推动医疗改革应制定分区医疗系统战略

医疗改革是一个世界性难题，各国在医疗改革中都会遇到各自相关的问题。改革艰巨，但并不是不可能完成，本文作者认为，通过关注以分区的方式提供医疗服务可以让医疗改革取得实效。本文从划定分区边界的方式出发，介绍了制定分区医疗战略的五个步骤，并讨论了各医疗系统成功实施各自战略所需采取的措施，这也可以为我国正在推行的医疗改革提供一定的借鉴和参考。     

全腹膜外补片植入术中补片不固定的实验研究

目的评价全腹膜外补片植入术中补片不固定的安全性和有效性。方法将50只SD大鼠建立疝缺损(3cm2)模型,按随机数字表分为2组,使用聚丙烯补片(12 cm2)采用腹膜外补片植入术进行修复。甲组为补片固定组,乙组为补片不固定组。大鼠于术后不同时间分批处死,记录补片的挛缩度、腹壁抗张强度以及组织细胞学变化。结果所有大鼠术后腹腔均无粘连。2组大鼠在术后7 d、14 d、30 d、60 d和90 d补片的挛缩度分别为6.7%±1.3%vs 7.3%±1.5%、12.3%±1.3%vs 12.4%±1.6%、14.0%±2.0%vs 14.5%±1.3%、17.4%±2.1%vs 18.4%±1.5%和18.9%±2.2%vs19.5%±2.6%(P>0.05);2组大鼠的腹壁抗张强度分别为(288.4±8.4)mm Hg vs(286.6±10.2)mm Hg、(300.4±11.2)mm Hg vs(298.8±11.4)mm Hg、(305.0±11.7)mm Hg vs(303.3±16.1)mm Hg、(309.0±10.8)mm Hg vs(307.6±8.9)mm Hg和(311.8±9.8)mm Hg vs(310.0±8.6)mm Hg(P>0.05);2组大鼠的组织细胞学变化一致。结论当补片面积是大鼠疝缺损的4倍以上时,不固定的腹膜外补片植入术是安全有效的。     

In vitro effects of detergent sclerosants on coagulation, platelets and microparticles.

OBJECTIVES: To investigate the in vitro effects of Sodium Tetradecyl Sulphate (STS) and Polidocanol (POL) on clotting tests, clotting factors, platelets and microparticles. MATERIALS AND METHODS: Platelet rich (PRP) and platelet poor (PPP) plasmas were incubated with varying concentrations of STS and POL. Clotting tests, platelet/plasma turbidity, and microparticle studies were performed. Specimens were mixed with individual factor deficient plasmas and clotting factor activities were studied. RESULTS: STS at high concentrations (>0.3%) destroyed platelets, microparticles and the clotting factors V, VII and X. It prolonged all clotting tests including prothrombin time (PT), activated partial thromboplastin time (APTT), non-activated partial thromboplastin time (NAPTT), thrombin time (TT), factor Xa clotting time (XACT) and surface activated clotting time (SACT). Higher concentrations of POL were required to achieve some anticoagulant activity. Low sclerosant concentrations shortened XACT and SACT, and induced release of procoagulant platelet derived microparticles. Increased exposure time resulted in increased procoagulant activity. STS at concentrations higher than 0.5% precipitated a complex containing apolipoprotein b and fibrinogen. CONCLUSIONS: Detergent sclerosants affect the clotting mechanism by interfering with clotting factor activities, procoagulant phospholipids and platelet derived microparticles. STS has more anticoagulant activity than POL in high concentrations. Low concentration sclerosants demonstrate procoagulant activity.     

《桐君采药录》的著者"桐君"

本文详细介绍了《桐君采药录》的著者桐君。鉴于桐君所处的时代已不可考,故出现4种异说:神农时代说、黄帝时代说、唐光时代说、上古时代说。并对后世采取多种方式缅怀桐君的情况作了全面的考证。     

性倒错：大丈夫变娇娇娇娘

“你太不懂女人了！”每次吵架妻子都会甩给他这句话，这让他产生了破解女人密码的强烈愿望。[编者按]     

Treatment of intervention sites of malignant pleural mesothelioma with radiotherapy: a Dutch-Belgian survey.

A survey was performed on the radiotherapy practice of malignant pleural mesothelioma in The Netherlands and Belgium in 2002. Thirty-eight out of 47 centres (81%) responded. Prophylactic radiotherapy to intervention sites is given by 32/38 (84%) centres, with all centres offering palliative radiation. For both prophylactic and palliative indications, all centres use hypo-fractionated schedules. The present study shows that in the radiotherapy community in The Netherlands and in Belgium, a de facto consensus exists that both prophylactic and symptomatic radiotherapy to intervention sites of malignant pleural mesothelioma are effective and that hypo-fractionated schedules should be used.     

Presentation and outcome of Marfan's syndrome patients with dissection and thoraco-abdominal aortic aneurysm.

BACKGROUND: In Marfan's syndrome, there is a paucity of data regarding intervention criteria for surgery of the dissected thoraco-abdominal aorta. METHODS: A retrospective analysis of 22 Marfan's patients with distal aortic dissection managed between September 1999 and April 2006 was performed. Serial diameters and linear expansion rates were calculated from imaging studies and the outcome of intervention was analysed. RESULTS: There were 14/22 male patients (median age 38 years), and 18 had prior aortic surgery. Surgery was recommended in 20 patients and undertaken in 19 (1 died prior to operation). Of the operated patients, 2 presented with rupture, 2 with airway obstruction, 1 with intermittent paraplegia and 14 underwent planned surgery for increased expansion rate or pain. All patients had residual type A or chronic type B dissection. The median aortic dimension at surgery was 6.7 cm (interquartile range (IQR) 5.5-8.2). The preoperative mean expansion rate increased from 0.5 cm/year to 1.7 cm/year (p<0.001), prior to operation. Fifteen patients underwent Crawford Extent II, two underwent Extent I and two underwent Extent III repair. Profound hypothermia and CSF drainage was used in 16 and 18 patients, respectively. There was no early mortality, paraplegia or renal failure. At a median postoperative follow-up of 56 months (range 6-86), the survival of the operated cohort was 90%. CONCLUSIONS: Thoraco-abdominal aortic aneurysm repair in Marfan's syndrome can be performed with good outcomes. Intervention should be based on size or accelerated expansion. Any role of endovascular management needs careful consideration.     

后腹腔镜治疗肾上腺肿瘤35例临床分析

目的总结后腹腔镜技术治疗肾上腺肿瘤的临床经验.方法采用后腹腔镜切除肾上腺肿瘤35例,男12例,女23例.年龄25岁～72岁,平均49.8岁.左侧15例,右侧20例.其中嗜铬细胞瘤5例,原发性醛固酮增多症10,柯兴氏病2例,神经节细胞瘤2例,无功能性腺瘤16例.腰部取3个套管针穿刺入路,用自制的水囊扩张器扩张后腹腔,用超声刀将肿瘤切除.结果 35例手术均成功,无中转开放手术病例.术中出血量10～500 ml,平均74 ml.病人均未输血.手术时间45～200 min,平均90 min.结论后腹腔镜手术切除肾上腺肿瘤手术效果确切,手术时间短,术中出血少,损伤小,术后恢复快,可以替代绝大多数肾上腺肿瘤开放手术.