ABSTRACT
The family doctor system is a collection of the rules and operating patterns formed during the interaction between the top design of "universal health coverage" and the "contractual experiment" at primary level. Its optimization and upgrading call for continuous attention to primary policy response. A questionnaire survey was made to medical workers at primary healthcare institutions in Zhejiang,to learn the comments and willingness of participation of family doctors for the contractual service policy. The survey found the poor policy response roots in such constraints as lack of effective connection between top level and primary level,poor incentive design,and delayed supporting policies. In view of upgrading supplier policy response,the authors recommended feasible strategies to optimize policy response, namely priori decision-making,process control,both hard and soft tactics,and parallel efforts for both internal and external sides.
ABSTRACT
Objective To investigate the efficacy of modified 270°spinal canal decompression combined with one-stage pedicle screw fixation and vertebral reconstruction for severe thoracolumbar fractures.Methods A retrospective case-control study was made on 44 cases of severe thoracolumbar fractures treated from January 2009 to June 2014.There were 34 males and 10 females, with age range of 20-68 years (mean, 37.9 years).The injured vertebrae included T11/12 in one case, T12-L1 in 10, L1/2 in 21, L2/3 in nine and L3/4 in three.Injury type was all AO type B2.According to the American Spinal Injury Association (ASIA), neurological deficit was Grade A in three cases, Grade B in five, Grade C in 22, and Grade D in 14.Load sharing score (LSC) was 7-9 points (mean, 8.1 points), while the thoracolumbar injury classification and severity score (TLICS) was 7-9 points (mean, 8.2 points).According to the difference of surgical procedures, all cases were divided into traditional group (21 cases) and improved group (23 cases).The patients in traditional group were treated by 270° spinal canal decompression combined with one-stage pedicle screw fixation and vertebral reconstruction, and those in improved group were treated by modified 270°spinal canal decompression combined with one-stage pedicle screw fixation and vertebral reconstruction.Between-group differences were compared with regard to operation time, intraoperative blood loss, postoperative drainage, allogeneic blood transfusion, pain visual analogue scale (VAS) at postoperative 72 hours, Cobb angle, anterior vertebral height, spinal canal compromise, Denis score, work state, neurological function, bone graft fusion and complications.Results Duration of follow-up was (32.4±15.8)months (range, 12-60 months).No wound infection or deterioration of neurological function was found after operation.Operation time was (2.4±0.5)hours in traditional group, less than (2.8±0.6)hours in improved group (P0.05).VAS was (3.2±0.9)points in traditional group and (3.3±0.9)points in improved group at postoperative 72 hours (P>0.05).Cobb angle, anterior vertebral height and spinal canal compromise in both groups obtained well recovery and maintained after operation (P0.05).At the last follow-up, ASIA Grade A was noted in three cases, Grade C in two, Grade D in 23, and Grade E in 16.Bone union was achieved in all cases, with no implant loosening or breakage observed.Thirteen cases in traditional group were found with residual bone fragments in the spinal canal after surgery, and two of them received revision surgery.Conclusions Either modified or traditional 270° spinal canal decompression combined with one-stage pedicle screw fixation and vertebral reconstruction can attain satisfactory clinical results in treatment of severe thoracolumbar fractures.However, the modified 270°spinal canal decompression can achieve more thorough decompression without reducing stability of the spine.
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Objective To explore the clinical efficacy and outcomes of thrombus aspiration in ST-elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PPCI). Methods A total of 664 cases of STEMI patients undergoing PPCI from Tianjin Chest Hospital from January 2013 to March 2015 were retrospectively analyzed. Patients were divided into two groups:primary PCI after thrombus aspiration group and conventional primary PCI without thromobus aspiration group. The base-line clinical characteristics, and the procedure of percutaneous coronary intervention were similar between two groups. The TIMI flow, LVEF, one-month outcomes and 12-month outcomes were compared between two groups. Results There were significant higher TIMI flow, LVEF in primary PCI after thrombus aspiration group than those of conventional primary PCI without thromobus aspiration group (P<0.05). At one-month follow-up, there were no significant differences in major adverse cardiac events (MACE) between the two groups. At 12-month follow- up, there were no significant differences in cardiovascular death, recurrent myocardial infarction and new hospitalization between two groups. The incidence of recurrent angina was significantly higher in non-aspiration group than that in aspiration group (P<0.05). There were the better survival functions without MACE in aspiration group than that of control group. Conclusion Thrombus aspiration, as an adjunctive method to primary PCI for STEMI, may improve TIMI flow, have beneficial effects on LVEF and reduce the incidence of recurrent angina at 12-month follow up.
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Objective To observe the effect of different doses of atorvastatin combined with probucol on contrast induced acute kidney injury (CIAKI) and serum uric acid in elderly patients.Methods Totally 121 cases admitted for coronary angioplasty were randomly divided into three groups.In standard combining treatment group (n＝35),atorvastatin 20 mg qn and probucol 0.25 g,tid were given with no loading dose intake before angioplasty.In intensively combined treatment group (n＝41),atorvastatin 40mg qn and probucol 0.25 g,tid were given with a loading dose of atorvastatin 40 mg and probucol 0.5 g at 2 hours before angioplasty.In intensive atorvastatin therapy group(n＝45),atorvastatin 40 mg qn were given,with a loading dose of atorvastatin 40 mg 2 hours before angioplasty.All patients were then evaluated 24 hours before and after angioplasty procedure,and their blood urea nitrogen (BUN),serum creatinine (Scr),serum uric acid (SUA),estimated glomerular filtration rate (eGFR) by modified diet in renal disease study (MDRD) method were tested.The serum and urine at 24 hours before and after operation were collected.Neutrophil gelatinase associated lipocalin (NGAL) were determinated by enzyme linked immunosorbnent assay (ELISA) method.Results After operation,eGFR was decreased in standard combining treatment group [(76.2±14.3) ml· min-1 · 1.73 m-2 vs.(71.9±17.9) ml· min-1 · 1.73 m-2,P＜0.05],while Scr,eGFR and uNGAL showed no changes in intensively combining treatment group and intensive atorvastatin therapy group (P＞0.05) ; BUN in the two groups was decreased [(5.6± 1.4)mmol/L vs.(4.7±0.9) mmol/L,(5.3±1.2) mmol/L vs.(4.8±1.2) mmol/L,P＜0.01,P＜0.05].SUA was reduced in intensively combining treatment group (P ＜ 0.05).uNGAL was increased in standard combining treatment group (P ＜ 0.05).Conclusions For elderly patients,intensive atorvastatin therapy and combining intensive treatment can both improve CIAKI.Only combination and intensive treatment benefit for decrease of uric acid.