贵州省"5+3"模式订单定向医学毕业生的离职意愿及影响因素研究

背景 我国基层全科医生的离职意愿较高，调查其离职意愿并分析影响因素，可以为减少基层卫生人才流失提供思路。目前，完成"5+3"模式（5年临床医学本科教育+3年住院医师规范化培训）培养的订单定向医学毕业生逐步履约进入基层工作，而针对该部分全科医生离职意向的研究相对较少。 目的 调查贵州省"5+3"模式订单定向医学毕业生回归基层工作后的离职意愿及影响因素，为完善吸引卫生人才留任、建设基层全科医生队伍相关政策提供依据。 方法 以贵州省截至2020年底已完成"5+3"模式培养并履约到基层医疗卫生机构工作的2015—2017级订单定向医学毕业生为研究对象。于2021-01-20至2021-02-10对其开展电子问卷调查，内容包括毕业生的一般情况、职业满意度、离职意愿、服务期满后职业方向。共回收问卷347份，其中有效问卷311份，问卷有效回收率为89.6%。采用单因素分析及多元逐步线性回归分析全科医生离职意愿的影响因素。 结果 贵州省"5+3"订单定向医学毕业生的整体离职意愿得分为（3.98±0.98）分，具有离职倾向者229例（73.6%）。不同性别、单位地理位置、每日工作量者的离职意愿得分比较，差异有统计学意义（P<0.05）。多元逐步线性回归分析显示，单位负责人对待下属的方式、在工作中获得的成就感、对当前收入满意程度、家人对工作的支持程度、当地激励政策执行程度是"5+3"订单定向医学毕业生离职意愿的影响因素（P<0.05）。服务期满后，计划留任原基层医疗卫生机构者12例（3.9%），计划去其他基层医疗卫生机构者21例（6.7%），计划离开基层去上级医院工作者196例（63.0%），计划攻读全日制硕士学位者60例（19.3%）。 结论 贵州省"5+3"模式订单定向医学毕业生的离职意愿较高，预计服务期满后基层全科人才流失较多，需从提高收入、重视全科医生心理需求、优化全科医生培养与使用、发展基层医疗卫生机构、加强全科宣传等方面着手改善。     

EEG power spectral density under Propofol and its association with burst suppression,a marker of cerebral fragility

ObjectiveUnder General Anesthesia (GA), age and Burst Suppression (BS) are associated with cognitive postoperative complications, yet how these parameters are related to per-operative EEG and hypnotic doses is unclear. In this prospective study, we address this question comparing age and BS occurrences with a new score (BP_TIVA) based on Propofol doses, EEG and alpha-band power spectral densities, evaluated for SEF₉₅ = 8–13 Hz.Methods59 patients (55 [34–67] yr, 67% female) undergoing neuroradiology or orthopedic surgery were included. Total IntraVenous Anesthesia was used for Propofol and analgesics infusion. Cerebral activity was monitored from a frontal electrodes montage EEG.ResultsBP_TIVA was inversely correlated with age (Pearson r = −0.78, p < 0.001), and was significantly lower (p < 0.001) when BS occurred during the GA first minutes (induction). Additionally, the age-free BP_TIVA score was better associated with BS at induction than age (AUC = 0.94 versus 0.82, p < 0.05).ConclusionWe designed BP_TIVA score based on hypnotics and EEG. It was correlated with age yet was better associated to BS occurring during GA induction, the latter being a cerebral fragility sign.SignificanceThis advocate for an approach based on evaluating the cerebral physiological age (« brain age ») to predict postoperative cognitive evolution.     

Accuracy of MRI-guided Versus Systematic Prostate Biopsy in Patients Under Active Surveillance: A Systematic Review and Meta-analysis

This meta-analysis focuses on the accuracy of upgrading to clinically significant prostate cancer (PCa) by multiparametric magnetic resonance imaging-targeted biopsy (MRI-TB) versus systematic biopsy (SB). We searched the Medline, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and Literatura Latino Americana em Ciências da Saúde databases through January 2020 for comparative, retrospective/prospective, paired-cohort, and randomized clinical trials with paired comparisons. The population consisted of patients with low-risk PCa in active surveillance with at least 1 index lesion on imaging. We evaluated the quality of evidence by using the Quality Assessment of Diagnostic Accuracy Studies-2 score. Group comparisons considered the differences between the area under the curve summary receiver operating characteristic curve in a 2-tailed method. We also compared the positive predictive value of the best single method (MRI-TB or SB) and the referral study test (combined biopsy, a combination of MRI-TB and SB). The meta-analysis included 6 studies enrolling 741 patients. The pooled sensitivity for the 2 groups was 0.79 (95% confidence interval, 0.74-0.83; I² = 75%) and 0.67 (95% confidence interval, 0.63-0.74; I² = 55.4%), respectively. The area under the curve for the MRI-TB and SB groups were 0.99 and 0.92 (P < .001), respectively. The positive predictive value for the MRI-TB and combined biopsy groups were similar. The accumulated evidence suggests better results for MRI-TB compared with SB. Therefore, use of MRI-TB alone may be preferable in patients in active surveillance harboring low-risk PCa.     

目标教学运用在神经内科临床护理带教中的效果及方法

目的探究目标教学运用在神经内科临床护理带教中的效果及方法。方法选取2018年6月-2019年6月期间到该院神经内科实习的48名女护生作为研究对象,采取随机双盲方法,将其均分为两组,各24例,对照组护生行常规护理带教模式,观察组护生行目标教学护理带教,对比两组护生出科综合成绩和带教满意度。结果观察组出科综合成绩显著高于对照组(t=3.732、6.862、6.715,P<0.05),且带教满意度优于对照组(χ~2=5.400,P<0.05)。结论在神经内科临床护理带教工作中运用目标教学法可调动护生学习积极性,提升护士对护理知识的掌握程度,提高带教满意度。     

Iron deficiency down-regulates the Akt/TSC1-TSC2/mammalian Target of Rapamycin signaling pathway in rats and in COS-1 cells

Iron deficiency (ID) is one of the most commonly known forms of nutritional deficiencies. Low body iron is thought to induce neurologic defects but may also play a protective role against cancer development by cell growth arrest. Thus, ID may affect cellular pathways controlling cell growth and proliferation, the mechanism of which is still not fully understood. The serine/threonine protein kinase Akt and its downstream target, the mammalian Target of Rapamycin (mTOR), is known to play a crucial role in the regulation of cell growth and survival. Therefore, we hypothesized that Akt/mTOR pathway could be influenced by ID. Three-week-old male Wistar-strain rats were divided into 3 groups and the 2 groups had free access to a control diet (C group) or an iron-deficient diet (D group). The third group (PF group) were pair-fed the control diet to the mean intake of the D group. After 4 weeks, rats were killed and their brains were sampled. In separate experiments, COS-1 cells were cultured with or without the iron chelator deferoxamine. Western blots of brain samples and COS-1 lysates were used to analyze the expression and phosphorylation state of Akt, TSC2, mTOR, and S6 kinase proteins implicated in the Akt/mTOR pathway. Using 2 different ID models, we show for the first time that iron deficiency depresses Akt activity in rats and in COS-1 cells, leading to a decrease in mTOR activity.     

鼻咽癌常规放疗靶体积合理性的初步探讨

目的分析鼻咽癌常规放疗的局部控制情况和局部复发的剂量学模式,初步探讨照射靶体积确定的合理性.方法共476例初治鼻咽癌患者接受规范化单纯常规根治性放疗.全部病例均采用常规模拟定位,鼻咽靶体积为CT检查所见的原发病灶范围以及可能侵犯的亚临床病灶区域.利用Kaplan-Meier方法计算局部累积复发率;将鼻咽局部复发患者疗前和复发时局部病灶范围（Vnx和Vrecur）勾画于三维治疗计划系统,复制首程放疗的射野并按原处方剂量进行计算,根据剂量体积直方图进行剂量学评价：recurV95（95%处方剂量曲线包括的Vrecur）≥95%定义为野内复发,95%＞recurV95≥20%定义为野边缘复发,20%＞recurV95定义为野外复发.结果局部复发共52例,全组1、2、3、4年局部累积复发率分别为0.6%、3.9%、8.7%、11.5%.对42例局部复发的剂量学分析显示野内复发占多数（52%）,而大部分野边缘复发和全部野外复发均与射野设置不当、影像学阅片能力欠缺使首程放疗剂量不足有关.结论较好的局部控制率、复发的剂量学模式的分析结果提示该靶体积的设置比较合理.提高影像阅片能力,准确的射野设计,充分利用生物影像学工具,有针对性地提高照射剂量,有望进一步提高局部控制率.     

Teacher＇s Adjustable Function on the Basis of Learner＇s Needs＇ Analysis

There are the problems that influence English teaching, because the learners have the wrong understandings about the target needs and learning needs. The article analyses and discusses the teaching methods on dealing with the matter. The author thinks the teachers＇ adjustable function counting for much more.     

Interaction of B and T lymphocyte subsets with high endothelial venules in the rat: binding in vitro does not reflect homing in vivo

Lymphocytes continuously migrate through the body, and their efficient extravasation from the blood via high endothelial venules (HEV) is essential for initiating an appropriate immune response. Most investigations have focused on the lymphocyte/HEV interaction in vitro. However, to what extent such systems reflect the situation in vivo is not known. It is also unclear whether lymphocyte subsets immigrate into the HEV in proportion to their presence in the blood, and whether import capacity is limited by the HEV. When rat mesenteric lymph node lymphocytes were incubated in vitro on cryostat sections, the well-known preferential binding of B lymphocytes to HEV of Peyer's patches (PP) and T cells to HEV of axillary lymph nodes (axLN) was observed (axLN vs. PP: B lymphocytes 21.2 ± 5.0% vs. 40.6 ± 11.0%, T lymphocytes 84.6 ± 6.3% vs. 56.5 ± 12.9%). However, when labeled mesenteric lymph node lymphocytes were injected and their location within the HEV was analyzed 15 min later, no preferential interaction was seen. After injection of labeled thoracic duct lymphocytes, the percentage of labeled cells among B and T lymphocytes in the blood was significantly different (4.4 ± 0.9% vs. 8.9 ± 3.6%), whereas that in HEV of axLN (19.0 ± 6.4% vs. 16.6 ± 6.0%) and PP (30.6 ± 6.1% vs. 33.9 ± 4.4%) was comparable. Although the number of injected lymphocytes was similar in magnitude to the total blood lymphocyte pool, after injection there was no increase in lymphocyte numbers in the HEV. Thus, the adhesion assay in vitro does not completely reflect immigration into HEV in vivo. In addition, our data suggest that both the availability of lymphocyte subsets in small venules and the immigration rate into HEV are actively regulated in vivo.     

血管细胞粘附分子调控造血的研究进展

本文简述了血管细胞粘附分子 (Vascularcelladhesionmolecule 1,VCAM 1)的结构和生物学功能 ,总结了VCAM 1在恶性血液病骨髓基质中的表达和意义 ,探讨了VCAM 1在造血干细胞动员和归巢中的作用 ,指出VCAM 1作用机制的深入研究将对恶性血液病的治疗提供更为有效的方法。     

持续靶控输注异丙酚复合硬膜外麻醉用于上腹部手术探讨

目的:评价持续靶控输注异丙酚复合硬膜外阻滞有用于上腹部手术的可行性。方法:30例胃癌手术患者,ASAⅠ～Ⅱ级。随机分成靶控输注异丙酚全麻(T)组15例,靶控异丙酚复合硬膜外阻滞(T+E)组15例。结果:(T+E)组术后躁动、芬太尼、丙泊酚的用量低于(T)组(P<0.05)。异丙酚单位标准化剂量亦较低。两组苏醒时间相似。诱导后两组血压均显著下降(P<0.05),T+E组在诱导后DBP的下降幅度较T组更为显著(P<0.05),T组在探查、术毕、拨管后的SBP、DBP、MAP比(T+E)组显著增高(P<0.05)。两组诱导后至术毕BIS、SEF显著下降,两组间的比较无统计学意义(P>0.05)。结论:靶控输注异丙酚复合硬膜外阻滞用于上腹部手术是可行的,具有异丙酚、芬太尼的用量少、苏醒快、术后躁动少,麻醉深度易于调控,血液动力学较稳定,是一种良好的麻醉方式。