老年患者不同靶浓度罗库溴铵肌松效应的比较

目的比较老年患者不同靶浓度罗库溴铵的肌松效应。方法择期全麻老年患者100例,ASAⅡ级,随机分为4组(n=25),A组、B组和C组麻醉诱导气管插管时效应室靶浓度(Ce)为3μg/ ml,术中维持Ce分别为0.6、0.8、1.0μg/ml;D组麻醉诱导气管插管时Ce为3.3μg/ml,术中维持Ce为0_8μg/ml。记录肌松起效时间、恢复时间和恢复指数。评价气管插管条件和术中肌松程度。记录手术及TCI时间、罗库溴铵总用药量和期间用药量[总用药量,(体重×TCI时间)]。结果4组均可顺利完成气管插管,D组起效时间较A组、B组和C组缩短(P<0.05);A组肌松满意率低,B组、C组和D组均可维持满意肌松,但C组罗库溴铵用量较多,术中肌松程度较大,术后恢复时间较长(P<0.05)。结论麻醉诱导气管插管时罗库溴铵Ce为3.3μg/ml、术中麻醉维持Ce为0.8μg/ml,可产生满意的肌松条件,且有利于术后肌松恢复,是一种适用于老年患者合理的TCI给药方案。     

Does the CT improve inter- and intra-observer agreement for the AO,Fernandez and Universal classification systems for distal radius fractures?

Introduction

Distal radius fractures are very common upper limb injuries irrespective of the patient's age. The aim of our study is to evaluate the reliability of the three systems that are often used for their classification (AO – Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation, Fernandez and Universal) and to assess the need for computed tomography (CT) scan to improve inter- and intra-observer agreement.

Materials and methods

Five orthopaedic surgeons and two hand surgeons classified radiographs and CT scans of 26 patients using the Fernandez, AO and Universal systems. All data were recorded using MS Excel and Kappa statistics were performed to determine inter- and intra-observer agreement and to evaluate the role of CT scan.

Results

Fair-to-moderate inter-observer agreement was noted with the use of X-rays for all classification systems. Intra-observer reproducibility did not improve with the addition of CT scans, especially for the senior hand surgeons.

Conclusions

The agreement rates observed in the present study show that currently there is no classification system that is fully reproducible. Adequate experience is required for the assessment and treatment of these injuries. CT scan should be requested only by experienced hand surgeons in order to help guide treatment, as it does not significantly improve inter- and intra-observer agreement for all classification systems.     

Beliefs and expectations of rural hospital practitioners towards a developing trauma system: A qualitative case study

BackgroundAn understanding of stakeholders’ views is key to the successful development and operation of a rural trauma system. Scotland, which has large remote and rural areas, is currently implementing a national trauma system. The aim of this study was to identify key barriers and enablers to the development of an effective trauma system from the perspective of rural healthcare professionals.MethodsThis is a qualitative study, which was conducted in rural general hospitals (RGH) in Scotland, from April to June 2017. We used an opportunistic sampling strategy to include hospital providers of rural trauma care across the region. Semi-structured interviews were conducted, recorded, and transcribed. Thematic analysis was used to identify and group participant perspectives on key barriers and enablers to the development of the new trauma system.ResultsWe conducted 15 interviews with 18 participants in six RGHs. Study participants described barriers and enablers across three themes: 1) quality of care, 2) interfaces within the system and 3) interfaces with the wider healthcare system. For quality of care, enablers included confidence in basic trauma management, whilst a perceived lack of change from current management was seen as a barrier. The theme of interfaces within the system identified good interaction with other services and a single point of contact for referral as enablers. Perceived barriers included challenges in referring to tertiary care. The final theme of interfaces with the wider healthcare system included an improved transport system, increased audit resource and coordinated clinical training as enablers. Perceived barriers included a rural staffing crisis and problematic patient transfer to further care.ConclusionsThis study provides insight into rural professionals’ perceptions regarding the implementation of a trauma system in rural Scotland. Barriers included practical issues, such as retrieval, transfer and referral processes. Importantly, there is a degree of uncertainty, discontent and disengagement towards trauma system development, and concerns regarding staffing levels and governance. These issues are unlikely to be unique to Scotland and warrant further study to inform service planning and the effective delivery of rural trauma systems.     

Optimizing access and configuration of trauma centre care in New South Wales

IntroductionGetting the right patient, to the right place, at the right time is dependent on a multitude of modifiable and non-modifiable factors. One potentially modifiable factor is the number and location of trauma centres (TC). Overabundance of TC dilutes volumes and could be associated with worse outcomes. We describe a methodology that evaluates trauma system reconfiguration without reductions in potential access to care. We used the mature trauma system of New South Wales (NSW) as a model given the perceived overabundance of urban major trauma centres (MTC).MethodsWe first evaluated potential access to TC care via ground and air transport through the use of geographic information systems (GIS) network analysis. Potential access was defined as the proportion of the population living within 60-min transport time from a potential scene of injury to a TC by ground or rotary-wing aircraft. Sensitivity analyses were carried out in order to account for potential pre-hospital interventions and/or transport delays; travel times of 15-, 30-, 45-, 60-, and 90-min were also analyzed. We then evaluated if the current configuration of the system (number of urban MTS in the Sydney basin) could be optimized without reductions in potential access to care using two GIS methodologies: location-allocation and individual removal of MTC.Results86% of the NSW population has potential access to a TC within 60 min ground travel time; potential access improves to 99% with rotary-wing transport. The 1% of the population without potential TC access lives in 48% of the land area (>384,000km2). Utilizing two different methodologies we identified that there was no change in potential access by ground transport after removing 1 or 2 MTC in the Sydney basin at the 30-, 45-, and 60-min transport times. However, 0.02% and 0.5% of the population would not have potential access to MTC care at 15 min after removing one and two MTC respectively.DiscussionRedistribution of the number of MTC in the Sydney basin could be achieved without a significant impact on potential access to care. Our approach can be utilized as an initial tool to evaluate a trauma system where overabundance of coverage is present.     

Observer‐based actuator fault estimation and proportional derivative fault tolerant control for continuous‐time singular systems

This paper focuses on designing fault estimation (FE) and fault tolerant control (FTC) schemes for continuous‐time singular systems affected by actuator fault. A novel observer called the extended proportional integral observer (PIO) is designed so that the estimations of system state and actuator fault can be obtained simultaneously. In contrast with the traditional PIO, better estimation performance can be obtained by using the designed observer. Furthermore, with the obtained FE information, a novel proportional derivative–type FTC scheme is given by means of the separation property and the free‐weighting matrix technique, which ensures that the closed‐loop system is normal and stable. All the feasible conditions are formulated in linear matrix inequality (LMI) frameworks. Finally, two examples are simulated to prove the superiority and practicability of the presented scheme.     

高年级与低年级医学生批判性思维能力的比较

通过高年级与低年级医学生批判性思维能力差异的比较,探讨目前医学教育对学生批判性思维能力的影响。通过批判性思维能力倾向量表检测暨南大学五年级和一年级临床医学专业学生的批判性思维能力。结果表明五年级和一年级临床医学专业学生批判性思维能力的得分在总体上没有显著性差异(P>0.05),都属于意义不明确批判性思维倾向。进而对批判性思维的7个特性进行比较,即在寻找真相、开放思想、分析能力、系统化能力、自信心、求知欲和认知成熟度方面也没有显著性差异(P>0.05)。在认知成熟度方面,五年级和一年级学生均为正性批判性思维倾向,其余6个方面都属于意义不明确批判性思维倾向。低年级和高年级临床医学专业医学生的批判性思维能力普遍偏弱,在医学教育中应当特别加强学生批判性思维能力的培养。     

Medicine in Future and Advantages of Integrated Chinese and Western Medicine

The history of medical development shows that oriental medicine, or traditional medicine, was born through medical practice during the times when science and technology were immature and underdeveloped, whereas with the development of science and technology, Western medicine, or modern medicine, was born through experimental analysis and research. With the development of medicine, the pros and cons of both medical systems become increasingly evident. How to integrate them and learn from each other will be the direction of future development of medicine. The formation and development of integrated medicine will, inevitably, usher in a new era for medicine.     

老年人潜在不适当用药评价工具2019年版Beers标准解读

Beers标准是目前运用最广泛的老年人潜在不适当用药评价工具。2019-01-29,美国老年医学会（AGS）再次更新了该标准。本文对2019年版Beers标准进行解读,该标准沿用了2015年版的制定方法,保留了既往标准中的5种类型列表,但基于新的循证医学证据,增加、删除及修订了标准中的具体内容,其中包括30种老年人避免使用的药物/药物类别、40种在某些疾病或综合征下应避免应用或谨慎使用的药物及16项标准的重新梳理,如删除了已不在美国使用、较少使用或非老年人群特有的药物,补充了与跌倒或骨折、帕金森病或老年人失眠等疾病相关的避免使用药物及药物相互作用,对某些药物评价依据的描述更加具体和细化。2019年版Beers标准的基本框架和大体内容与2015年版Beers标准差异不大,但目标人群更为明确,内容更为精简,是保障老年人合理用药的有力工具。 老年人;给药系统,医院;潜在不适当用药;Beers标准,2019年版     

以岗位胜任力为导向对“5+3”一体化学生现代临床思维递增式培养的实践

目前,部分“5+3”一体化学生在各阶段存在角色转换、专业知识和技术、沟通能力和人文关怀能力、临床思维和循证医学观念及临床科研思维、学习和工作态度等方面不同程度的认识、理解和应用问题。本文将以岗位胜任力为导向的现代临床思维培养渗透并贯穿于“5+3”一体化学生诊疗操作能力培训的始终,全程融入人文关怀、循证医学、学习态度、工作态度、对患者的态度,逐步完成以岗位胜任力为导向的临床思维+诊疗操作能力的综合培养目标。