在回顾归纳台湾地区RBRVS的发展历程及不同阶段的技术体系基础上,提出对大陆地区医保支付制度改革的政策启示:建立定调价多元主体参与机制,强化专科医学会对支付制度的支撑功能;建立医务人员人力技术价值评价体系和支付标准点值体系;完善公立医院区域成本数据库建设,健全专科间串联机制;探索基于点值体系的收付费一体化机制;建立健全公立医院薪酬制度与支付制度联动机制等政策建议.

目的 探讨在优质护理模式下如何提升护士能力可有效的适应新形势.方法 选取2016年1月—2017年1月我院临床护士54名作为研究对象.按照随机数字表法,将其均分两组,每组各27名.参照组予以常规指导,实验组在优质护理模式下予以指导.分析两组临床护士对各方面知识的掌握度.结果 实验组临床护士对各方面知识的掌握度相比于参照组均较高,组间数据对比,差异具有统计学意义(P<0.05).结论 在优质护理模式下对临床护士进行培养,可使护士的执行能力显著提升,并满足医疗新形势的需求.

RBRVS在公立医院内部绩效管理实践的重点在于建立“人价高、点值高”与“结余高、绩效高”一体化机制.本研究基于RBRVS框架,从操作时间、技术水平、技术风险、工作强度、工作难度、价格成本比六个维度构建了公立医院内部绩效管理指标体系,并实现与医疗物价体系、真实医疗服务项目成本、薪酬制度改革要求、医保支付制度改革、公立医院补偿机制的对接.

目的 分析早期肠内与肠外营养结合在胃肠道肿瘤切除术后的应用效果.方法 本次参与研究的胃肠道肿瘤切除术患者64例,纳入时间为2017年2月—2018年3月.依据治疗方法的不同均分为两组,予以肠外营养的32例患者为参照组,予以早期肠内与肠外营养结合的32例患者为研究组,最后对比实施效果.结果 研究组患者术后的血清白蛋白和血红蛋白含量高于参照组,数据对比差异有统计学意义(P<0.05).结论 在胃肠道肿瘤切除术后应用早期肠内与肠外营养结合可对肠道功能恢复起到促进作用.

目的 探讨快速康复理念应用于腹腔镜胃癌根治术术后护理中的效果,以及对疼痛和胃肠功能的影响.方法 选择我院2015年1月——2017年6月所收治患者102例,随机分为研究组和对照组.对照组51例,仅予以常规护理内容;研究组51例,应用快速康复理念进行护理干预.比较两组患者术后疼痛、胃肠功能情况.结果 研究组患者中,肛门排气时间为(57.31±10.15)h、首次排便时间为(4.71±1.05)d及肠鸣音恢复时间为(11.21±3.15)h,均明显低于对照组,t分别为8.030、7.814、6.063,差异显著(P<0.01).干预前,两组VAS评分无显著差异,P>0.05;干预后,研究组VAS评分(3.17±1.22)分,显著高于对照组的(54.19±13.41)分,t为6.217,差异具有统计学意义(P<0.01).结论 快速康复理念护理可有效改善腹腔镜胃癌根治术术后患者胃肠功能、疼痛程度,有利于康复质量提升,值得临床推广应用.

Objective To investigate the effect of lowering insulin-like growth factor 1 receptor (IGF1 R) expression on invasion and migration abilities of gastric cancer cells and its mechanism.Methods The gastric cancer GC9811-P cells were cultured in vitro,and logarithmic phase cells were used for the transfection of GC9811-P cells by RNA interference technique.The cells in interfering group were transferred by small interference RNA targeting IG1R (IGF1-siRNA).The cells in negative group were transferred by siRNA-NC.No any treatment was given for the cells in the control group.Transwell test was used to detect cell invasion and migration abilities.Western Blot method was used to detect the relative expression levels of IGF1 R,serine/threonine protein kinase (AKT),phosphorylated AKT (p-AKT),phosphoinositide3-kinase(PI3K) andphosphorylated PI3K (p-PI3K)proteins in transferred cells.Results The relative expression level of IGF1 R protein in cells in interfering group was significantly lower than those in cells of negative group and control group (all P ＜ 0.05).The number of cells of invasion and migration in interfering group was significantly lower than those in cells of negative group and control group (all P ＜ 0.05).There were no significant differences in the expression levels of AKT and PI3 K proteins among three groups (all P ＞ 0.05).The relative expression levels of p-AKT and p-PI3 K proteins in cells of interfering group were significant lower than those in cells of negative group and control group (all P ＜ 0.05).Conclusion Silencing IGF1R expression can decrease the invasion and migration abilities of gastric cancer cells,and the mechanism may be through the classic PI3K/AKT signaling pathway.

Objective To assess the short-time economics of various glutamine dipeptide-enriched parenteral nutrition (PN) for patients undergoing elective surgery for gastrointestinal tumors, with an attempt to provide evidence for decision makers on clinical nutrition support.Methods A prospective cohort study was designed.From payer/disburser''s perspective, a cost-effectiveness decision-tree model was developed to assess the clinical outcomes and short-time economic effects of glutamine dipeptide-enriched PN that used in different time points (early postoperative or perioperative).Cost-effectiveness analysis, cost-utility analysis, and incremental cost-effectiveness analysis were adopted in the decision-tree model.One-way sensitivity analysis was performed to determine the robustness of the results.Results Totally 107 patients were included.There was no significant difference between the perioperative alanine(Ala) glutamine(Gln) nutrition support (group A) and early postoperative Ala-Gln nutrition support (group B) in the ratio of 5％ weight declines on the 8th day after surgery and infection-related postoperative complications (72.1％ vs.78.1％, χ2=0.509, P=0.498 and 2.32％ vs.4.69％, χ2=0.060, P=0.806).The levels of prealbumin (PA) and albumin(Alb) and the level of total lymphocyte count(TLC) also the time of recovering gastrointestinal function, length of stay nutritional discharge index(LOSNDI), and direct costs were significantly different [PA:(208.19±56.92)mg/L vs.(187.97±62.05)mg/L, t=2.283,P=0.039;Alb:(33.82±3.91)×109 vs.(31.96±4.57)×109, t=2.184, P=0.036;TLC:(1.19±0.55)×109 vs.(0.89±0.66)×109, t=2.461, P=0.015;the time of recovering gastrointestinal function(3.06±0.28)d vs.(3.39 ± 0.34)d, t=-3.675, P=0.000;LOSNDI:(16.84±2.92)d vs.(18.52 ±3.47)d, t=-2.613, P=0.011;direct costs:￥(17 029.05±317.28) vs.￥(15 610.64±292.56), t=23.764, P=0.000].When LOSNDI and quality-adjusted life years (QALYs) were estimated as indicators of effectiveness, the incremental cost-effectiveness ratios and incremental cost-utility ratios of group A were ￥844.3 and ￥70 920.5, respectively.Net monetary benefit of group B was more than that of group A.One-way sensitivity analysis showed that parameters had no significant effect on the model.Conclusion When using local per capita gross domestic product as threshold, early postoperative Ala-Gln PN was more economical than perioperative Ala-Gln PN strategy evaluation.

目的：分析研究员工援助计划在护理管理应用中的有效性。方法随机抽取不同科室的护理工作人员100名作为研究对象，以1年为期，实施员工援助计划前后分别对其心理状态和工作质量进行评定。结果员工援助计划实施后，护理人员的SDS评分和SAS评分分别为（25.1±6.9）分、（23.4±7.3）分，与实施前相比均显著降低，而护理质量评分为（82.5±5.1）分，显著高于实施前，差异均有统计学意义（P＜0.05）。结论通过员工援助计划的实施，护理人员的心理状态显著改善，工作积极性提高，护理质量提升，可以为患者提供更高效高质量的医疗服务，值得推广应用。

OBJECTIVETo evaluate the clinical effectiveness of Onodera prognostic nutrition index (OPNI) in the predictive value of nutrition risk.METHODSIn a prospective cohort study from July 2014 to June 2015 in the Department of General Surgery of the Ninth People's Hospital of Chongqing, NRS2002 and OPNI were conducted in 200 patients undergoing gastrointestinal elective operation. OPNI was calculated with serum albumin (Alb) and peripheral lymphocyte (TLC) [OPNI=Alb(10(9)/L)+5×TLC(10(9)/L)]. By using the results of NRS2002 as the golden standard for diagnosis of nutrition risk (A NRS2002 score≥3 was deemed as nutritional risk and a nutritional care plan should be initiated. A NRS2002 score <3 was deemed as no nutritional risk), the effectiveness of OPNI was evaluated by the receiver operator characteristic(ROC) curve. The sensitivity, specificity, positive and negative predictive values, Youden indexes and area under ROC curve(AUC) of different diagnostic cut-off points of OPNI were analyzed to determine the optimal operating point (OOP). Kappa test was used to estimate the consistency of different cut-off points for OPNI with NRS2002 in defining nutrition risk.RESULTSA total of 103 patients were of NRS2002 ≥3 group, and 97 of NRS2002 <3 group. The overall OPNI was 45.4±7.4. When OOP was 45.8, the AUC of OPNI was 0.914 (95% CI: 0.873 to 0.954); the sensitivity, specificity, Youden indexes were 85.4%, 85.6%, 0.711; the positive predictive value and negative predictive value were 85.3% and 83.7%, respectively. According to this OOP, the subjects were divided into the OPNI ≥45.8 group(n=102) and OPNI <45.8 group (n=98). Compared with OPNI ≥45.8 group, OPNI <45.8 group were older [(66.5±12.1)years vs. (57.0±15.3) years, t=-4.905, P=0.000], and had lower BMI[(20.4±3.0) kg/m(2) vs. (21.7±3.0) kg/m(2), t=3.069, P=0.002], lower albumin[(34.7±4.7)10(9)/L vs.(43.6±3.4)10(9)/L, t=15.542, P=0.000] and lower TLC[(1.0±0.5)10(9)/L vs.(1.6±0.7)10(9)/L, t=7.254, P=0.000], respectively. Kappa test indicated that when using OPNI=45.8, the diagnostic value of OPNI on nutrition risk was consistence with NRS2002(Kappa=0.691, P=0.000).CONCLUSIONSOPNI can be used as a relatively simple and reliable method for clinical screening and assessment of nutrition risk.

<正>腹腔镜技术目前已广泛应用于小儿外科,具有良好的应用前景[1,2]。与传统开腹手术比较,腹腔镜治疗小儿腹股沟疝具有安全可靠、创伤小、手术时间短、疼痛轻、恢复快、无明显瘢痕等优势[3,4]。我科在单孔腹腔镜下改进了该术式[5],引入临床常见的双通道深静脉穿刺针,通过注水分离腹膜与输精管、精索血管[6,7],简化了手术步骤,避免了过去穿

<正>老年肝胆疾病患者一般病情较重,将承受很大的心理压力,这种心理压力将直接影响到治疗效果。笔者将心理护理应用到整个护理过程中,获得了较满意的疗效,现报道如下。1临床资料1.1一般资料2008-07-2010-12对肝胆外科择期手术老年患者100例的心理护理,其中男51例,女49例,年龄65~92岁。对入选患者填写评估表和护理问题项目单,评估记录患者

通过经验丰富的医生和护士组成专门的医疗和护理小组,根据患者的特点制订针对性的心理护理措施,取得患者的充分信任和合作;根据医源性胆道损伤患者都有梗阻性黄疽的特点给予充分的术前准备;术后做好管道和营养的护理;密切观察肺部感染、腹腔感染、切口感染、多脏器功能不全等并发症的症状和体征,协助医生给予积极的对症处理。

<正>我院1998年9月至2008年1月,收治老年重症急性胰腺炎(SAP)60例,经采用中西医结合治疗及精心护理,效果满意,现就其护理体会报道如下:1资料和方法1.1一般资料