回顾分析40份封存病案看病案质量的控制

目的提高病案质量管理水平,增强医务人员的法律意识及自我保护意识。方法对2002年-2008年我院因医疗纠纷被封存的40份病案进行分析。结果发生医疗纠纷较多的临床科室有骨外科、妇产科和颅脑外科;产生医疗纠纷的原因以医患沟通不足和期望值过高多见;封存病案的质量问题以字体潦草、涂改或错别字、漏填项目等多见。结论医疗行业是高风险的行业尤其是骨外科、妇产科和颅脑外科等I临床科室。医务人员在执业过程中,不但要提高自己的业务能力,也要做好医患沟通、按规定书写病历,才能避免医疗纠纷的发生。     

医疗纠纷大样本研究

近年医疗纠纷引发伤害医护人员事件时有发生,引起医疗行业内外广泛关注。本期特别策划通过对北京5445件非诉讼医疗纠纷、北京2013年诉讼医疗纠纷案件、500件司法鉴定医疗纠纷大样本研究,同时介绍了英国、德国非诉讼医疗纠纷情况,以期为医院管理人员和临床医护人员合理认识我国医疗纠纷发生状况,针对性采取预防医疗风险的措施,     

北京市2013年诉讼医疗纠纷大样本研究

北京市法院2013年一审受理的医疗纠纷案件为1152件,一审审结的医疗纠纷案件共1044件。通过对案件的分析,发现当前北京市医疗纠纷呈快速增长趋势,三级医院和二级医院更容易发生医疗纠纷。医疗纠纷高发科室相对恒定,妇产科、骨科、普外科、急诊科均为医疗纠纷高发科室。在医疗纠纷诉讼案件中,患方获赔几率为71.21%,医疗纠纷约46%进行医疗责任鉴定。     

运用法律手段 维护自身权益

有关资料显示，近年来我国医患纠纷呈上升趋势，其结果表明：医院越大，收治的疑难重症病人越多，产生纠纷也越多，索赔金额也越高。发生医疗纠纷后，通过法律途径解决医疗纠纷是少数，大多数病人和家属采取较为过激的方式要求索赔。军队医院作为社会的一个载体，同样面临着这样的局面。对此，军队医院在对外有偿服务中，出现医疗纠纷，是继续采取“忍、让、赔”的高姿态，还是拿起法律之剑，公正地处理双方的权利、义务和责任。我们医院经过几年的实践探索，总结了一套既适合当今社会保护措施，又保护了军队利益不受损害的方案，树立了依法办事新概念。从而，真正实现了军队医院社会效益和经济效益的双丰收。     

内蒙古某三级甲等医院医疗纠纷原因探析

目的：论述医疗纠纷在医院的专业分布、形成的主要原因以及解决纠纷中发现的问题,为医院的医疗工作营造良好的环境。方法：通过对内蒙古某三级甲等医院在2004年1月至2007年12月发生的68例医疗纠纷案例进行分析,比较发生医疗纠纷的医院因素、患者因素、社会因素等因素的构成比分布。结果：68例医疗纠纷科室分布居前三位的分别是：外科、妇产科和骨科,外科发生26例,占38.2%;妇产科发生15例,占22.1%;骨科发生9例,占13.2%;医疗纠纷发生较少的是医技科室。在引发纠纷的因素分析中,医院方面主要以诊疗不规范、服务态度为主,患者方面主要与缺乏医疗知识有关,社会方面主要以媒体过度炒作为主。结论：为避免医疗纠纷,应从医院、患者、社会三方面开展工作,将医院的手术科室作为工作的重点。     

乡村医疗纠纷日渐凸显

近年来,以诉讼方式解决医疗纠纷的案件增加,涉及乡村医生的医疗损害赔偿案增加尤为明显,并且患方索赔金额也越来越高。以四川省泸县法院为例,现在每年审理医疗损害赔偿纠纷案件50多件,其中起诉乡村医生的医疗纠纷案已占20％左右。乡村医疗纠纷诉讼案增多的原因如下。     

论医患沟通在妇产科临床工作中的重要性

目的：为了降低医院妇产科医疗纠纷事件发生的频率，妇产科具有十分特别的性质，同时在妇产科也存在许多的问题，这些问题导致了医疗纠纷事件的发生。方法：在妇产科临床工作中，注重医生和患者之间的沟通，医生尽可能用和蔼的语言和态度同患者进行交流，可以降低医患之间的矛盾发生。结果：实际证明良好的医生和患者之间的关系可以有效的避免医疗纠纷事件的发生，医患之间的交流沟通，和谐稳定和医患关系可以十分有效的缓解医患矛盾。本文主要通过对妇产科临床工作中的医患沟通现状进行研究，分析出改善医患关系的措施以及医患沟通的重要性。     

产科护理纠纷发生的原因及防范

妇产科是医疗纠纷的高发科室。通过分析妇产科医疗纠纷的发生原因,提高对妇产科医疗纠纷的认识,提出防止发生纠纷的策略,达到减少或避免纠纷发生的目的。     

医患关系:从对抗到和谐

中国医师协会2002年对北京、四川等五地区116家医院、623位医师进行的医患纠纷调查显示:从2000年到2002年,平均每家医院发生医疗纠纷66起,发生打砸医院事件5.42件,打伤医师5人:单起医疗纠纷最高赔付金额为92万元,平均每起医疗纠纷赔付金额为10.81万元。     

妇产科医疗纠纷原因分析及探讨

医疗纠纷是指病人或其家属认为医疗机构和医务人员实施了错误的诊断、治痕操作导致病人出现了不良后果而与医疗机构及医务人员发生争议。妇产科由于工作对象和工作性质的特殊陛，医疗纠纷发生率在国内各地、各医院和各科室中均居前位。笔者统计了2003年5月1日-2008年6月30日医院受理的妇产科医疗纠纷投诉27起，占全院120起的22．7％，居全院首位，怎样防范医疗纠纷值得我们探讨。     

Value of D-Dimers in patients with acute aortic dissection

Objective: To evaluatel the value of D-dimers in patients with acute aortic dissection (AAD). Methods: This study consisted of 16 patients with AAD and 27 non-AAD patients. Serum D-dimets were measured by Sta-Liatest D-DI immunoturbidimetric assay. Results: D-dimer level was higher (P ＜ 0.001) in patients with AAD(7.91 ± 5.52 μg/ml) than that in non- AAD group(1.57±1.24 μg/ml). D-dimer was positive (＞0.4 μg/ml) in all patients with AAD and in 10 control group patients (37%). Among patients with acute AAD, D-dimers tended to be higher in Stanford A than in Stanford B (8.67 ± 4.31 μg/ml vs. 3.24±1.27 μg/ml, P ＜0.01). D-dimer values tended to be higher in more extended disease(3.84 ± 1.65 μg/ml, 8.57 ± 3.58 μg/ml and 11.87 ± 5.69 μg/ml in thoracic aorta, thoracic and abdominal aorta, thoracic and abdominal aorta and iliacal arteries, respectively, P ＜ 0.05 for both 8.57 ± 3.58 and 11.87 ± 5.69 vs. 3.84 ± 1.65 ). Including the control group into the analysis, we found a sensitivity of 100%, a negative predictive value of 100%, and a specificity of 66% and a positive predictive value of 64% for D-dimer in diagnosis of AAD in our patients with suspected AAD. Conclusion: D-dimer was elevated in patients with AAD. A negative D-dimer test result could be useful in excluding AAD.     

Research of combined liver-kidney transplantation model in rats

Objective： To set up a simple and reliable rat model of combined liver-kidney transplantation. Methods： SD rats served as both donors and recipients. 4℃ sodium lactate Ringer＇s was infused from portal veins to donated livers,and from abdominal aorta to donated kidneys, respectively. Anastomosis of the portal vein and the inferior vena cava （IVC） inferior to the right kidney between the graft and the recipient was performed by a double cuff method, then the superior hepatic vena cava with suture. A patch of donated renal artery was anastomosed to the recipient abdominal aorta. The urethra and bile duct were reconstructed with a simple inside bracket. Results： Among 65 cases of combined liver-kidney transplantation, the success rate in the late 40 cases was 77.5%. The function of the grafted liver and kidney remained normal. Conclusion： This rat model of combined liver-kidney transplantation can be established in common laboratory conditions with high success rate and meet the needs of renal transplantation experiment.     

BLOOD PRESSURE CHANGE WITH AGE IN SALT-SENSITIVE TEENAGERS

Objective To observe blood pressure change with age in salt-sensitive teenagers whose salt sensitivity were determined by repeated testing.Methods Salt sensitivity was determined through intravenous infusion of normal saline combined with volume-depletion by oral diuretic furosemide in 55 teenagers. After five years, salt sensitivity was re-examined and subject blood pressure was followed up. Blood pressure changes in salt-sensitive teenagers were compared to that of non-salt sensitive teenagers over five years.Results After 5 years, the repetition rate of salt sensitivity determined by intravenous saline loading is 92.7%. In teenagers with salt sensitivity on the baseline, both the systolic blood pressure increments and increment rates were much higher than non-salt sensitive teenagers (12.7±12.1 mmHg vs. 2.8±5.2 mmHg, P＜ 0.01; 12.2%± 12.0% vs. 2.5% ±4.4%, P＜ 0.001,respectively). There was a similar trend for diastolic blood pressure (8.4 ± 6.4 mmHg vs. 3.7 ± 6.4 mmHg, P = 0.052; 13.2% ±10.6 % vs. 6.8%± 10.1%, P = 0.053, respectively).Conclusions Salt sensitivity determined by intravenous saline loading showed good reproducibility. Blood pressure increments with age were much higher in salt-sensitive teenagers than non-salt sensitive teenagers, especially in terms of systolic blood pressure.     

安心颗粒对急诊经皮冠状动脉介入术后生活质量影响的研究

目的：评价使用安心颗粒对急诊经皮冠状动脉介入术（PPCI）术后生活质量的影响.方法：将160例接受PPCI的急性ST段抬高型心肌梗死患者随机分为安心颗粒组（术前顿服安心颗粒8.8g,术后安心颗粒4.4 g/次,每日2次）和对照组（仅接受基础药物治疗）.所有患者均服用阿司匹林、氯吡格雷和阿托伐他汀.分别在入院时、出院前1d、出院后180 d时,应用心肌梗死多维度量表（MIDAS）、中文版SF-36评价量表对患者生活质量评分.并观察术后30 d以内的出血并发症、血小板减少症发生情况.结果：入院时和出院前1d,两组患者的心肌梗死MIDAS、SF-36量表评分比较无差异（P＞0.05）;出院后180 d时,与对照组比较,安心颗粒组MIDAS、SF-36评分明显减低（P＜0.05）;组内与入院时比较,两组出院前1d、出院后180 d时,MIDAS、SF-36评分均降低（P＜0.05）.两组患者在随访期间均无大量出血、少量出血、重度和极重度血小板减少症发生,安心颗粒组有4例、对照组有7例发生不明显出血（P＞0.05）.两组发生轻度血小板减少症的患者数比较无差异（P＞0.05）.结论：PPCI使用安心颗粒,能改善急性ST段抬高型心肌梗死患者的生活质量,且不增加出血风险.     

The comparative studies of the influences of Urapidil and Nicardipine on sino-atrial node function, atrio-ventricular node function and hemodynamics

Objective:To investigate the influences of urapidil and nicardipine on rabbit sinus function,atrio-ventricular node function and hemodynamics.Methods:Thirty-two Angora's rabbits were selected and randomly divided into four groups.U1 group:urapidil 0.25 mg/kg;U2 group:urapidil 0.5 mg/kg;N1 group:nicardipine 10 μg/kg;N2 group:nicardipine 20 μg/kg.All these medicine were administrated within 30 seconds.Measurements were taken before and after the administration of urapidil or nicardipine for the following data:mean blood pressure(MAP),heart rate(HR),sino-atrial conduction time(SACT),maximal sinoatrial recovery time(SNRTmax)corrected sinus node recovery time(CSNRT),index of sinus node recovery time(SNRTI),Wenckebach A-V conduction frequency (WB),and P-R interval.Results:Significant MAP and HR changes were identified in all of the four groups before and after administration of both urapidil and nicardipine.No significant changes could be found in the rest of the parameters.Intergroup analysis showed that SACT and CSNRT of N1 and N2 groups were shorter than those of the U2 group(P＜0.01);the MAP decreased(P＜0.01)and the HR increased drastically(P＜0.01).Conclusions:Neither urapidil(0.25 mg/kg,0.5 mg/kg)nor nicardipine(10μg/kg,20μg/kg)has any significant influence on rabbit sinus function or rabbit atrio-ventricular node function.Nicardipine could be a better choice than urapidil for parafunctional sinus node patients.     

Expression of OPGmRNA and ODFmRNA in the patients of hip fracture due to osteoporosis

Objective：To investigate the gene expression of osteoprotegerin（OPG） and osteoclast differentiation factor（ODF） in the bone tissue of patients with hip fracture due to osteoporosis. Methods：OPGmRNA and ODFmRNA in the bone tissue in 50 cases of osteoporosis sufferers（over 50 years old） with hip fracture（Observer Group） and 30 cases of hip facture sufferers with no osteoporosis（Control group） were analyzed with the Semi-Quantitative RT-PCR method. Results：The mRNA expressed of ODF, OPG were both high in the patients with hip fracture. In the control group, the expression of OPG mRNA was observed, while the expression of ODF mRNA was very slight. Conclusion：Aged patients contained all signals including OPG, ODF that are essential for inducing osteoclastogenesis and promoting bone resorption.     

The clinicopathological and immuohistochemical analysis of solid-pseudopapillary tumor of the pancreas： report of 9 cases

Objective：To investigate the clinical features, pathological characteristics and immunophenotype of solid-pseudopapillary tumor of the pancreas（SPTP）. Methods：Nine surgically treated cases of SPTP were retrospectively reviewed. Hematoxylin and Eosin（HE） staining and immunohistochemical staining were used to analyze all cases, and the general clinical data was collected. Results：Six patients were asymptomatic except for a palpable mass. Two patients complained of vague-epigastric pain. One patient appeared jaundice. The tumor was encapsulated and solid tissues alternately with cystic tissues. Histologically, the histological structure of solid portion was pseudopapillary with a fibrovascular core. Tumor cells were uniform and medium-sized which were arranged in sheets ets or nests or pseudopapillary patterns. Immunohistochemical studies demonstrated that SPTP proved positive in vimentin（9/9 cases）, AAT（9/9 cases）, NSE（9/9 cases）, ACT（7/9 cases）, CK20（2/9 cases）, CgA（1/9 cases）, S-100（3/gcases）, PR（4/gcases）, Syn（3/9 cases） and CD56（5/9cases）, negative in CEA and ER. Conclusion：SPTP is a tumor predominantly occurring in young women frequently without special symptoms. This tumor has various characteristical histological patterns with different immunophenotype.     

Dynamic Changes in Serum Estradiol and Progesterone levels in Patients of Premenstrual Syndrome with Adverse Flow of Liver-qi

Objective:To probe into the influence of changes of ovarian hormones on the pathogenesis of the specific sub-type premenstrual syndrome(PMS)and reveal partial microcosmic mechanisms of adverse flow of liver-qi.Methods:Estradiol(E2)and progesterone(P)levels in serum were determined at different phases of menstrual cycle by radioimmunoassay.Results:In the group of PMS with adverse flow of liver-qi.the secretive peak value Of E2 and P at the follicular phase significantly decreased,and the secretive peak value at the luteal phase did not come into being.Conclusions:Low E2 and P secretive peak at the follicular phase and absence of secretive peak at the luteal phase is one of the microcosmic mechanisms of PMS with adverse flow of liver-qi.One of the pathophysiologic mechanisms of specific sub-type PMS is probably the continuous low level of E2and P.     

Real-time Three-dimensional Echocardiography in Assessment of Left Ventricular and Right Ventricular Volumes

Real-time three-dimensional echocardiography (RT3DE)is a new ultrasound technique that enables dynamic threedimensional visualization and quantification of the heart in real time. Investigation of feasibility and methodology of RT3DE in determining left ventricular (LV) and right ventricular (RV) volumes, RT3DE was performed in 35 normal adults using Philips SONOS 7500 system with a 2-4 MHz matrix array transducer. The 60°×60° "pyramid" volume database was obtained and analyzed on a TomTec echo workstation. Both LV and RV volumes were calculated with four 3DE methods (i.e. apical 2, 4, 8, and 16-plane) through manually tracing ventricular endocardial borders in end diastole and end systole. Stroke volumes were then calculated. LV volume was also measured by 2DE Simpson's rule using GE VIVID 7 ultrasound machine.     

SCREENING FOR A 21-CHROMOSOME ABNORMALITY IN PREIMPLANTED EMBRYOS OF ELDERLY WOMEN

Increasing maternal age is the only etiological factor unequivocally linked to Down's syndrome in humans. The occurrence rate of newborns with Down's syndrome is about 1/220 in women over 35 years old. However, the occurrence rate in embryos fertilized in vitro, of the elder woman is unclear. Using FISH we screened the number of chromosome 21 in preimplanted embryos of 5 elderly women (average age, 38.4 years) to study the feasibility and necessity of screening trisomy 21 in embryos in patients over 35 years old at the in vitro fertilization (IVF) center.