军队医院医疗质量管理存在的问题及对策

随着我国医疗体制改革的不断推进,医院面临着自身管理体系和管理方式的重要革新。在新形势下,如何保证医疗质量管理更加规范、管理体系更加完善是医院管理者普遍重视的问题。医疗质量是医疗技术和医疗服务的核心、是医院竞争力的实质、是医院发展的根本。医院医疗质量的水平直接影响着患者的受益程度,也影响着医院自身的声誉和效益。因此,加强医疗质量管理可以有效地保证患者的利益,提高医院竞争力,促进医院可持续发展。随着社会的发展、科技的进步、医学模式的转变及国防建设的需要,军队医院的职能和作用也发生了变化,其不仅为军人提供医疗服务,也为地方群众就医提供便利。军队医院的医疗质量管理直接关系着军人的健康保障,也影响着地方群众的治疗效果。本文通过分析军队医院医疗质量管理存在的问题提出相应的对策,部队医院医疗质量管理部门应与时俱进,顺应国家医药卫生体制改革的同时,着眼于未来发展,建立健全医疗质量管理体系,改进管理模式,从而提高医疗质量,创造更高的经济效益和社会效益,以实现科学的可持续发展。     

Fatigue sacral fractures: A case series and literature review

Objectives:Fatigue sacral fractures (FSFs) are rare and often misdiagnosed. This study presents a series of FSFs and a meticulous literature review.Methods:The present is an 11-year (2010-2021) retrospective observational study. The characteristics of all adult patients with FSF, including demographics, fracture type, treatment, history of fatigue fracture and imaging were evaluated.Results:Eight cases (6 females; 75%), suffering from 12 fractures (4 bilateral cases) with mean age=33.4 years were studied. Two patients (25%) had suffered another fatigue fracture in the past. Mean symptoms’ duration prior diagnosis was 8.5 weeks, while mean symptoms’ duration after diagnosis was 10.75. In most cases (7; 87.5%), MRI revealed the fracture. According to the Kaeding-Miller classification; five fractures (42%) were grade III, four (33%) IV and three (25%) II. All patients were treated conservatively, with rest and analgesics, while three received vitamin D and calcium. One patient, due to delayed union, was commenced on teriparatide.Conclusions:FSFs are often misdiagnosed; therefore, they should be included in the differential diagnosis for chronic low back-or-hip pain in athletes. History of other fatigue injuries seems to be a predisposing factor. It is of paramount importance to obtain advanced imaging for identifying a FSF.     

No sex differences in evoked contractile properties after fatiguing isometric and isotonic exercise for the plantar flexors

Objectives:Females tend to fatigue less than males after isometric exercise, but less is clear for isotonic exercise. Further, there have been relatively few sex comparisons for fatigability of the plantar flexors (PFs). We sought to investigate potential sex differences in contractile properties after a sustained maximal voluntary isometric contraction (MVIC) and isotonic contractions.Methods:Twenty-seven physically active males (n=14; 22±2 yrs) and females (n=13; 21±2 yrs) randomly performed a 2 min MVIC and 120 concentric isotonic (30% MVIC) contractions for the PFs on separate visits. Before and after each fatiguing task, muscle activation was obtained from brief MVICs, which was followed (~2 sec) by tibial nerve stimulation at rest. Contractile properties including peak twitch, absolute and normalized time to peak twitch, and half relaxation time were calculated.Results:No sex differences existed for fatigue-induced changes in muscle activation (p=0.09-0.41; d=0.33-0.69) or contractile properties (p=0.19-0.96; d=0.06-0.94).Conclusions:Peripheral fatigue, as indicated by contractile parameters, did not differ between sexes after isometric or isotonic exercise. The PFs similar fiber type proportions between sexes or greater fiber type heterogeneity may explain why sex differences in fatigability, though common in other muscle groups (e.g., knee extensors), were not expressed in this muscle group.     

Recovery of the first and second phases of the M wave after prolonged maximal voluntary contractions

IntroductionWe compared the recovery of muscle electrical properties after maximal voluntary contractions (MVCs) of 1 and 3 min duration by examining separately the first and second phases of the muscle compound action potential (M wave).MethodsM waves were evoked by supramaximal single shocks to the femoral nerve throughout the 30-min recovery following 1-min and 3-min MVCs. The amplitude, duration, and area of the M-wave first and second phases, along with peak-to-peak amplitude and total area, were measured from the knee extensors.Results(1) The amplitude of the M-wave first phase increased to the same extent (and had the same time course of recovery) after the 1 and 3-min MVCs, whereas the amplitude of the second phase increased more markedly after the 1-min than after the 3-min MVC (P < 0.05). (2) The first phase remained enlarged for 2 min after exercise, whereas the augmentation of the second phase only lasted for 30 s. (3) After 30 min of recovery, the amplitude, area, and duration of both the first and second phases were decreased compared to control values (P < 0.05).ConclusionsThe similar enlargement of the M-wave first phase after the 1 and 3-min MVCs suggests that the extracellular K⁺ concentration attained after these contractions was similar. The mechanisms responsible for the long-term decreases in M-wave amplitude and duration are unknown at present, but are likely due to a decrease in the amplitude of individual transmembrane potentials and an increase in conduction velocity.     

Contribution of the rest–activity circadian rhythm to quality of life in cancer patients

Quality of life (QoL) is estimated from patients scores to items related to everyday life, including rest and activity. The rest–activity rhythm reflects endogenous circadian clock function. The relation between the individual rhythm in activity and QoL was investigated in 200 patients with metastatic colorectal cancer. Patients wore a wrist actigraph (Ambulatory Monitoring Inc., New York, NY) for 3–5 d before chronotherapy, and completed a QoL questionnaire developed by the European Organization for Research and Treatment of Cancer (QLQ-C30) plus the Hospital Anxiety and Depression Scale. The rest–activity circadian rhythm was characterized by the mean activity level (m), autocorrelation coefficient at 24h (r24), and the dichotomy index (I<O), a ratio between the amount of activity while in and out of bed. The distribution of the rest–activity cycle parameters and that of QoL scores was independent of sex, age, primary tumor, number of metastatic sites, and prior treatment. Both the 24h rhythm indicators were positively correlated with global QoL score as well as physical, emotional, and social functioning. Negative correlations were found between m, r24, or I<O and fatigue, appetite loss, and nausea. The rest–activity circadian rhythm appeared to be an objective indicator of physical welfare and QoL. This analysis suggests that circadian function may be one of the biological determinants of QoL in cancer patients.     

A bioenergetic model for simulating athletic performance of intermediate duration

Simulating factors affecting human athletic performance, including fatigue, requires a dynamic model of the bioenergetic capabilities of the athlete. To address general cases, the model needs inputs, outputs, and states with a set of differential equations describing how the inputs affect the states and outputs as functions of time. We improve an existing phenomenological muscle model, removing unnecessarily fast dynamic behavior, adding force–velocity dependence, and generalizing it to task level activities. This makes it more suitable for simulating and calculating optimal strategies of athletic events of medium duration (longer than a sprint but shorter than a marathon). To examine the validity and limitations of the model, parameters have been identified from numerical fits to published experimental data.     

137Cs uptake in spring wheat (Triticum aestivum L.cv. Tonic) at varying K supply

Spring wheat (Triticum aestivum L. cv. Tonic) was grown for 16 days in a sandy loam soil which was contaminated with ¹³⁷Cs. The soil was fertilised with K at three rates (0,1 and 2 mmol K per 950 g dry soil) and with NO₃ ^--N at two rates (0 and 2 mmol per 950 g dry soil) in a factorial design. The ¹³⁷Cs Activity Concentration (AC) in the shoot tissue significantly reduced 8.2-fold (nil N treatment, p<0.001) and 9.3-fold (highest N dose, p<0.001) with increasing K supply. In contrast, the K application increased the ¹³⁷Cs AC in soil solution 1.7 fold (nil N treatment) or had no significant effect (highest N dose). At similar K application, the application of N increased the ¹³⁷Cs AC in the shoot compared to the control. This effect is most probably due to the increased NH₄ ⁺ concentration in soil solution which increased the ¹³⁷Cs AC in soil solution. The soil solution composition (¹³⁷Cs and K concentration) in the rhizosphere was estimated from the average soil solution composition at day 16 and solute transport calculations. The ¹³⁷Cs AC in the shoot tissue was predicted from the estimated soil solution composition in the rhizosphere and the relationship between K concentration and ¹³⁷Cs uptake derived from a nutrient solution experiment. The predictions of ¹³⁷Cs AC's in the shoot are qualitatively correct for the fertiliser effects but underestimate the observations between 1.4 and 9.9 fold.     

Evaluation of the anti-fatigue effects of a traditional herbal drug,Gongjin-dan,under insufficient sleep conditions: study protocol for a randomised controlled trial

BackgroundMany herbal medicines are traditionally used as anti-fatigue agents in east Asian countries; however, there is a dearth of clinical evidence supporting the anti-fatigue effects of such medicines and their mechanisms. This study is a feasibility trial to assess the clinical efficacy of Gongjin-dan (GJD) and verify its mechanisms by exploring fatigue outcomes, including endocrine and immunological biomarkers in humans.Methods/DesignTo investigate the anti-fatigue effects of GJD and the mechanism underlying these effects, a randomised, double-blind, placebo-controlled crossover clinical trial was designed. Participants (24 healthy male volunteers) will be hospitalised for 4 days (3 nights), during which acute fatigue and stress conditions will be induced by sleep deprivation, and GJD or a placebo will be administered (twice daily). The primary outcome will be changes in serum cortisol levels, measured in the morning, as an objective biomarker of sleep deprivation-induced fatigue and stress. The secondary outcomes will include: the Fatigue Severity Scale; the Brief Fatigue Inventory, and the Leeds Sleep Evaluation Questionnaire scores; levels of salivary cortisol, epinephrine, norepinephrine, oxidative stress-related biomarkers, homocysteine, and immunological factors; and heart rate variability. After a washout period of more than 4 weeks, a second treatment phase will commence in which participants who were previously administered the placebo will receive the drug and vice versa, following the same treatment regime as in the first phase.DiscussionThis study protocol provides a unique opportunity to enhance our understanding of fatigue and the effects of GJD on fatigue in terms of endocrine and immunological mechanisms by validating the study design and determining feasibility. Findings from this trial will help researchers to design a pilot or definitive clinical trial of traditional herbal medicine for chronic fatigue.

Trial registration

Korean National Clinical Trial Registry CRIS; KCT0001681, registered on 29 October 2015.     

Blood lactate responses in incremental exercise as predictors of constant load performance

Seven trained male cyclists (VO2max = 4.42 +/- 0.23 l.min-1; weight 71.7 +/- 2.7 kg, mean +/- SE) completed two incremental cycling tests on the cycle ergometer for the estimation of the "individual anaerobic threshold" (IAT). The cyclists completed three more exercises in which the work rate incremented by the same protocol, but upon reaching selected work rates of approximately 40, 60 and 80% VO2max, the subjects cycled for 60 min or until exhaustion. In these constant load studies, blood lactate concentration was determined on arterialized venous ([La-]av) and deep venous blood ([La-]v) of the resting forearm. The av-v lactate gradient across the inactive forearm muscle was -0.08 mmol.l-1 at rest. After 3 min at each of the constant load work rates, the gradients were +0.05, +0.65* and +1.60* mmol.l-1 (*P less than 0.05). The gradients after 10 min at these same work rates were -0.09, +0.24 and +1.03* mmol.l-1. For the two highest work rates taken together, the lactate gradient was less at 10 min than 3 min constant load exercise (P less than 0.05). The [La-]av was consistently higher during prolonged exercise at both 60 and 80% VO2max than that observed at the same work rate during progressive exercise. At the highest work rate (at or above the IAT), time to exhaustion ranged from 3 to 36 min in the different subjects. These data showed that [La-] uptake across resting muscle continued to increase to work rates above the IAT. Further, the greater av-v lactate gradient at 3 min than 10 min constant load exercise supports the concept that inactive muscle might act as a passive sink for lactate in addition to a metabolic site.     

Modelling human power and endurance

A generalised three component hydraulic model has been proposed to represent the human bioenergetic processes relating internal energy stores to performance during exercise, and into recovery. Further development of the model allows testable predictions to be made. In particular in this paper I examine certain hypotheses of chemical fuel shortage as a subgroup of the potential causes of fatigue, and their implications for maximal power and for endurance. The assumption that the limitation to sustainable power is direct proportionality to the glycogen store remaining, appears the most feasible. Based on this assumption, equations for the decline in maximum attainable power over time, the endurance at fixed workrates and the endurance at incremental tests (as a function of the increment slope) are obtained. Using published data for fit males, the maximum exertable power declines after about 6 s at 972 W to very low levels after about 2 min. For constant powers selected between 208 and 927 W, endurance declines from ad infinitum to only 6 s. Endurance at VO2max is predicted to be about 9 min. For incremental exercise tests of slope ranging from 30 W/min to 60 W/min, endurance lessens from 14 to 9 min. In these tests the anaerobic threshold is reached in times between 6 and 3 min. Although the power at termination of a test increases with incremental slope, terminal oxygen consumption is effectively constant. Almost all these model predictions are observed to correspond well with published experimental findings. These results suggest that the model can be used to represent an adequate overview of the operation of the human bioenergetic system.