Improving the quality of child health services: participatory action by providers.

OBJECTIVE: To test a quality improvement approach called COPE (Client-Oriented, Provider-Efficient services), for use in strengthening health systems and supporting Integrated Management of Child Health (IMCI) efforts. DESIGN: Pre- and post-intervention observations of client/provider interactions, facility audits, staff and client surveys, and focus groups to evaluate differences between eight COPE intervention and eight matched non-intervention facilities after a 15-month intervention in 2001. SETTING: Primary care clinics in Guinea and Kenya. STUDY PARTICIPANTS: Health care providers and child caregivers. INTERVENTIONS: Over 15 months, the intervention supported four COPE exercises at each intervention site, supported supervisor training in quality management, and organized minimal training in topics selected by site staff as areas where training was needed. MAIN OUTCOME MEASURES: Differences in staff's and child caregiver's knowledge, attitudes, and practices; differences in the quality of services provided. RESULTS: On almost every quality indicator (over 65 indicators), whether reported by staff, observed by evaluators, or reported by clients, the intervention sites performed statistically significantly better than control sites. INTERVENTION: sites were cleaner and more pleasant, with more respect and information for clients, and more privacy. Staff had better personal communication skills, better diagnostic skills, and prescribing practices and gave better home care instructions to carers. Clients in intervention sites were more informed and more satisfied, and their children had better immunization coverage than those in control sites. CONCLUSION: COPE is a simple process, yet our study confirms that it can have a very dramatic effect on the quality of services. This study demonstrated how all areas of quality can be addressed by empowering health care providers to take action by using COPE. We suggest that COPE can complement Integrated Management of Childhood Illness (IMCI) training and can help to achieve better health for children.     

急性肛周脓肿手术方法的改进

目的:探讨、研究急性肛周脓肿一期根治新术式.方法:回顾分析 1996～ 2004年 123例急性肛周脓肿一期根治术式 改进后病人的临床资料.结果:所有病人均一次性治愈,无术后复发肛瘘及遗留肛门失禁.结论:采用该术式治疗急 性肛周脓肿,具有治愈率高、病人痛苦小、手术恢复快、费用低、并发症少等优点.     

枕下经颈-颈静脉突入路达颈静脉孔区的显微解剖研究

目的 研究一期切除颈静脉孔区复杂性肿瘤的微创手术人路。方法 选择经10％福尔马林固定成人头颈标本10具，显微镜下模拟枕下经颈一颈静脉突人路的手术操作，逐层显露颈静脉孔区，研究该区显微解剖特征及显露范围。结果 该人路直接沿乙状窦、颈内静脉的移行方向显露颈静脉孔区结构，其中后颅窝可经枕下显露，颞下窝藉寰椎与下颌升支间的自然间隙显露。通过切除颈静脉突和迷路下骨质分别自后、外、下和上方显露颈静脉孔。头侧直肌是界定颞下窝结构和枕下三角内结构的确切标志。后组颅神经，交感千和颈内动、静脉行于其前方，椎动脉寰椎上段及其周围的静脉丛行于其后方。结论 枕下经颈一颈静脉突人路可自多个方向充分显露颈静脉孔区结构，且可保护面神经、迷路、耳蜗和椎动脉等结构免受不必要的损伤。     

上颌骨外旋入路切除颅底及咽旁间隙肿瘤

目的：探讨颅底及咽旁间隙肿瘤切除的最佳手术入路。方法：2例咽旁间隙肿瘤、1例颅底肿瘤患者均采用上颌骨外旋入路，取Weber-Ferguson-Longmire切口，形成以咬肌为蒂的上颌骨肌皮瓣并外旋，充分暴露鼻咽部及咽旁间隙，直视下完整切除肿瘤。以颊部脂肪堵塞残留空腔，行上颌骨骨瓣复位。结果：3例术后切口愈合良好，颌面部无明显畸形及颌面功能障碍，其中1例术后行放疗。3例术后随访10个月～2年，肿瘤均无复发。结论：上颌骨外旋是切除颅底及咽旁间隙肿瘤的较佳手术入路，能充分暴露颅底及咽旁间隙、鼻咽部，在直视下完整分离切除肿瘤，手术安全，损伤小，术后功能恢复良好。     

单层斜口吻合加盖大网膜治疗贲门癌200例临床分析

目的 探讨贲门癌的手术治疗方案。方法 1999年6月至2003年10月本科手术治疗贲门癌200例．采用单层斜口吻合加盖大网膜，对术后并发症及生活质量进行评价。结果 200例均手术治愈。吻合口瘘1例．占0．5％；吻合狭窄2例，占1％。多数患者术后生活质量良好，少数患者术后进食量减少、进食后返流及腹泻，对症治疗后好转。结论 单层斜口吻合加盖大网膜是一种有效治疗贲门癌的手术方式。     

经腹腔镜先天性肥厚性幽门狭窄手术

目的 探讨小儿先天性肥厚性幽门狭窄腹腔镜微创手术操作要点及经验教训。方法 回顾性分析本组20例患儿全麻下经腹腔镜行幽门环肌切开术。结果 18例一次手术成功，1例术中中转开腹，1例3d后二次手术。全部病例随访2月，预后较好。结论 腹腔镜手术治疗先天性肥厚性幽门狭窄是腔镜技术在新生儿外科领域的成功运用，掌握操作要点，可推广使用。     

445例先天性尿道下裂的治疗

目的 探讨不同术式对445例不同类型先天性尿道下裂患儿的手术治疗效果。方法 回顾性分析我院1988年—2003年445例先天性尿道下裂病例资料，其中采用阴茎阴囊纵隔带蒂皮瓣尿道成型术311例，包皮内板带蒂皮瓣尿道成型术52例，包皮及阴茎阴囊联合皮瓣尿道成型术61例，膀胱粘膜代尿道术21例。每例均同时行耻骨上膀胱造瘘术。结果 治愈率90．6％，并发症为9．4％。其中尿道狭窄11例，尿瘘31例。尿道狭窄中膀胱粘膜法1例，包皮内板法2例，阴茎阴囊纵隔法5例，联合皮瓣法3例；尿瘘中膀胱粘膜法1例，包皮内板法3例，阴茎阴囊纵隔法24例，联合皮瓣法3例。结论 根据尿道下裂类型选择不同的术式 尿流改道，并严格遵守整形外科的原则是尿道下裂手术成功的关键。     

手术治疗中晚期胃癌126例报告

目的研究分析胃癌围手术期处理及并发症预防。方法本组126例,男84例,女42例,年龄34岁￣79岁,平均64岁,术前行特殊准备,纠正贫血、低蛋白血症,进行CRIS分级及FEV1测定。选择时机行胃空肠Roux-en-Y吻合手术治疗。结果临床治愈123人,死亡3人,并发症:切口感染8例,切口裂开6例,心肌梗死1例,十二指肠残端瘘1例,吻合口瘘2例,肺炎1例,并发症发生率15.0(%19/126)。结论①术前充分纠正贫血、低蛋白血症、水电解质紊乱,对心肺疾病者行CRIS分级评定和FEV1测定是保证手术成功的要点。②手术原则上行根治性切除,减少瘤负荷,以Roux-en-Y术式为佳。③术后输入端充分减压,输出端适时肠内营养,并严格心肺功能监测,合理应用抗生素,可望降低死亡率。