Objective:To observe the efficacy of maintenance treatment of thiopurines after exclusive enteral nutrition (EEN) therapy for Crohn′s disease (CD) children, and explore the influencing factors of recurrence.Methods:A retrospective case-control study was conducted. CD children treated in the Children′s Hospital of Zhejiang University School of Medicine from March 2013 to March 2021 were included retrospectively. Data before EEN were collected including general demographics, Paris classification, the pediatric Crohn′s disease activity index (PCDAI), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and serum albumin levels. According to the recurrence at 1 year of follow-up, patients were divided into remission group and recurrence group. The differences in clinical data before EEN between the 2 groups were analyzed. The factors influencing the recurrence were analyzed.Results:Thirty-five children were enrolled, including 25 (71.4%) males and 10 (28.6%) females. The age at diagnose was (11.2 ± 3.1) years old and the disease duration was 3.5 (2.2, 6.9) months. After 1 year of follow-up, 15 children had recurrence at least for one time and were divided into the recurrence group. Twenty (57.1%) children continued to maintain 6-mercaptopurine (6-MP) monotherapy and were divided into the remission group. There was no significant differences in gender, diagnostic age, and CRP, ESR, serum albumin and PCDAI before EEN between the two groups (all P>0.05). There was significant difference in the percentage of patients with disease duration of longer than 1 year before EEN between the two groups ( P = 0.026) . Conclusions:The children with the disease duration of longer than 1 year before EEN may be in high risk of recurrence on the regimen of maintenance treatment of thiopurines after EEN.

Objective: To explore the incidence and the risk factors of post-polypectomy bleeding and polyp recurrence after colonoscopic high-frequency electrocoagulation snare polypectomy. Methods: Clinical data of 1 826 children who underwent colonoscopic high-frequency electrocoagulation snare polypectomy in the Children's Hospital, Zhejiang University School of Medicine from January 2009 to December 2020 was retrospectively analyzed. Demographic characteristics, endoscopic manifestations, pathological features, diagnosis, occurrence of post-polypectomy bleeding and polyp recurrence were collected. The associated risk factors were analyzed by Logistic regression. Results: A total of 1 826 children (1 191 males and 635 females) with 1 967 polypectomies were included. The age was 4.6 (3.2, 6.4) years at initial diagnosis. According to the initial colonoscopy, 1 611 children (88.2%) had solitary polyps, 1 707 children (93.5%) had pedicled polyps, 1 151 children (63.0%) had polyps involving the rectum, and 1 757 children (96.2%) had hamartomatous polyps. Polyposis syndromes were diagnosed in 73 children (4.0%). The post-polypectomy bleeding occurrence was 3.8% (75/1 967). Polyps recurred in 88 children (4.8%). Girls (OR=2.01, 95%CI 1.26-3.23) and sessile polyps (OR=2.28, 95%CI 1.15-4.49) were risk factors for post-polypectomy bleeding (both P<0.05). Multiple polyps (OR=17.49, 95%CI 9.82-31.18), right-colon involvement (OR=3.44, 95%CI 1.89-6.26) and non-hamartoma (OR=2.51, 95%CI 1.04-6.07) were risk factors for polyp recurrence (all P<0.05). Conclusions: Colonoscopic high-frequency electrocoagulation snare polypectomy has low incidence of post-polypectomy bleeding and polyp recurrence. Female patients and sessile polyps have higher risk for post-polypectomy bleeding. Multiple polyps, right-colon involvement and non-hamartoma polyps increase the risk for polyp recurrence.

Objective:To analyze the research hot topics, knowledge evolution context, potential frontier trends and future breakthrough directions in the field of medical security governance in China.Methods:Subject term retrieval was used to study the literatures related to medical security governance published by CNKI from January 2009 to December 2021. CiteSpace V software was used to draw the keyword co-occurrence network, time zone map, cluster map, and emergent word graph, and to visually analyze and predict the frontier hotspots and evolution trends in the field of medical security governance.Results:A total of 793 literatures were retrieved. The cooperation network among medical security governance research institutions in China needed to be strengthened; the mainstream of research focused on basic research on medical insurance system design, research on medical security governance paths and methods, and empirical research combined with the era background or policy hotspots.Conclusions:There are some problems in the current rerearch on medical security governance, such as imperfect theoretical construction, research content to be expanded, insufficient communication and cooperation, etc. Future research hotspots tend to be innovation of the goal, structure and path of medical security governance, application of big data in the field of medical security governance, and research on crisis response and challenges of medical security governance under public health emergencies. Future research should strengthen multi-cooperation to jointly tackle key problems, pay attention to the cross-integration of disciplines, develop localized medical security governance innovation systems and mechanisms, and enrich problem-oriented empirical research.

Objective To construct a simulation course of opioid-induced clinical crisis management for pain nurse in ward and evaluate its effects. Methods Following the best practice standards of International Nursing Association for Clinical Simulation and Learning,according to the five basic dimensions of scenario development,facilitator preparation,equipment preparation,environmental preparation and pre-course student preparation,a opioid-induced clinical crisis management simulation course was constructed. From November to December 2019,a group of61 pain nurses in wards from a tertiary general hospital in Zhejiang Province were selected for training in the simulation teaching center of the Anesthesia-Operation Department of the hospital. The teaching evaluation was carried out by using the questionnaire of Critical Thinking Disposition Inventory and clinical decision-making self-confidence assessment of excessive sedation and respiratory depression caused by opioids. Results After training,the total score of critical thinking was（264.57±2.77）. There were statistical differences before and after the training（P＜0.05）. After training,the clinical decision-making self-confidence of the trainees in the excessive sedation and respiratory depression caused by opioids was（3.89±0.82） and（3.89±0.80） respectively,which were statistically different compared with those before the training（P＜0.001）. Pain nurses in wards were highly satisfied with the simulation teaching course. Conclusion The simulation course can effectively improve the clinical crisis management ability and clinical decision-making confidence of pain nurses in wards,and can provide reference for the training of comprehensive emergency response ability of pain nurses.

对老年人吞咽障碍危险因素与筛查工具进行综述,旨在为老年人吞咽障碍风险筛查提供依据.老年人吞咽障碍受生理性因素、病理性因素及社会因素与心理因素影响,可通过使用问卷筛查工具、床旁筛查工具、仪器筛查方法等进行早期评估,但目前仍缺乏高特异度和高灵敏度的筛查方案,需进一步研究.

An amendment to this paper has been published and can be accessed via the original article.

The incidence of Crohn′s disease(CD) in children is increasing year by year.Compared with adults, children with CD face a more rapidly changing course, a larger range of intestinal involvement and growth and development problems.The advent of biological agents has broadened the treatment pathway for pediatric CD, among which the most widely used anti-TNF therapy, including Infliximab(IFX), Adalimumab(ADA), has been approved for the induction and remission therapy for pediatric CD.The efficacy and safety of biological agents from other pathways, such as the interleukin inhibitor Ustekinumab(UTK), the anti-integrin monoclonal antibody Vedolizumab(VDZ) and biosimilars have been progressively demonstrated in pediatric CD.Loss of response is a major problem in the treatment of biologic agents, and the development of more biologics as an alternative treatment is the direction that still needs to be worked on in the future.This article reviews the efficacy of biological agents in pediatric CD, aiming to provide recommendations for clinicians when making treatment decisions.

Antibiotic-associated diarrhea(AAD) is a frequent adverse effect of antibiotic in children.AAD is associated with longer hospitalization, higher healthcare cost and even lead to death.Pediatricians usually do not pay enough attention to AAD.Domestic experts from pulmonary medicine, infection and gastroenterology are organized to develop the consensus, to improve the diagnosis, treatment and prevention of AAD, and contribute the children health in future.

目的 观察活动性疼痛管理在肝胆胰加速康复外科中的应用效果.方法 根据病区将115例患者分为对照组(55例)和观察组(60例),对照组采取肝胆胰加速康复外科常规措施进行治疗、护理,观察组在对照组基础上采取活动性疼痛管理,比较两组疼痛宣教掌握率、术后24 h数字疼痛评分最高值、首次下床活动时间、术后住院时间以及术后疼痛控制满意度.结果 观察组疼痛宣教掌握率高于对照组,术后24 h数字疼痛评分最高值低于对照组,首次下床活动时间、术后住院时间均短于对照组,术后疼痛控制满意度得分高于对照组,差异均具有统计学意义(P<0.05).结论 活动性疼痛管理有利于提高肝胆胰加速康复外科患者的疼痛宣教掌握率,促进术后康复,提高患者术后疼痛控制满意度.

目的 分析政府、公立医院、社会多元主体对患者就医获得感的治理作用及影响,为增强患者就医获得感乃至进一步协同提升患者满意度提供借鉴及思考.方法 采用定额抽样的方法对浙江省15家城市和县级公立医院的住院患者进行问卷调查,通过多重线性回归分析患者就医获得感的治理影响因素.结果 政府对医疗服务公平性问题改善情况、居住地医疗机构整体规划和布局合理性、分级诊疗政策引导效果等因素影响患者就医获得感(P<0.05),医院公平公正处理医疗纠纷、对基层医疗卫生机构转诊提供便利以及为患者提供便利畅通的投诉渠道影响患者就医获得感(P<0.05),社会公众积极主动向政府反映医患双方意见及诉求、社会专业组织发挥医疗行业行为自律和内部监督职责、患者对当前医生群体所处社会医疗环境看法等因素影响其就医获得感(P<0.05).结论 可以通过推动政府切实履行职责、提升医院管理水平和调动社会公众参与治理积极性以协同增强患者就医获得感.

目的 从多元主体治理视角分析影响公立医院医务人员工作积极性的因素,为激发和调动医务人员工作主观能动性及潜能提供依据.方法 采用定额抽样方法选取浙江省19家市、县级公立医院的1855名医务人员进行问卷调查,运用多重线性回归分析医务人员工作积极性的治理影响因素.结果 政府对公立医院公益性的维护、对三医联动改革的领导协调、对综合改革措施的宣传解读、对培训方案的完善和对分级诊疗的引导政策影响医务人员工作积极性(P<0.05),医院内部收入分配制度、分工协作机制、战略目标、民主管理影响医务人员工作积极性(P<0.05),社会专业组织提供的高质量业务培训、对医疗事故鉴定的公平性、公共媒体及时报导医疗相关事件影响医务人员工作积极性(P<0.05),医务人员对所在医院形象及医疗行业环境的自我认知与态度影响其工作积极性(P<0.05).结论 政府治理职责履行、医院管理水平、社会治理职责履行和医务人员自身认知态度影响医务人员工作积极性,可从强化政府治理职责、加强医院科学管理、激活社会主体协同发力和重视医务人员思想工作建设4个方面调动医务人员工作积极性.

Objective:To analyze the efficacy and safety of adalimumab in the treatment of pediatric inflammatory bowel disease (IBD) patients.Methods:Clinical data of pediatric IBD patients who switched to adalimumab therapy after the failure of infliximab in the Children′s Hospital, Zhejiang University School of Medicine from January 2019 to September 2020 were analyzed retrospectively. A descriptive method was used to analyze the general information, disease activity index and mucosal inflammation before and after the treatment of adalimumab. The pediatric Crohn′s disease activity index (PCDAI) and pediatric ulcerative colitis activity index (PUCAI) were used to evaluate the disease activity. The Crohn′s disease endoscopic index of severity (CDEIS) and ulcerative colitis endoscopic index of severity (UCEIS) were used to evaluate the mucosal inflammation.Results:A total of 10 children diagnosed with IBD were treated with adalimumab, including 9 patients of Crohn′s disease (CD) and 1 of ulcerative colitis (UC) . There were 6 males and 4 females, with disease onset age of 0.3 to 13.3 years and median duration of 38 (3 to 81) months before the treatment of adalimumab. In lesion location of 9 CD patients, 2 patients only involved the small intestine (L4a+L4b) and 7 patients involved the whole digestive tract (L3+L4a+L4b) according to Paris classification. The reasons of switching infliximab to adalimumab were as follows: primary loss response to infliximab occurred in 1 patient, secondary loss response to infliximab in 6 and severe anaphylaxis in 3. According to PCDAI and PUCAI, the clinical remission was achieved in 1, mild activity in 4, moderate in 3 and severe in 2 before the treatment of adalimumab. Clinical remission was achieved in 6, clinical response in 1 and non-response in 1 at the 10th week. After the median follow-up period of 25 (10 to 86) weeks, clinical remission was achieved in 8, the clinical symptom of 1 non-responsive patient was improved during the follow-up. The left 1 non-responsive patient stopped treatment of adalimumab and received gene sequencing test, and the results showed a hemizygote mutation of X-linked inhibitor of apoptosis protein ( XIAP) gene and the X-linked lymphocytic proliferation syndrome was considered. Five cases of side reaction occurred in 10 patients, mainly the respiratory infections, and no other serious side reactions occurred. Conclusion:Switching to adalimumab attains good outcome in pediatric IBD patients after the failure of infliximab.

异物摄入是儿科急诊的常见原因,在过去20年里,磁铁摄入的发生率在不断增加.虽然在儿童吞食的所有异物中,磁铁不常见,但是磁性异物尤其是钕铁硼(NdFeB)磁珠能够通过肠壁相互吸引,导致肠坏死、肠梗阻、穿孔、腹膜炎和死亡.该文介绍了磁铁摄入损伤的背景和机制,以及推荐的治疗方法和潜在的并发症.

目的 探讨全身麻醉下膝关节置换术后恶心呕吐的诱因,及术后早期咀嚼运动对其术后恶心呕吐的影响.方法 选取全身麻醉下膝关节置换手术治疗患者192例,分为对照组112例和观察组80例,对照组采用常规护理预防术后恶心呕吐,观察组在对照组基础上采用术后早期咀嚼口香糖预防术后恶心呕吐.比较两组患者年龄、性别、吸烟史、手术时间、术前禁食、禁饮时间,术中激素使用、补液量,术后进食、进饮时间、术后使用昂丹司琼和恶心呕吐等情况.结果 观察组手术时间短于对照组(P<0.05),恶心呕吐发生率低于对照组(P<0.05).单因素分析显示,膝关节置换术后恶心呕吐患者较术后无恶心呕吐患者手术时间、术前禁食时间和禁饮时间延长(均P<0.05),术中使用激素比例增高(P<0.05),术后早期咀嚼口香糖比例降低(P<0.05).多因素分析显示,手术时间和术前禁饮时间延长及术中使用激素是膝关节置换术后恶心呕吐发生的危险因素(P<0.05),而术后早期咀嚼口香糖是预防术后恶心呕吐发生的保护性因素(P<0.05).结论 全身麻醉下膝关节置换术后恶心呕吐与手术时间和术前禁饮时间延长及术中激素使用存在相关性,早期进行咀嚼运动可降低术后恶心呕吐的发生风险.

目的 构建科学、可行的疼痛专科护士临床实践教学体系,为我国疼痛专科护士临床实践培训提供依据.方法 以核心胜任力理论为指导,通过文献研究和半结构式访谈构建疼痛专科护士临床实践教学指标条目,采用德尔菲专家咨询法选取20名专家进行2轮咨询,形成疼痛专科护士临床实践教学体系.结果 2轮专家咨询问卷有效回收率均为100％,权威系数为0.881,模块指标、一级指标、二级指标专家意见的肯德尔和谐系数分别为0.512、0.455、0.423(P＜0.01).最终形成的疼痛专科护士临床实践教学体系包括4项模块指标、5项一级指标、21项二级指标.结论 基于核心胜任力理论构建的疼痛专科护士临床实践教学体系科学、可靠,能为我国疼痛专科护士临床实践培训提供参考依据.

婴幼儿轮状病毒胃肠炎是全球严重的公共卫生问题之一。尽管近年来卫生环境方面有了较大程度的改善，感染性腹泻总发病呈现逐年下降趋势，但轮状病毒胃肠炎的发病率并未随之有显著改变。接种口服轮状病毒减毒活疫苗是预防轮状病毒胃肠炎有效的方法之一。尽管已有批准上市的轮状病毒疫苗可用，但在临床推荐、预防接种以及健康教育等一级预防环节中仍存在诸多问题，有待临床医务人员与公共卫生人员予以重视，加强医防融合，逐一解决，有效推进儿童轮状病毒胃肠炎的免疫预防。.

目的 评价经皮内镜胃造瘘空肠置管术(PEG-J)在反复吸入性肺炎患儿肠内营养中应用疗效.方法 纳入2013年1月至2018年3月在浙江大学医学院附属儿童医院消化科行PEG-J的12例患儿.分析患儿的PEG-J手术并发症、肠内营养并发症,以及术后营养状况、原发疾病转归和拔管情况等.结果 12例患儿行PEG-J,其中男8例、女4例,平均年龄1岁5月龄(4月龄至6岁1月龄).手术前平均病程7月龄(2月龄至2岁),所有患儿均存在反复吸入性肺炎,其中9例(75％)患儿生后就出现喂养障碍伴反复吸入性肺炎,合并重度营养不良4例(33.3％),中度营养不良3例(25.0％).所有患儿手术均1次取得成功.3例(25％)出现手术相关的近期并发症.2例(16.7％)出现营养管相关并发症.在行PEG-J行空肠肠内营养后,11例患儿基本未发生吸入性肺炎,1例患儿(球麻痹合并胃食管反流患儿)吸入性肺炎发作次数明显减少.肠内营养前后年龄别体重Z评分显著增高(P＜0.05),年龄别身高Z评分显著增高(P＜0.05).结论 PEG-J可用于反复吸入性肺炎患儿的肠内营养治疗,不仅可以减少吸入性肺炎的发作次数,改善营养状态,同时具有副反应少、并发症少以及适用于长期肠内营养支持治疗的优点.

2019年12月以来,全世界陆续发现了多例不明原因的肺炎患者,从患者下呼吸道分离出来的冠状病毒为一种新型冠状病毒,国际病毒分类委员会命名其为严重急性呼吸系统综合征冠状病毒 2 (severe acute respiratory syndrome coronavirus 2, SARS-Cov-2),其传播途径主要是经呼吸道飞沫和接触传播[1-2].由于此次新型冠状病毒肺炎(以下简称"新冠肺炎")累及患者广,传播速度快,武汉成为重灾区,需要大量的医疗资源,全国各地纷纷派出医疗队支援武汉.浙江大学医学院附属第一医院作为浙江省收治新冠肺炎患者的三甲定点医院,积累了丰富的救治与管理经验.2020年2月14日,我院增派1支140人的援鄂医疗队,整建制接管华中科技大学同济医学院附属协和医院肿瘤中心的1个重症病区,现将应急护理管理经验介绍如下.

目的 评估新型冠状病毒(SARS-CoV-2)流行期间,因为不可抗力因素导致延迟使用英夫利昔单抗(IFX)对炎症性肠病(IBD)患儿疾病活动指数的影响.方法 多中心横断面调查.纳人2020年1月20日至2020年3月20日(疫情中)国内19家医院使用IFX的IBD连续病例,疫情中较疫情前(2020年1月20日前)儿童克罗恩病疾病活动指数(PCDAI)或儿童溃疡性结肠炎疾病活动指数(PUCAI)评分疾病分期加重为病例组,未加重为对照组.考察年龄、性别、延期治疗时间、WBC、Hb、PLT和CRP对疾病分期加重的影响.结果 19家医院参加了本次调查,232例应该接受IFX治疗的IBD患儿中,67例(28.9％)因疫情因素未按时使用IFX.暂停使用2例,疫情中失访;延迟使用65例,其中9例疫情中失访.56例延迟使用IFX[(17.9±9.9)d]并采集到疫情前和中数据的IBD患儿进人本文分析.男27例,女29例,平均年龄(11.3±4.1)岁.病例组11例(诱导阶段3例,维持阶段8例),对照组45例(诱导阶段2例,维持阶段43例).疫情中与疫情前相比,延迟使用IFX的患儿WBC、Hb、PLT、CRP和疾病活动指数差异均无统计学意义(P分别为0.44、0.60、0.80、0.34和0.33).11例疾病分期加重,其中6例需要住院,无因为延迟治疗而需要外科手术或死亡的病例.结论 维持治疗阶段延迟3周使用IFX未改变IBD患儿疾病活动指数.

患者安全是医疗服务的核心目标,患者和家庭参与可以改善患者安全和医疗质量.本文综述了患者和家庭参与的基本概念及患者和家庭参与患者安全的主要形式,以期为我国开展相关研究提供借鉴.