高端医疗服务发展的国际经验与启示

高端医疗服务业是健康服务业发展的关键领域,但由于公立医院特需服务不断扩张、社会办医政策存"玻璃门"等原因,我国高端医疗服务业的发展尚处于初期阶段。事实上,高端医疗服务业在部分国家(特别是发达国家)已经初具规模,并在发展基础、运营模式、保障体系等方面积累了比较丰富的经验。本研究介绍了英国、美国、德国、新加坡、澳大利亚和印度发展高端医疗服务业的经验:建立国家安全网医院起兜底作用,实行分层定价和差异化补贴政策,借助商业健康保险,运用公私合作模式,优先发展若干领域。并结合我国实际情况,提出我国发展高端医疗服务业的启示:在确保基本医疗服务的前提下,实行有差别的支付政策;推广商业健康保险,拓展公私合作,确定发展高端医疗的优先领域。     

Impacts of geriatric nutritional risk index on prognosis of patients with non-ST-segment elevation acute coronary syndrome: Results from an observational cohort study in China

Background and aimsIt is recognized that malnutrition increases risk of worse prognosis in patients with various diseases. The present study investigated if poor nutritional status predicts adverse outcomes in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) undergoing percutaneous coronary intervention (PCI).Methods and resultsThe study enrolled 2299 patients (mean age: 60.01 ± 8.95 years; 71.8% male) with NSTE-ACS who underwent PCI at Beijing Anzhen Hospital from January to December 2015. The entire cohort was divided into training set (n = 1519) and testing set (n = 780) at a ratio of approximate 2 : 1. Nutritional status was assessed by geriatric nutritional risk index (GNRI). The primary endpoint was a composite of adverse events as follows: all-cause death, non-fatal myocardial infarction (MI) and any revascularization. Multivariate Cox analysis showed that GNRI significantly associated with primary endpoint, independent of other risk factors [hazard ratio (HR) 1.159 per 1-point decrease of GNRI, 95% confidence interval (CI) 1.130–1.189, p < 0.001]. The addition of GNRI to a baseline model had an incremental effect on the predictive value for adverse prognosis in training set [AUC: from 0.821 to 0.873, p < 0.001; category-free net reclassification improvement (NRI): 0.313, p < 0.001; integrated discrimination improvement (IDI): 0.108, p < 0.001]. The incremental effect of GNRI was further validated and confirmed in testing set.ConclusionLower GNRI is a significant predictor of adverse prognosis in patients with NSTE-ACS undergoing PCI. Further studies need to be performed to determine whether nutritional interventions have a positive impact on improving clinical prognosis.     

郑州中华按蚊自然种群净增殖率和其他参数的研究

目的：获得中华按蚊自然净增殖率和其他种群动力学参数。方法：于1993年、1994年的7～8月份,在郑州郊区的水塘和稻田内,以实验种群动力学为基础,采用数学模型,计算出中华按蚊的净增殖率和其他种群参数值,并和实验种群参数值进行比较。结果：和实验种群动力学相比,除了平均世代周期长和12 d后成蚊存活百分比相近外,其余各项参数值明显偏低。结论：野外自然因素和天敌对中华按蚊所构成的环境阻力是很大的。计算出该蚊自然种群动力学的参数值对防蚊灭疟策略的制定具有重要意义。     

协同式医疗诊断系统的模型及其仿真

提出了基于合同网机制的分布式协同医疗诊断系统的改进模型，并进行了仿真实现。     

Unbiased estimates of long‐term net survival of hematological malignancy patients detailed by major subtypes in France

Long‐term population‐based survival data detailed by cancer subtype are important to measure the overall outcomes of malignancy managements. We provide net survival estimates at 1, 3, 5 and 10‐year postdiagnosis on 37,549 hematological malignancy (HM) patients whose ages were >15 years, diagnosed between 1989 and 2004 and actively followed until 2008 by French population‐based cancer registries. These are, to our knowledge, the first unbiased estimates of 10‐year net survival in HMs detailed by subtypes. HMs were classified according to the International Classification of Diseases‐Oncology 3. Net survival was estimated with the unbiased Pohar‐Perme method. The results are reported by sex and age classes. The changes of these indicators by periods of diagnosis were tabulated and the trends of the net mortality rates over time since diagnosis graphed. In all, 5‐ and 10‐year age‐standardized net survivals after HMs varied widely from 81 and 76% for classical Hodgkin lymphoma (CHL) to 18 and 14% for acute myeloid leukemia (AML). Even in HMs with the most favorable prognoses, the net survival decreased between 5‐ and 10‐year postdiagnosis. Women had better prognoses than men and age at diagnosis was an unfavorable prognostic factor for most HMs. In patients <55 years old, the net mortality rate decreased to null values 5‐year postdiagnosis in AML and 10‐year postdiagnosis in CHL, precursor non‐HL, chronic myelogenous leukemia, diffuse large B‐cell lymphoma and follicular lymphoma. The prognoses improved for various HMs over the study period. The obtained unbiased indicators are important to evaluate national cancer plans.     

医学影像诊断设备网络化在放射科管理中的应用探讨

目的:试探讨实现医学影像诊断设备网络化对提高放射科质量的重要性及实用性。材料和方法:CT、MRI、Sun Advantage Windows(简称AW)2.0工作站连接成医学数字影像传输(DICOM)网络;DICOM服务器与各图像浏览及诊断报告书写终端连接成Ethernet网络;二者再通过集线器连接成PACS。结果:应用PACS技术,实现数字化图像在医学影像诊断设备网络化内的传送,中心存储,在DICOM 3.0标准水平的相互兼容图像交流以及诊断的报告的规范化、计算机化、实现无胶片管理医院。结论:实现医学影像诊断设备网络化提高了工作效率和管理水平,具广阔的应用前景。     

Effects of parathyroid hormone and calcitonin on Na+, Cl−, K+, Mg2+ and Ca2+ transport in cortical and medullary thick ascending limbs of mouse kidney

The effect of parathyroid hormone (PTH) on transepithelial Na⁺, Cl^–, K⁺, Ca²⁺ and Mg²⁺ transport was investigated in isolated perfused cortical thick ascending limbs (cTAL) and that of human calcitonin (hCT) was tested in both cortical and medullary thick ascending limbs (mTAL) of the mouse nephron. The transepithelial ion net fluxes (J _x) were determined by electron probe analysis of the perfused and collected fluids. Simultaneously, the transepithelial voltage (PD_te) and resistance (R _te) were recorded. In cTAL segments, PTH and hCT significantly stimulated the reabsorption of Na⁺, Cl^–, Ca²⁺ and Mg²⁺. hCT generated a net K⁺ secretion towards the lumen and PTH tended to exert the same effect. Neither PD_te nor R _te were significantly altered by either PTH or hCT. However, in the post-experimental period a significant decrease in PD_te was noted. Time control experiments carried out under similar conditions revealed a significant decrease in PD_te with time, which could have masked the hormonal response. In mTAL segments, Mg²⁺ and Ca²⁺ transport was close to zero. hCT did not exert any detectable effect on either PD_te or J _Cl ^–, J _Na ⁺ J _K ⁺, J _Mg ²⁺ and J _Ca ²⁺ in these segments. In conclusion, our data demonstrate that PTH and hCT stimulate NaCl reabsorption as well as Mg²⁺ and Ca²⁺ reabsorption in the cTAL segment of the mouse. These data are in agreement with and extend data obtained in vivo in the rat.     

Effect of intensive versus standard blood pressure control on major adverse cardiac events and serious adverse events: A bivariate analysis of randomized controlled trials

Background: Intensive blood pressure (BP) lowering may offer protective effects against major adverse cardiac event (MACE) but is also associated with a greater risk of a serious adverse event (SAE). The risk-benefit profile of intensive versus standard BP control has not been comprehensively assessed. Methods: Four studies were identified from a systematic literature search for randomized controlled trials comparing intensive versus standard BP lowering that reported both MACE and SAE endpoints. A previously described statistical approach was applied to characterize the efficacy-safety tradeoff of BP control. The bivariate outcome was computed to quantitatively assess the net clinical benefit (NCB) of intensive BP lowering as compared to standard treatment, with positive values indicating increased risks and negative values indicating decreased risks. Results: Data from the SPRINT trial demonstrated that intensive strategy was superior in MACE but inferior in SAE, thereby eroding the NCB (bivariate outcome: 0.33% [?0.50% to 1.21%]). Intensive strategy from the SPS3 trial fulfilled non-inferiority in both MACE and SAE but did not reach a favorable NCB (?1.31% [?2.25% to 0.01%]). The ACCORD trial suggested that intensive strategy was non-inferior in MACE but inferior in SAE (?0.19% [?0.79% to 1.37%]). Results from the VALISH trial were inconclusive for SAE but suggested non-inferiority in MACE (?1.19% [?3.24% to 0.68%]). Conclusions: Compared to the standard blood pressure target, pooled data from randomized controlled trials suggest that intensive strategy did not achieve a net clinical benefit when weighing the benefit of MACE reduction against the risk of SAE under the bivariate framework.Abbreviations: Blood pressure (BP), diastolic blood pressure (DBP), major adverse cardiac event (MACE), net clinical benefit (NCB), serious adverse event (SAE), systolic blood pressure (SBP).     

Rationing and the Role of the Emergency Department as Society''s Safety Net

Emergency medicine has an integral role in the establishment of universal access to health care for all persons living in the United States. Currently, emergency departments provide the only unfunded mandate available to millions of American residents who otherwise have no access to health care coverage. Any effort to establish universal care must accept health care rationing as a basic principle, and establish a minimum standard of benefits to which all human beings are entitled in this country. People and employers should be allowed to purchase additional care based on their willingness and ability to pay, but under no circumstances should anyone be denied a basic package of health care benefits. Emergency care must be part of those basic benefits. Emergency medicine charges should be structured so that they are not unduly onerous to society, and should reflect true expenses, including marginal costs for nonurgent care. Emergency physicians (EPs) and hospital administrations should recognize their critical role in serving society in roles that are not strictly medical, and allocate resources to benefit the general population in the greatest way. This role will be expanded to include preventive care, to provide for basic pharmacologic coverage as needed, and to provide necessary immunizations when traditional primary care has failed. We have a moral obligation to recognize that resources are limited and to allocate them so as to benefit the greatest number of patients in the greatest way. As members of the medical profession best equipped to assume such a task, it is incumbent upon EPs to act as advocates to the public to enable us to fulfill this mission.     

Evaluation of the wash resistance of three types of manufactured insecticidal nets in comparison to conventionally treated nets

The present study evaluated the efficacy and wash resistance of several commercial deltamethrin-treated nets (PermaNet™, from factory (PN-F) and market (PN-M), Yorkool (Y) and AZ net) that were claimed by the manufacturers to be Long-Lasting Insecticide Treated Nets (LLITNs), compared to ITNs conventionally treated with deltamethrin (23-27 mg/m², using one K-O Tab^® tablet (KO) per net). Montpellier washing technique was used for washing the pieces of the nets. Insecticidal activity was assessed on dried pieces of nets after 0, 2, 5, 8, 11, 15, 18 and 21 washes, using two types of bioassay (mean median knock down times and mortality 24 h after a 3-min exposure) and reared female Anopheles stephensi. To evaluate the effect of heat on diffusion of insecticide from inside of the nets to the surface of them, some Permanet nets were heated. For all the types of nets tested the median knock down time (MKDT) increased approximately linearly with number of washes. The slopes of the lines (increase of MKDT per wash) were low with the PN-F and PN-M, intermediate with Y and equally high with KO and AZ. No significant differences can be claimed with the 3-min exposure tests. The slopes of the regression lines did not differ significantly between the heated and unheated samples. It is concluded that diffusion at ambient temperature is fast enough to rapidly compensate for the loss of insecticide on the surface with no need to artificially stimulate diffusion by heating.