硬化大脑中动脉及豆纹支管壁弹性结构改变及意义

本文用光镜、电镜观察了正常和硬化大脑中动脉及其豆纹支管壁弹性结构的形态。结果显示，硬化大脑中动脉内弹力膜断裂，且以外层断裂明显，波纹状外观消失；而豆纹支内弹力膜结构完整，波纹状外观清晰可见。平滑肌萎缩、变性，胶原纤维增多。提示硬化大脑中动脉破裂出血是内弹力膜破坏，平滑肌萎缩，管壁脆性增加所致；而豆纹动脉是根部存在＂中膜缺损＂，此外受血流冲击引起破裂的可能性大。     

Surgical Treatment for Women with Breast Cancer in Relation to Socioeconomic and Insurance Status

Based on the National Breast Cancer Audit of the Royal Australasian College of Surgeons an association between patient age and type of breast cancer surgery received has already been demonstrated. The aim of this study is to assess the patterns of surgical treatment for women with early breast cancer in relation to socioeconomic and insurance status. Data on patient demographics, diagnostic, and surgical procedures and cancer characteristics in 115,872 episodes of early breast cancer reported to the National Breast Cancer Audit between 1998 and 2012 is used for this study. Tumor size, histologic grade, number of tumors, lymph node positivity, and lymphovascular invasion are the major prognostic factors adjusted for. Reconstruction following mastectomy is the most likely surgical procedure for the higher socioeconomic and privately insured patients. Mastectomy alone is the most likely surgical procedure for the lower socioeconomic and for public patients. No surgery is the most likely surgical outcome for the lower socioeconomic and the least likely for the higher socioeconomic population. Open biopsy is the most likely diagnostic procedure for the lower socioeconomic and fine needle aspiration for the higher socioeconomic population. Socioeconomic and insurance status, are both independently associated with the types of treatment and diagnostic procedure for women with breast cancer. Opportunities present to investigate an association of these factors with morbidity and survival outcomes.     

The Brazilian Founder Mutation TP53 p.R337H is Uncommon in Portuguese Women Diagnosed with Breast Cancer

Since the first studies reporting the TP53 p.R337H mutation as founder mutation in Southern and Southeastern Brazil, there has been controversy on its origin. Preliminary analysis of a small subset of Brazilian mutation carriers revealed that the haplotype incided on a Caucasian background. The vast majority of carriers identified today reside in Brazil or, if identified in other countries, are Brazilian immigrants. To our knowledge, the only two exceptions of carriers without a recognizable link with Brazil are two European families, from Portugal and Germany. Haplotype analysis in the Portuguese family revealed the same haplotype identified in Brazilian individuals, but in the German family, a distinct haplotype was found. Knowing that a significant proportion of women with breast cancer (BC) in Southern Brazil are p.R337H carriers, we analyzed p.R337H in a Portuguese cohort of women diagnosed with this disease. Median age at diagnosis among the first 573 patients tested was 60 years and 100 (17.4%) patients had been diagnosed at or under the age of 45 years. Mutation screening failed to identify the mutation in the 573 patients tested. These results are in contrast with the mutation frequency observed in a study including 815 BC‐affected women from Brazil, in which carrier frequencies of 12.1 and 5.1% in pre‐ and postmenopausal women were observed, respectively. These findings suggest that the Brazilian founder mutation p.R337H, the most frequent germline TP53 mutation reported to date, is not a common germline alteration in Portuguese women diagnosed with BC.     

Changes, challenges and choices for the primary health care workforce: looking to the future

AIMS: The main aim of this paper is to draw attention to problems facing the primary health care workforce in terms of demand for treatment of minor illness over the next two decades. These predictions have implications for the community nursing workforce in particular and the flexibility of primary health care teams in general. BACKGROUND: Care delivered in the primary care sector influences, and is influenced by, the characteristics of the health care workforce. These characteristics fall into two main groups: firstly, the shape of the present medical and nursing workforce and manpower trends; and secondly, the changes in doctors' and nurses' workloads. DESIGN: This paper draws on two studies, both commissioned by the Department of Health; the first study focusing on skill mix and delegation in primary health care teams and the second addressing the implications of skill mix for medical workforce scenarios in the changing policy environment. FINDINGS: From the first study, general practitioners across ten general practices were prepared to delegate at least one topic from over a third of 836 consultations and a further 17% of entire consultations. This potential delegation fell mainly to practice nurses and nurse practitioners. The second study used data extracted from the National Morbidity Surveys of 1981 and 1991 predicting that minor consultations are set to increase by 11 million from the 1990s to 2020--a minimal estimate. The authors argue that many of these extra predicted consultations will find their way onto practice nurses' and nurse practitioners' caseloads. CONCLUSIONS: Workforce issues and questions of professional roles and boundaries, in the context of the "greying" community nursing workforce, demand solutions if patient/client demand is to be met over the next two decades.     

The mechanisms and evidence of efficacy of electrical stimulation for healing of pressure ulcer: A systematic review

The objective of this article is to provide a systematic review of the efficacy of electrical stimulation in healing pressure ulcer and to review its mechanism of action. The Cochrane Library, PubMed, CINAHL, Medline, EMBASE, and NHS EED were searched for relevant interventional studies including randomized controlled trials (RCTs) and observational studies. A best‐evidence synthesis was performed to summarize the results of the included studies. A total of seven RCTs and two observational studies met the inclusion criteria. Moderate level of evidence of efficacy with low risk of bias was shown in all seven RCTs. Although some studies have used continuous direct current, most other investigators opted to use high‐voltage pulsed current to minimize the risk of skin burn and to achieve greater current penetration. Overall, the incidence of adverse effects was very low. Two studies that assessed the economic impacts of electrical stimulation revealed substantial health care cost savings. The mechanisms through which electrical stimulation exerts a positive effect on pressure ulcer healing are reasonably well established. Clinical trials have revealed a moderate level of evidence to support its use as an ancillary treatment modality for healing pressure ulcer. Recommendations regarding the optimal electrical stimulation parameters and dosage of use are provided. Further studies to investigate potential barriers that may impede widespread use in different clinical settings are needed.