公立医院院长职业化：中层管理者的看法与启示

??????? 目的 通过对公立医院中层管理者问卷调查,分析当前我国医院院长职业化建设的问题与原因。方法 定量与定性相结合,抽样调查和统计武汉市173名医院中层管理者对院长职业化认知情况,通过文献分析深入挖掘深层次问题与原因。结果 多数中层医院管理者了解并支持院长职业化但认为难度较大;倾向于临床与管理复合型院长,主张通过医院自主公开招聘选拔院长,不愿意放弃临床工作。结论 改革公立医院管理体制,对现任院长职业化再造,改革院长管理绩效考核和薪酬分配制度。     

河南省公立医院院长职业化现状调查与分析

目的 分析河南省公立医院院长职业化现状和存在的问题,为制定院长职业化培训规划和相关政策提供依据。方法 在2014年河南省公立医院院长培训班上对318名医院院长进行问卷调查,对院长的教育经历、专业情况、管理培训和管理知识来源进行描述性分析。结果 河南省公立医院院长性别比例不协调,学历层次和技术职称级别结构方面相对合理,职业化培训不足,缺少管理类相关知识储备,对公立医院院长职业化的认知参差不齐。结论 应加强公立医院院长的管理类相关知识储备,重视管理队伍的职业化培训,培养具备职业化要求的高层管理人员。     

公立医院理事会绩效评价指标体系的构建

目的 构建公立医院法人治理结构改革试点理事会绩效评价的指标体系。方法 首先通过文献研究和个人深入访谈法构建北京公立医院理事会绩效评价初步指标体系，然后通过德尔菲专家咨询法对指标体系进行优化。结果 专家打分结果显示，三级指标中，有4个指标的均值在重要性、可操作性和敏感性中只有一个维度小于7分，有3个指标的变异系数在重要性、可操作性和敏感性中只有一个维度大于0.3。结论 理事会绩效评价指标体系中理事会结构较理事会运作过程和结果的可操作性高，但重要性敏感性较低；有3个增加的三级指标分别是“战略与政策制定的效果评价”、“理事的培训效果评价”和“卫生行政部门对医院的绩效评价。     

公立医院卫生资源配置和服务利用效率的分析及思考

?????? 目的 了解我国公立医院的卫生资源配置与利用效率情况。方法 运用数据包络分析法(DEA)对6家公立医院2010的投入与产出情况进行分析。结果 2家二级公立医院的效率评价排名优于4家三级医院。结论 加大对基层医疗单位的卫生资源投入力度,加强对三级公立医院卫生资源的整合重组,以提高公立医院的卫生资源配置与利用效率。     

医护人员心理契约满足及其测量

??????? 目的 ? 探讨医护人员心理契约满足的内容结构,了解医护人员心理契约满足的维度,加强对医护人员心理契约管理。方法? 对294名临床科室医护人员进行心理契约问卷调查,并进行统计分析。结果? 医护人员心理契约满足为三维结构。发展责任,对总变异的贡献率为46.010%;规范责任,对总变异的贡献率为8.797%;人际责任,对总变异的贡献率为6.888%。表明该量表可靠性良好,也充分表明了心理契约量表的维度具有文化特性。结论?量表可靠性良好,充分表明了心理契约量表的维度具有文化特性,对医院人力资源管理具有指导性意义,有助于提升医院管理水平。     

三级医院医疗质量评价指标体系的构建及优化

目的 在原有医疗质量评价体系的基础上,建立一套科学合理、可操作性强的三级综合性医院医疗质量评价指标体系。方法 采用典型研究方法,通过文献研究筛选初始指标,通过知情人访谈法确定质量评价框架,运用德尔菲法并借鉴平衡积分卡的原理和思想优化并确定指标及权重系数。结果 确定了以医疗基础质量、环节质量和终末质量为基本结构的三级综合性医院质量评价框架和指标体系,由3个一级维度、8个二级维度、24个三级维度指标体系及其相应权重。结论 医疗质量评价指标体系关注医院质量管理中的难点和重点环节,能够满足上海市三级综合性医院医疗质量管理的实际需要。     

精神卫生护理服务项目成本核算

???? 目的 为提高精神卫生护理服务项目的收费提供依据。 方法 采用全成本核算和剔除财政补助收入的成本核算方法。结果 精神特级护理成本为7.70元/小时,剔除财政后成本为7.40元/小时;一级和二级护理成本为135.00元/日和63.50元/日,而剔除财政补助后成本为130.50元/日和61.40元/日。结论 应提高精神科的护理服务项目的收费标准,同时标准应该体现护理级别。收费标准的确定按照护理服务项目的成本和剔除财政补助后的成本确定。

     

国际临床路径研究热点与前沿的文献计量分析

目的 揭示国际临床路径的研究热点、研究前沿和主题结构，为国内学者及相关机构临床路径战略研究领域的选择与临床路径的制定提供决策依据。方法 采用高频主题词共词聚类分析方法，依据各类的内容分析当前研究热点，并通过主题战略坐标揭示研究前沿与主题结构。结果 2001—2010年，国际临床路径研究形成了13个主要的热点主题。结论 临床路径具有多学科特征，已经形成腹腔镜手术、肿瘤与临终关怀、精神疾病、循证医学和临床指南依从性研究等比较成熟和稳定的研究主题；老年病人健康服务成为该领域的研究中心，有着巨大的发展潜力；临床路径电子化、艾滋病和护士角色等主题可能成为未来研究的热点和新的发展方向。     

基于泰国DRGs的阑尾切除术分组研究与探索 ——以云南省4所公立医院为例

目的 运用泰国DRGs方法学对云南省4所公立医院阑尾切除术进行分组研究，找出分组过程中存在的问题，为进一步的研究提供依据。方法 运用泰国分组软件“Grouper”对实行阑尾切除术的患者进行分组，统计学分析运用软件SPSS17.0。结果 3 333例阑尾炎切除术分为单纯性阑尾切除术、腹腔镜下阑尾切除术、复杂诊断阑尾切除术3个大组共10个DRGs组。结论 在分组中由于病案首页信息填写不完整而影响了有效分组，部分组内的数据难以代表其资源消耗程度。     

北京市公立医院管理人员职业化培训需求调查

目的 了解北京市公立医院管理人员的职业化需求,为设置针对性的培训课程体系提供依据。方法 按照分层整群抽样的方法,从北京市10家公立医院中抽取628名管理人员,发放自编“北京市公立医院管理人员职业化培训调查问卷”。结果 （1）调查对象中87.10%认为医院管理人员应从“医学专家型”向“医院管理型”转变, 51.59%表示不愿意全职从事管理工作;（2）医院管理人员有97.13%表示愿意参加管理培训课程,并对培训课程的内容、形式、时间、师资等提出了具体化的要求。结论（1）北京市公立医院管理人员具备职业化意识但职业化意愿不强,应建立完善的长效激励机制以增加管理岗位的吸引力;（2）北京市公立医院管理人员参加管理职业化培训的需求较强,应设置针对性的培训课程体系来提高其管理水平。

     

Anthropology and genetics of the caucasus peoples and the problem of the origin of the caucasoids

The electrophoretical polymorphisms of some blood proteins were studied in the Talysh population of Pirasora situated in South-East Azerbaidjan. We calculated the gene frequencies of these polymorphisms and determined the genetic distances between the Talyshes and some Iranian populations of North, Central and South Iran, Afghans, and three populations of Azerbaijan. The Talyshes are very close to Iranians of Shiraz, whereas they are distant from the Azerbaijanians. Anthropological investigations showed that the Caucasoids and Mongoloids lived in the Aragvi Basin since the Eneolithic period. This was stated by Alexeev (1974), who emphasized the mixture of the Caucasus populations from ancient times on. We calculated the genetic distances between the Caucasus populations and numerous populations of other geographic regions, considering 28 alleles of 12 loci of blood group, serum protein and red cell enzyme polymorphisms and constructed the dendrogram of these populations. The position of the Caucasus populations in the dendrogram corresponds on principle to the earlier anthropological observations. The clustering of the Caucasoid populations corresponds completely with anthropological and historical data, and supports our earlier hypothesis (Nazarova 1999) concerning the differentiation of Caucasoids, Northern Mongoloids and Amerinds from the populations, which inhabitated Asia in palaeolithic times.     

On the structure and dynamics of the complex of the nucleosome and the linker histone

Several different models of the linker histone (LH)–nucleosome complex have been proposed, but none of them has unambiguously revealed the position and binding sites of the LH on the nucleosome. Using Brownian dynamics-based docking together with normal mode analysis of the nucleosome to account for the flexibility of two flanking 10 bp long linker DNAs (L-DNA), we identified binding modes of the H5-LH globular domain (GH5) to the nucleosome. For a wide range of nucleosomal conformations with the L-DNA ends less than 65 Å apart, one dominant binding mode was identified for GH5 and found to be consistent with fluorescence recovery after photobleaching (FRAP) experiments. GH5 binds asymmetrically with respect to the nucleosomal dyad axis, fitting between the nucleosomal DNA and one of the L-DNAs. For greater distances between L-DNA ends, docking of GH5 to the L-DNA that is more restrained and less open becomes favored. These results suggest a selection mechanism by which GH5 preferentially binds one of the L-DNAs and thereby affects DNA dynamics and accessibility and contributes to formation of a particular chromatin fiber structure. The two binding modes identified would, respectively, favor a tight zigzag chromatin structure or a loose solenoid chromatin fiber.     

Kinematics and dynamics of the temporomandibular joint and of the movements of the mandible

In order to analyze the complicated movements of the mandible as the open-closing movement and the protrusio are, it is useful to evaluate the basic kinematic principles and reduce them to simple technical constructions. Both the open-closing movement and the protrusio could be reduced to 4-bar links, which were used to simulate the movements with help of a computer. Besides, the polodes and the curves of points in the muscular attachments could be constructed. The 2 entirely different 4-bar links have 3 things in common: The resting system - cranium, the moving system - mandibula, and 1 of the 2 arms connecting these 2 systems - the ligamentum laterale. As this ligament is taut during movements it can be considered a "guiding ligament" representing 1 of the 3 determining components of the mandibular movements. The other of the 2 arms has no anatomical equivalent; this arm, however, is "replaced" by the 2 other determining components of the mandibular movements: the joint and the muscles. The curves, which the Caput mandibulae describes, are practically identical for the open-closing movement and the protrusio despite of the different 4-bar links and these curves exactly correspond to the Discus articularis, taut by the upper part of the M. pterygoideus lateralis. The muscles do not only just move the mandibula, but they are also the component, which can choose between the different mandibular movements. By means of the curves, which points in the muscular attachments describe, the function of the masticatory muscles could be analyzed exactly.     

Biophysics and Structure of the Patch and the Gigaseal

Interpreting channel behavior in patches requires an understanding of patch structure and dynamics, especially in studies of mechanosensitive channels. High resolution optical studies show that patch formation occurs via blebbing that disrupts normal membrane structure and redistributes in situ components including ion channels. There is a 1-2 μm region of the seal below the patch where proteins are excluded and this may consist of extracted lipids that form the gigaseal. Patch domes often have complex geometries with inhomogeneous stresses due to the membrane-glass adhesion energy (E_a), cytoskeletal forces, and possible lipid subdomains. The resting tension in the patch dome ranges from 1-4 mN/m, a significant fraction of the lytic tension of a bilayer (∼10 mN/m). Thus, all patch experiments are conducted under substantial, and uneven, resting tension that may alter the kinetics of many channels. E_a seems dominated by van der Waals attraction overlaid with a normally repulsive Coulombic force. High ionic strength pipette saline increased E_a and, surprisingly, increased cytoskeletal rigidity in cell-attached patches. Low pH pipette saline also increased E_a and reduced the seal selectivity for cations, presumably by neutralizing the membrane surface charge. The seal is a negatively charged, cation selective, space with a resistance of ∼7 gigohm/μm in 100 mM KCl, and the high resistivity of the space may result from the presence of high viscosity glycoproteins. Patches creep up the pipette over time with voltage independent and voltage dependent components. Voltage-independent creep is expected from the capillary attraction of E_a and the flow of fresh lipids from the cell. Voltage-dependent creep seems to arise from electroosmosis in the seal. Neutralization of negative charges on the seal membrane with low pH decreased the creep rate and reversed the direction of creep at positive pipette potentials.     

Serology and systematics of the Ebenales and the Theales

The systematic position ofthe Ebenaceae, Sapotaceae, Styracaceae, Ochnaceae, Stachyuraceae, Dipterocarpaceae, Clusiaceae and Hypericaceae has been investigated using serological comparisons of sets of antigenic determinants. The results show that the Sytracaceae and Sapotaceae are undoubtedly more closely associated with the Actinidiaeceae and Theaceae, respectively, than with each other. We found no corresponding determinants betnween antigen systems from the Ebenaceae and systems from any other family whose relations to this family have been proposed. As discovered previously, investigations of antigen systems from the Ochnaceae, Dipterocarpaceae, Stachyuraceae, Clusiaceae and Hypericaceae are against the idea of a natural order “Theales” in which these families, or at least some of them, are combined with the Theaceae and Actinidiaceae. This paper completes our previous investigations which largely support a superorder Ericanae sensu Ehrendorfer and Takhtajan. We propose to include the Actinidiaceae and Theaceae in this superorder, assigning them a central position laong with the Sapotaceae and Sytracaeae on one side and the Primulales and Ericales on the other. Another most interesting finding is that there are corresponding determinants between antigen systems from the members of the Ericanae and representatives of the Polemoniaceae and Loasaceae.     

人类基因组及后基因组研究进展及其应用与开发研究现状

人类对自身基因组的研究,随着人类基因组工作草图的绘制完成和对基因功能研究的深入已加快进入了实质性、关键性的开发利用阶段。本文概述了人类基因组及后基因组的研究进展及依此开展基因治疗及基因（组）药物研制等应用开发研究的现状。     

Comparison of the Effects of Flexion and Extension of the Thumb and Fingers on the Position and Cross-Sectional Area of the Median Nerve

Objective

To assess the separate effects of thumb and finger extension/flexion on median nerve position and cross-sectional area.

Methods

Ultrasonography was used to assess median nerve transverse position and cross-sectional area within the carpal tunnel at rest and its movement during volitional flexion of the individual digits of the hand. Both wrists of 165 normal subjects (11 men, 4 women, mean age, 28.6, range, 22 to 38) were studied.

Results

Thumb flexion resulted in transverse movement of the median nerve in radial direction (1.2±0.6 mm), whereas flexion of the fingers produced transverse movement in ulnar direction, which was most pronounced during flexion of the index and middle fingers (3.2±0.9 and 3.1±1.0 mm, respectively). Lesser but still statistically significant movements were noted with flexion of the ring finger (2.0±0.8 mm) and little finger (1.2±0.5 mm). Flexion of the thumb or individual fingers did not change median nerve cross-sectional area (8.5±1.1 mm²).

Conclusions

Volitional flexion of the thumb and individual fingers, particularly the index and middle fingers, produced significant transverse movement of the median nerve within the carpal tunnel but did not alter the cross-sectional area of the nerve. The importance of these findings on the understanding of the pathogenesis of the carpal tunnel syndrome and its treatment remains to be investigated.     

On the Microanatomy of the Brain and the Innervation and Homologues of the Cephalic Appendages of Hesionidae and Syllidae (Polychaeta)

Abstract Earlier papers dealing with the anatomy of the hesionids and syllids were studied. Thereby it was found that information about the structure of the central nervous system was meagre. As a result, the anterior end appendages, especially the large, laterloventral ones of the Syllidae, have been differently interpreted. This prompted a re-investigation. The circum-oesophageal connectives, the brain commissures and the innervation of the alimentary canal and the cephalic appendages of a number of hesionid and syllid species were studied. The results, summarized in schematic diagrams, were compared with corresponding observations in other polychaete families. Among other things, it was concluded that not only the latero-ventral cephalic appendages of the hesionids but also those of the syllids are homologous with the palps of the nereids and of many other “errant” and “sedentary” families.