医院融资经营提高资本利用质量

着重从资本运作中最主要的手段——融资,去剖析医院以融资方式实现医疗规模迅速扩张的全过程。介绍了经营租赁与融资租赁及其优缺点,并附案例加以说明。     

Severe odontogenic infections, part 2: prospective outcomes study.

PURPOSE: The purpose of this study was to identify significant predictors of 4 outcomes in patients with severe odontogenic infections: abscess formation, penicillin therapeutic failure (PTF), length of hospital stay (LOS), and need for reoperation. PATIENTS AND METHODS: We used a prospective case series study design and enrolled 37 consecutive patients admitted for severe odontogenic infection between March 1996 and June 1999. Treatment consisted of intravenous penicillin (PCN) or clindamycin in PCN-allergic patients, surgical incision and drainage, and extraction(s) as soon as possible. Study variables were categorized as demographic, preadmission, time-related, preoperative, anatomic, treatment, microbiologic, and complications. The primary outcome variables were abscess formation, PTF, LOS, and reoperation. Multivariate linear and logistic regression techniques were used to measure associations between study variables and the outcome variables. RESULTS: The sample consisted of 37 subjects (23 male, 14 female) with a mean age of 34.9 +/- 15.8 years. Multivariate analyses, controlling for confounding variables, indicated that culture of Peptostreptococci was a negative predictor of abscess formation. LOS was predicted by the number of infected spaces and duration of operation. There was no significant predictor of PTF or reoperation on multivariate analysis, although PCN-resistant organisms were isolated in all cases of PTF. CONCLUSION: Increased LOS in severe odontogenic infections is predicted by the anatomic extent and severity of the infection and the occurrence of complications such as PTF and the need for reoperation. PTF is significantly associated with later identification of PCN-resistant organisms. The role of Peptostreptococci in abscess formation warrants further investigation.     

Coagulation changes following hepatic revascularization during liver transplantation

The coagulation changes during liver transplantation have been studied in 14 selected patients. Blood usage in all cases was limited to 8.5 liters, and the preoperative coagulation results were only minimally deranged. Bleeding during the operative procedure was easily managed in all cases. Nonetheless, even in this selected group of "low risk" patients, we have demonstrated that during the anhepatic phase and particularly following hepatic revascularization there is activation of both coagulation and fibrinolysis. These findings imply that if bleeding occurs following revascularization, in addition to the use of replacement blood products, treatment should be directed at reducing the consumptive coagulopathy and inhibiting fibrinolysis. We suggest as a first step antithrombin supplementation to maintain activity above 70%, and an antifibrinolytic agent, such as aprotonin, should be considered as adjuncts to therapy at revascularization.     

Differential ability of Th1 and Th2 T cells to express Fas ligand and to undergo activation-induced cell death

Stimulation of previously activated T cells through the antigenreceptor can result in the apoptotic death of the respondingcell, a process referred to as activation-induced cell death(AICD). This process appears to involve Fas (CD95) and tts ligand(Fas-L). The distribution of Fas and Fas-L on various T cellsubsets has not been extensively characterized. We have thereforeanalyzed cells committed to a T_h1- or T_h2-type differentiationpattern for the expression and function of Fas-L. Using botha sensitive bloassay and flow cytometry, we demonstrate thatcloned T_h1 cells express high levels of Fas-L, whereas clonedT_h cells express only low levels. The expression of Fas-L byT_h1 and T_h2 cells correlates with the relative abilities ofthese two cell types to undergo AICD. Whereas AICD is readilyobserved in cultures of cloned T_h1, but not T_h2 cells, T_h2 cellsare capable of undergoing apoptosls in the presence of T_h1 cellsexpressing Fas-L The ability of T cells to undergo AICD appearsto be unrelated to the presence of various cytokines. Thus,the Fas/Fas-L pathway appears to be critical for the inductionof AICD and this pathway is differentially regulated in cellscommitted to either T_h1 or T_h2 differentiation.     

Ligand interactions by activating and inhibitory Ly-49 receptors

Summary: Natural killer (NK) cells express families of homologous receptors, members of which either activate or inhibit NK cells. We demonstrate that mouse Ly-49D is an activating receptor for the MHC antigen H2-D^d, which is also a ligand for the related inhibitory receptor Ly-49A. To compare and contrast their interactions with class I MHC ligand, we studied each of these receptors expressed in a rat NK-cell line, RNK-16, for their capacity to recognize wild-type or mutated H2-D^d. Our studies with Ly-49A reveal that functional interaction with H2-D^d depends on residues in the floor of the H2-D^d peptide-binding groove. The recent co-crystal of Ly-49A with H2-D^d indicates that these are not contact residues, thus they may contribute to allelic specificity through conformational changes in H2-D^d. We found that structural requirements for functional recognition of H2-D^d by Ly-49D differ markedly from those for recognition by Ly-49A. We note that H2-D^d expression on certain target cells is not sufficient to activate lysis mediated by Ly-49D, though the additional requirements for functional interaction are not yet identified. Here we review recent studies of Ly-49 receptor ligand specificities and their molecular basis. The functions of these related receptors with opposing functions and shared allospecificity remains unclear.
This work was supported by the Veterans Administration. M.C.N. is also supported by the Arthritis Foundation and the American Cancer Society. W.E.S. received NIH grant RO1 CA69299. We thank J.C. Ryan for communication of unpublished results. We thank H. Houtkooper and T. Ferrin for the molecular graphics image in Fig. 3 , which was created with the MidasPlus modeling system, supported by the NIH grant P41-RR-01081.     

Primary myeloid sarcoma of the testicle with t(15;17)

The first case of acute promyelocytic leukemia presenting as a solitary testicular mass (myeloid sarcoma) that relapsed in the contralateral testicle is described. The neoplastic cells strongly expressed chloroacetate esterase, myeloperoxidase, CD33, CD43, and weakly, CD117. The presence of many azurophil granules and Auer rods was detected by electron microscopy. Translocation (15;17)(q22;q21.1) was revealed by cytogenetics and was verified by fluorescence in situ hybridization. Contralateral testicle is a favorite site for recurrence in a subset of testicular myeloid sarcomas. Subclassification of all cases of myeloid sarcoma ought to be attempted.     

Opportunistic Infections After Induction With Alemtuzumab or Basiliximab: A 3-Year Kidney Transplantation Experience

BackgroundAntibody induction immunosuppression is commonly used in kidney transplantation to decrease the risk of early acute rejection. However, infectious complications may arise in patients treated with higher intensity induction immunosuppression. In this study, we compared the rate of opportunistic infections during the 3 years after kidney transplantation in recipients who received either alemtuzumab or basiliximab for induction therapy.MethodsAll renal transplant recipients from our center who received induction with alemtuzumab between 2011 and 2016 were included and matched 1:2 (by age and date of transplant) to renal transplant recipients who received basiliximab. The primary outcome was the rate of opportunistic infections.ResultsTwenty-seven patients received alemtuzumab (mean age = 50.8 years; SD ±12), and 54 received basiliximab (mean age = 50.8 years; SD ±11.8). Infections within 3 years posttransplant were not different between groups: BK viremia (P = .99), BK nephritis (P = .48), cytomegalovirus infection (P = .13), varicella zoster virus (P = .22), and all infections (P = .87). Time to infection (P = .67), patient survival (P = .21), and time to rejection (P = .098) were similar in both groups. There were also no group differences in delayed graft function (P = .76), graft loss (P = .97), or rejection (P = .2).ConclusionThe rate of infection was not significantly increased in recipients receiving lymphocyte-depleting alemtuzumab compared to recipients receiving basiliximab induction therapy, despite receiving similar maintenance immunosuppression. Although the immunologic risks differed between the 2 groups, there was no observable difference in clinical outcomes.     

The Ileal Ureter Neobladder is Associated with a High Success and a Low Complication Rate

Purpose

Several different methods to construct a bladder substitute after cystectomy have been described. We evaluated our experience with the Studer ileal ureter neobladder during the last 5 years.

Materials and Methods

We reviewed retrospectively the results in 32 patients who underwent construction of a slightly modified ileal neobladder from that originally described. Mean followup was 25 months (range 6 to 68).

Results

Patients experienced few complications and only 1 required reoperation. Daytime and nighttime continence rates were 94 and 74 percent, respectively. One patient sustained a ureteral stricture resulting in hydronephrosis (1 of 64 renal units).

Conclusions

The results reveal the ileal neobladder to be an easily constructed pouch with a low complication rate, and a high success rate in regard to continence and the establishment of adequate capacity at low pressure. Within the study period upper tract preservation was excellent. However, a 10 to 15-year followup is indicated to confirm our initial results.