibrin formation. This review provides details about fibrinogen and fibrin structure, and correlates this information with biological functions that include: (i) suppression of plasma factor XIII-mediated cross-linking activity in blood by binding the factor XIII A2B2 complex. (ii) Non-substrate thrombin binding to fibrin, termed antithrombin I (AT-I), which down-regulates thrombin generation in clotting blood. (iii) Tissue-type plasminogen activator (tPA)-stimulated plasminogen activation by fibrin that results from formation of a ternary tPA-plasminogen-fibrin complex. Binding of inhibitors such as alpha2-antiplasmin, plasminogen activator inhibitor-2, lipoprotein(a), or histidine-rich glycoprotein, impairs plasminogen activation. (iv) Enhanced interactions with the extracellular matrix by binding of fibronectin to fibrin(ogen). (v) Molecular and cellular interactions of fibrin beta15-42. This sequence binds to heparin and mediates platelet and endothelial cell spreading, fibroblast proliferation, and capillary tube formation. Interactions between beta15-42 and vascular endothelial (VE)-cadherin, an endothelial cell receptor, also promote capillary tube formation and angiogenesis. These activities are enhanced by binding of growth factors like fibroblast growth factor-2 (FGF-2) and vascular endothelial growth factor (VEGF), and cytokines like interleukin (IL)-1. (vi) Fibrinogen binding to the platelet alpha(IIb)beta3 receptor, which is important for incorporating platelets into a developing thrombus. (vii) Leukocyte binding to fibrin(ogen) via integrin alpha(M)beta2 (Mac-1), which is a high affinity receptor on stimulated monocytes and neutrophils.     

创伤高血糖与感染和MODS早期诊断和干预

本文详细介绍了创伤后血糖应激适度理论,以及高血糖与感染和多器官功能不全综合征的关系;提出涉及胰岛B细胞功能不全的MODS实验诊断新方案和极化液个体化干预新措施,可早期发现创伤MODS、降低感染率及MODS发生率和病死率。     

腹膜后纤维化与肾积水发生关系的临床研究

目的：探讨腹膜后纤维化（RPF）导致肾积水的原因及诊治经验。方法：回顾分析2004年1月—2010年12月24例腹膜后纤维化致肾积水患者的诊治资料。结果：（1）RPF患者常见首发症状为腰背痛或腹痛（69.2%）;（2）红细胞沉降率（ESR）增快和血清IgG4升高最常见。超声检查仅提示上尿路积水。RPF的静脉肾盂造影（IVP）和CT尿路成像（CTU）表现具有特征性。IVP肾盂输尿管显影不良时,CTU能较清晰的显示上尿路影像。CT扫描发现腹膜后软组织肿块9例（37.5%）,优于超声检查;（3）输尿管松解和腹腔化手术治疗22例;行肾切除术1例;行输尿管置双J管术1例。最终确诊为继发性RPF8例,其中4例为术前诊断,3例为术中腹膜后软组织肿块冷冻活检证实,1例为术后病理证实;（4）特发性RPF手术后肾积水均获长期缓解,而继发性RPF的预后取决于原发疾病及其治疗方案。结论：影像学检查是诊断RPF的重要手段,CTU优于超声检查和IVP。输尿管松解和腹腔化手术可以使特发性RPF输尿管梗阻得到长期的缓解,术中对肿块进行冷冻活检有助于鉴别特发性和继发性RPF,及时调整治疗方案。     

Telemedicine and teleradiology technologies and applications

Summary. Telemedicine and teleradiology hold the key for improving future health care delivery. In this paper we first review current communication and computer technologies used in telemedicine and teleradiology. Five examples in teleradiology applications are given including hospital-integrated picture archiving and communication systems, tele-neuro-imaging, telemammography, university consortium teleradiology service, and teleradiology for second opinion. Parameters important to teleradiology applications like costs, image quality, system reliability, and turn around time are considered. Data security is discussed, including patient confidentiality and image authenticity-which will be a major issue in future teleradiology applications.     

探讨儿童慢性顽固性咳嗽与支原体感染的关系及临床治疗观察

目的探讨儿童慢性顽固性咳嗽与肺炎支原体（MP）感染的关系及临床疗效观察。方法采用回顾性研究方法对于现将2005年3月至2008年3月在我院的55例确诊慢性顽固性咳嗽患儿,主要表现为肺炎支原体感染为临床特点进行分析,并进一步临床治疗研究。结果①临床特点：在55例确诊慢性咳嗽的患儿中,以慢性顽固性咳嗽为主要症状。58％（32／55）的病例无肺部体征;②外周血：85％（47／55）的病例外周血变化不大,WBC（4—10）×10 9／L之间,嗜酸性粒细胞增多;③特别检查：47．27％（26／55）肺炎支原体IgM（MP—IgM）抗体阳性,83．64％（46／55）PeR技术检测肺炎支原体特异性DNA;④X光报告为多种形式。结论肺炎支原体（MP）感染是引起儿童慢性顽固性咳嗽的病因之一,对儿童慢性咳嗽,特别是顽固性咳嗽的诊治中应更加重视。     

Acetaminophen and acetylcysteine dose and duration: Past,present and future

Abstract

Acetylcysteine has been utilized successfully in the treatment of acetaminophen overdose since the 1970s. Although prospective trials as to efficacy and safety of acetylcysteine were conducted, there were no randomized controlled trials. This commentary addresses the reasons for this, and the background to choice of dose of acetylcysteine utilized in the oral and IV dosing regimens. Nomograms to predict possible hepatotoxicity based upon time of ingestion of acetaminophen were developed from a relatively arbitrary definition of toxicity as an aspartate aminotransferase/alanine aminotransferase (ALT/AST) greater than 1000 IU/L. While these have proved generally useful, patients still continue to develop hepatic damage after acetaminophen overdose, particularly if they present late after ingestion. The optimum management of these patients remains unclear, and one area of uncertainty is the dose and duration of acetylcysteine in various circumstances. This article discusses the issues that need to be elucidated to better target changes in acetylcysteine dose. The potential for measurements of other markers to improve treatment selection is the subject of further research.     

Physician and Nurse Practitioner Teamwork and Job Satisfaction: Gender and Profession

Designing interprofessional primary care teams composed of physicians and nurse practitioners (NPs) is a national priority. We assessed how profession and gender affect teamwork and job satisfaction among primary care physicians and NPs by using survey data from 186 physicians and 398 NPs practicing in New York State. Our regression models show profession (NP vs physician) moderates the associations of gender with teamwork and job satisfaction. Among NPs, men had higher job satisfaction than women. Among physicians, women had higher job satisfaction than men. Our results can benefit interprofessional primary care teams to optimize their professional and gender mix.