新型农村合作医疗支付制度研究

新农村合作医疗制度在运行中因医疗费用过快增长和基金被过度消耗而影响其健康运行,而支付制度是控制医疗费用增长的关键,支付制度的缺陷直接影响新农合健康运行。在国外行之有效的付费制度,在中国农村的实践中遭遇了严峻的挑战。文章在支付制度本身和政策、法律环境等实施环境方面分析缺陷产生的原因,借鉴美、德、日及巴西、泰国的农村医疗保险实施的成功经验,提出选择引入昏迷分级、DRGs、病人管理分组等辅助度量工具的按人/次门诊支付和按服务项目支付、有起付线和封顶线、固定自负比例相结合住院支付的混合型支付制度的建议,并在法律和政策上相应完善。     

三联麻醉法在混合痔手术中的应用

目的:评价丙泊酚、芬太尼静脉基础麻醉联合局麻即三联麻醉法在混合痔手术中的麻醉效果及安全性。方法:将60例混合痔患者随机分为联合组和对照组,每组30例,联合组病人麻醉方式采用丙泊酚、芬太尼做基础麻醉,辅以肛周局部神经阻滞麻醉;对照组单纯采用肛周局部神经阻滞麻醉。观察并记录术中病人HR、MBP、SpO2、手术肌松程度、患者满意度、术后不良反应和尿潴留情况。结果:两组患者基础心率无差异,术中10min、20min、手术结束时心率联合组慢于对照组,P<0.05;两组患者在SpO2、MBP方面差异无统计学意义,P>0.05。联合组的肌松满意度、患者满意度均优于对照组,P<0.05;两组在尿潴留、不良反应方面差异无统计学意义,P>0.05。结论:三联麻醉法安全性较好,麻醉效果理想,患者易于接受。     

Carboxymethylpachymaran enhances immunologic function of dendritic cells cultured in two kinds of hepatoma carcinoma cell line’s supernatant via nuclear factor κB/Rel pathway

Objective:To study the immunologic function of dendritic cells(DCs) cultured in two kinds of hepatoma cell line’s supernatant and the enhancing effects of carboxymethylpachymaran(CMP) on DCs.Methods:DCs were harvested after stimulation by granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin(IL)-4 from umbilical cord blood using density-gradient centrifugation method. Cultured supernatant of two hepatoma cell lines(HepG2 and HepG2.2.15) were collected for condition medium(CM) according to a volume ratio of supernatant to incomplete RPMI-1640 medium,which was 3:1.CMP was dissolved in incomplete RPMI-1640 medium.Experimental groups were divided according to the culture medium,either CM or with CMP in it.DCs subsets CD83,CD86,CD1a,and d-related human leukocyte antigens(HLA-DR) were analyzed by flow cytometry.The proliferation ability of allogeneic T cells in mixed lymphocyte reaction(MLR) stimulated by DCs was examined by 3-(4,5-dimethylthiazol-2-yl)-2,5- diphenyltetrazolium bromide(MTT) analysis.IL-12p70,interferon-γ(IFN-γ),and nuclear factor k B(NF- k B) were detected by enzyme-linked immunosorbent assay analysis.Results:The proliferation of lymphocytes and secreting level of IL-12 and expression of phenotype of DCs cultured in two kinds of CM were lower than those of normal group(P<0.01).Compared with the normal group,groups treated with CMP showed a higher expression level of DCs subsets,lymphocyte reproductive activity,as well as IL-12 and IFN-γsecretion levels.Groups treated with CMP also demonstrated higher levels of DCs phenotype expression and IL-12 and IFN-γsecretion in supernatant of MLR and higher lymphocyte reproductive activity compared with CM group(P<0.05).Compared with the normal group,the expression level of NF-k B in DCs nuclear was higher in CMP groups but lower in two CM groups(P<0.05).After CMP was added,the NF-κB expression levels of two CM groups were increased compared with levels before CMP was added(P<0.05).However,there was no significant difference between the two CM groups(P>0.05).Conclusions:Two kinds of hepatoma cell line’s supernatant can inhibit the immunologic function of DCs.This suppressive effect may be related to the inhibition of NF-κB/Rel pathway.CMP may up-regulate the DCs function by activating the NF-κB/Rel pathway.     

“局麻-PPH-门诊留观三日”模式治疗重度环状痔578例临床分析

为探讨“局麻-PPH-门诊留观三日”模式治疗重度环状痔的疗效及可行性,回顾分析578例局麻下行PPH治疗的患者资料。结果显示,本组全部治愈,平均手术时间25rain,平均门诊留观时间2．9d,局麻时感疼痛难忍者189例,术后发生尿潴留35例,术后近期发生创口活动性出血而再次进手术室止血3例,术后发生肛门创缘水肿38例,术后发生急性便秘20例,但无一例发生肛门失禁、肛门狭窄及肛周化脓性感染。结果表明,“局麻-PPH-门诊留观三日”模式治疗重度环状痔安全、有效、可行。     

PPH治疗出血性内痔128例临床观察

为探讨吻合器痔上黏膜环切术（PPH）治疗出皿性内痔的町行性,对128例出血性内痔行PPH。结果显示,128例患者手术顺利,手术时间30～45min,平均35min．住院时间4～7d．术后48h无疼痛,术后未见肛门有明显的出血;5例术后出现直肠刺激症状,肛门见异常。结果表明,PPH治疗出血性内痔疗效确切．并发症少,恢复快,值得临床推广。     

改良混合痔切除术的临床研究

为探讨改良混合痔切除术的临床疗效,本研究将40例重度混合痔患者随机分为两组,一组予改良混合痔切除术（治疗组）治疗,一组予传统外剥内扎术（对照组）治疗,对比分析两组患者疗效、术后并发症、创面愈合时间、药比、住院费用、住院时问及患者满意度。结果显示,两组疗效、创面愈合时间、药比及肛门狭窄和尿潴留方面差异均无统计学意义,P〉0．05;但在住院费用、住院时间、患者满意度及后遗皮赘、肛缘水肿、创面出血、术区疼痛方面差异有均统计学意义,P〈0．05,且治疗组优于对照组。结果表明,改良混合痔切除术治疗重度混合痔疗效确切,术后并发症少,不影响肛门功能和外观,患者满意度高,值得临床推广。     

个性化护理干预对混合痔手术患者术后疼痛的改善效果

目的分析个性化护理干预对混合痔手术患者术后疼痛的改善效果。方法选取2017年7月至2019年10月我院收治的100例混合痔手术患者作为研究对象,随机将其分为对照组和观察组,各50例。对照组给予常规护理干预,观察组在对照组基础上给予个性化护理干预。比较两组的护理满意度、疼痛程度、睡眠质量及心理状态。结果观察组患者的护理满意度明显高于对照组(P<0.05)。术后6、12、24 h,两组的VAS评分呈依次降低的趋势(P<0.05);观察组术后6、12、24 h的VAS评分明显低于对照组(P<0.05)。护理后,两组PSQI评分均降低,且观察组明显低于对照组(P<0.05)。护理后,两组SCL-90各项评分均降低,且观察组明显低于对照组(P<0.05)。结论个体化护理干预能够有效缓解患者的术后疼痛,改善患者的负性情绪,提高患者睡眠质量和护理满意度,值得临床推广应用。     

Gas Exchange and Ventilatory Efficiency During Exercise in Pulmonary Vascular Diseases

Background and ObjectiveVentilatory inefficiency (high V′_E/V′CO₂) and resting hypocapnia are common in pulmonary vascular disease and are associated with poor prognosis. Low resting PaCO₂ suggests increased chemosensitivity or an altered PaCO₂ set-point. We aimed to determine the relationships between exercise gas exchange variables reflecting the PaCO₂ set-point, exercise capacity, hemodynamics and V′_E/V′CO₂.MethodsPulmonary arterial hypertension (n = 34), chronic thromboembolic pulmonary hypertension (CTEPH, n = 19) and pulmonary veno-occlusive disease (PVOD, n = 6) patients underwent rest and peak exercise arterial blood gas measurements during cardiopulmonary exercise testing. Patients were grouped according to resting PaCO₂: hypocapnic (PaCO₂ ≤34 mmHg) or normocapnic (PaCO₂ 35–45 mmHg). The PaCO₂ set-point was estimated by the maximal value of end-tidal PCO₂ (maximal P_ETCO₂) between the anaerobic threshold and respiratory compensation point.ResultsThe hypocapnic group (n = 39) had lower resting cardiac index (3.1 ±0.8 vs. 3.7 ±0.7 L/min/m², p < 0.01), lower peak V′O₂ (15.8 ± 3.5 vs. 20.7 ± 4.3 mL/kg/min, p < 0.01), and higher V′_E/V′CO₂ slope (60.6 ± 17.6 vs. 38.2 ± 8.0, p < 0.01). At peak exercise, hypocapic patients had lower PaO₂, higher V_D/V_T and higher P_(a-ET)CO₂. Maximal P_ETCO₂ (r = 0.59) and V_D/V_T (r = −0.59) were more related to cardiac index than PaO₂ or PaCO₂ at rest or peak exercise. Maximal P_ETCO₂ was the strongest correlate of V′_E/V′CO₂ slope (r = −0.86), peak V′O₂ (r = 0.64) and peak work rate (r = 0.49).ConclusionsResting hypocapnia is associated with worse cardiac function, more ventilatory inefficiency and reduced exercise capacity. This could be explained by elevated chemosensitivity and lower PaCO₂ set-point. Maximal P_ETCO₂ may be a useful non-invasive marker of PaCO₂ setpoint and disease severity even with submaximal effort.     

Parsing the antidepressant effects of non-invasive brain stimulation and pharmacotherapy: A symptom clustering approach on ELECT-TDCS

BackgroundTranscranial direct current stimulation (tDCS) presents small antidepressant efficacy at group level and considerable inter-individual variability of response. Its heterogeneous effects bring the need to investigate whether specific groups of patients submitted to tDCS could present comparable or larger improvement compared to pharmacotherapy. Aggregate measurements might be insufficient to address its effects.Objective/Hypothesis: To determine the efficacy of tDCS, compared to pharmacotherapy and placebo, in depressive symptom clusters.MethodsData from ELECT-TDCS (Escitalopram versus Electrical Direct-Current Therapy for Treating Depression Clinical Study, ClinicalTrials.gov, NCT01894815), in which antidepressant-free, depressed patients were randomized to receive 22 bifrontal tDCS (2 mA, 30 min) sessions (n = 94), escitalopram 20 mg/day (n = 91), or placebo (n = 60) over 10 weeks. Agglomerative hierarchical clustering identified “sleep/insomnia”, “core depressive”, “guilt/anxiety”, and “atypical” clusters that were the dependent measure. Trajectories were estimated using linear mixed regression models. Effect sizes are expressed in raw HAM-D units. P-values were adjusted for multiple comparisons.ResultsFor core depressive symptoms, escitalopram was superior to tDCS (ES = −0.56; CI_95% = -0.94 to −0.17, p = .009), which was superior to placebo (ES = 0.49; CI_95% = 0.06 to 0.92, p = .042). TDCS but not escitalopram was superior to placebo in sleep/insomnia symptoms (ES = 0.87; CI_95% = 0.22 to 1.52, p = .015). Escitalopram but not tDCS was superior to placebo in guilt/anxiety symptoms (ES = 1.66; CI_95% = 0.58 to 2.75, p = .006). No active intervention was superior to placebo for atypical symptoms.ConclusionsPharmacotherapy and non-invasive brain stimulation produce distinct effects in depressive symptoms. TDCS or escitalopram could be chosen according to specific clusters of symptoms for a bigger response.Trial registrationClinicalTrials.gov, NCT01894815