卫生体制改革的目标与政策选择--国际卫生体制改革的经验与教训

引入市场机制,采取分权、分级与分类管理等政策与措施是当今国际卫生体制改革中的主流特点,由于各个国家的社会经济体制与卫生保健制度不同,这些改革政策与措施所产生的影响与效果也各具特色.因此,在深化我国卫生体制改革的进程中,借鉴国际卫生体制改革的经验与教训具有一定的现实意义.     

The Role of Surgery in Neonatal Respiratory Distress

Compression of the newborn's lungs by one or another type of space-occupying lesion results in a crisis that can be dealt with only through immediate differential diagnosis followed by appropriate surgery. Most common among these space-occupying lesions are those caused by air trapped inside the pleural cavity or within the lung itself. Dr. Pickett outlines the steps in the essential differentiation and correction.     

Variations in the evaluation of colorectal cancer risk

OBJECTIVES: To test the variability in estimating cancer risk and demonstrate the consequences that subjectivity has on patient care. SUBJECTS AND METHODS: Forty-three clinicians were each asked to assess 40 symptomatic colorectal referrals. Each clinician was provided with a comprehensive history on the 40 patients. The clinicians graded the referral according to a malignancy risk score, decided on the required first line investigation and the priority of that investigation. The main outcome measures used was accuracy in cancer detection and appropriateness of investigations selected. RESULTS: There was a wide degree of variation among all clinicians grading both benign and malignant disease with the overall correct classification of 54% (P-value of <0.001). On average, the clinicians correctly diagnosed 71.3% of the cancer patients as compared to 44% of the benign patients. Of the cancer patients, 47% were correctly classified as an urgent referral whilst 52% of the benign patients were over classified and graded as an urgent referral. The mean number chosen by clinicians to have a flexible sigmoidoscopy as the appropriate first investigation was 13 (of 40 patients); this was despite the diagnosis being possible in all cases with a flexible sigmoidoscopy. The choice to use full colonic investigation was seen throughout all disciplines. Junior doctors demonstrated the highest tendency choosing full colonic investigation in 92.3%. Consultants and senior grades showed the least tendency to choose full colonic imaging although even here colonoscopy or barium enema represented 48.5%. CONCLUSION: Subjective assessment of cancer referrals is a significant problem that needs to be confronted. Improvements are needed to resolve the inherent problems of subjectivity and operator bias if uniform quality of patient care and best use of resources is to be achieved.     

武汉市社区卫生服务发展概述

本文对武汉市近年来大力发展社区卫生服务工作所取得的成绩和经验进行了总结,对存在的问题进行了分析,对下一步社区卫生服务的发展提出了建议。     

我国现行中医药教育政策实施和发展趋势

现行中医药教育政策促进了中医药教育在各个方面的发展，但其存在的主要雾要和问题也是明显的，在学科建设方面存在着与西医教育不平衡和不适应的状况。对比国外的传统医药教育政策，本文探讨了我国中医药教育政策未来的发展趋势。     

Genomic tests to guide prostate cancer management following diagnosis

Introduction: Prostate cancer (PCa) is a common cancer in men, but variable clinical behaviors make its management challenging. Risk stratification is a key issue in disease management. Patient-tailored strategies are strongly advocated to reduce unnecessary treatment while maximizing the oncological outcomes of patient who need active treatment in the primary, adjuvant or salvage setting. Recently, tissue-based biomarkers or genomic tests have become available to improve the clinical decision-making.

Areas covered: In this review, the authors present recent evidence about these tissue-based biomarkers, discussing the application of each of them in the clinical setting, focusing on the tests aimed to provide a better risk stratification and to guide decision-making after the diagnosis of PCa (i.e. OncotypeDX^?, Prolaris^?, ProMark^?, Ki-67, Decipher^?, PTEN, PORTOS, AR-V7 and DNA repair gene mutations).

Expert commentary: Even if the clinicopathologic features are still the most frequently-used predictors of disease progression, these tools can be helpful in decision-making at every stage of the PCa management. Actually, OncotypeDX^?, Prolaris^? and Decipher^? are recommended in the clinical setting by guidelines at different steps of PCa management. Consequently, further studies are indispensable to better tailor the right therapy for the right patient and at the right time.     

A novel emergency medical services-based program to identify and assist older adults in a rural community

Rural-dwelling older adults experience unique challenges related to accessing medical and social services. This article describes the development, implementation, and experience of a novel, community-based program to identify rural-dwelling older adults with unmet medical and social needs that leveraged the existing emergency medical services (EMS) system. The program specifically included geriatrics training for EMS providers; screening of older adult EMS patients for falls, depression, and medication management strategies by EMS providers; communication of EMS findings to community-based case managers; in-home evaluation by case managers; and referral to community resources for medical and social interventions. Measures used to evaluate the program included patient needs identified by EMS or the in-home assessment, referrals provided to patients, and patient satisfaction. EMS screened 1,231 of 1,444 visits to older patients (85%). Of those receiving specific screens, 45% had fall-related, 69% medication management-related, and 20% depression-related needs identified. One hundred and seventy-one eligible EMS patients who could be contacted accepted the in-home assessment. Of the 153 individuals completing the assessment, 91% had identified needs and received referrals or interventions. This project demonstrated that screening by EMS during emergency care for common geriatric syndromes and linkage to case managers is feasible in this rural community, although many will refuse the services. Further patient evaluations by case managers, with subsequent interventions by existing service providers as required, can facilitate the needed linkages between vulnerable rural-dwelling older adults and needed community-based social and medical services.     

Implementation of NIAAA College Drinking Task Force Recommendations: How Are Colleges Doing 6 Years Later?

Background: In 2002, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) College Drinking Task Force issued recommendations to reduce heavy drinking by college students, but little is known about implementation of these recommendations. Current discussion about best strategies to reduce student drinking has focused more on lowering the minimum legal drinking age as advocated by a group of college and university presidents called the Amethyst Initiative than the NIAAA recommendations. Methods: A nationally representative survey of administrators was conducted at 351 4‐year colleges in the United States to ascertain familiarity with and progress toward implementation of NIAAA recommendations. Implementation was compared by enrollment size, public or private status, and whether the school president signed the Amethyst Initiative. Results: Administrators at most colleges were familiar with NIAAA recommendations, although more than 1 in 5 (22%) were not. Nearly all colleges use educational programs to address student drinking (98%). Half the colleges (50%) offered intervention programs with documented efficacy for students at high risk for alcohol problems. Few colleges reported that empirically supported, community‐based alcohol control strategies including conducting compliance checks to monitor illegal alcohol sales (33%), instituting mandatory responsible beverage service (RBS) training (15%), restricting alcohol outlet density (7%), or increasing the price of alcohol (2%) were operating in their community. Less than half the colleges with RBS training and compliance checks in their communities actively participated in these interventions. Large colleges were more likely to have RBS training and compliance checks, but no differences in implementation were found across public/private status or whether the college president signed the Amethyst Initiative. Conclusions: Many colleges offer empirically supported programs for high‐risk drinkers, but few have implemented other strategies recommended by NIAAA to address student drinking. Opportunities exist to reduce student drinking through implementation of existing, empirically based strategies.     

Improved Mechanical and Tribological Properties of Metal-Matrix Composites Dispersion-Strengthened by Nanoparticles

Co- and Fe-based alloys produced by powder technology are being widely used as a matrix for diamond-containing composites in cutting, drilling, grinding pplications, etc. The severe service conditions demand that the mechanical and tribological properties of these alloys be improved. Development of metal-matrix composites (MMCs) and alloys reinforced with nanoparticles is a promising way to resolve this problem. In this work, we have investigated the effect of nano-sized WC, ZrO₂, Al₂O₃, and Si₃N₄ additives on the properties of sintered dispersion-strengthened Co- and Fe-based MMCs. The results show an increase in the hardness (up to 10 HRB), bending strength (up to 50%), wear resistance (by a factor of 2–10) and a decrease in the friction coefficient (up to 4-fold) of the dispersion-strengthened materials. The use of designed alloys as a binder of cutting diamond tools gave a 4-fold increment in the service life, without reduction in their cutting speed.