Lean Management in Obstetrics and Gynecology: Application in the Ambulatory Clinic Pre- and Post-Kaizen

OBJECTIVE: The ambulatory clinic was an important departmental problem. Providers hated working there and patients complained about the wait times there. It seemed there were equal numbers of patients and provider complaints. In the spirit of solving the problem, data was gathered, a LEAN intervention was planned, and data was collected. METHODS: We defined the service families in the clinic as registration, vital signs, provider or ultrasound visit, nursing visit, and registration for the return visit. We walked the Gemba engaging all the staff in the process. Many observations pointed to long waits between and among the five stations. In order to study the current state, time data was collected by attaching a sheet of paper to a folder that the patient would carry themselves to all the clinical steps. On the sheet of paper each station logged the time that patient appeared and the time the patient left their sight. Data was gathered each day and every day from October 2016 to the summer of 2017. The data was analyzed. Leadership met and identified value and waste in the process. A Kaizen event was scheduled after the first set of measurements engaging all the staff. After the data was thoroughly analyzed and digested, brainstorming occurred. Together we determined our future state. We created a vision and strategic goals to reach our future state. RESULTS: The data pre-Kaizen event showed that the process of arrival to leaving took 124 minutes. We discovered that not every patient passed through each station. We learned the patients were on time or early for their visit most of the time. The providers were late most of the time by 1 - 1.5 hours. We learned how long each station took from the patient’s point of view. There were no statistically significant differences between ultrasound and provider visits;there were no statistically significant differences between midwife and physician visits. Each day of the week was similar. The arrival rate was higher in the morning because of the template. After the event, the total time in clinic did not change however the variability in time between and among each station decreased in variance. We informed the staff of these findings so that they could take responsibility for their part in the process. The atmosphere in clinic changed dramatically and the complaints from both providers and patients stopped. CONCLUSION: LEAN management was used to improve the clinic. It yielded important results, got the staff engaged in the process, and provided a way for the patients to see the efforts made by staff to improve.

HANS超前镇痛对宫腔镜术后疼痛及恶心呕吐的作用

目的:观察在妇科宫腔镜术前使用韩氏穴位神经刺激仪,对患者术后疼痛与恶心、呕吐症状的影响。方法:接受妇科宫腔镜手术患者80例,通过计算机生成随机对照表,依随机对照表将患者按1:1的比例随机分配到2组,每组40例。研究组(A组)术前30 min及术后即刻使用韩氏穴位神经刺激仪刺激患者内关-外关、劳宫-合谷穴30分钟,对照组(B组)术后即刻使用韩氏穴位神经刺激仪刺激患者内关-外关、劳宫-合谷穴30分钟,术后即刻、30 min及1 h使用疼痛量表评价患者疼痛及恶心、呕吐情况。结果:与对照组相比,研究组患者在术后即刻及术后30 min,疼痛及恶心、呕吐等不良反应均低于对照组,差异有统计学意义(P<0.05),术后1小时两组间各不良反应无明显差异。结论:术前使用韩氏穴位神经刺激仪,能有效降低妇科宫腔镜术后患者术后1 h内疼痛与恶心、呕吐症状。

A preliminary report on adjuvant analgesic efficacy of HANS in opioid tolerant patients with cancer pain

Objective： To observe the adjuvant analgesic efficacy of Han＇s Acupoint Nerve Stimulator （HANS） in opioid tolerant patients with cancer pain. Methods： A prospective non-controlled study was conducted. Opioid tolerant patients with cancer pain were enrolled and treated with both routinely analgesics and adjuvant HANS （2/100 Hz for 30 min/d, 5 d on and 2 d off for two weeks）. Cancer pain, quality of life （QOL）, anxiety and depression were assessed before enrollment and on d 8 and d 15 with the BPI-C, EORTC QLQ-C30, and self-rating anxiety scale （SAS）/ self-rating depression scale （SDS）, respectively; the therapeutic frequency of breakthrough pain （BP） and daily opioid dose were also recorded. Results： Totally 47 patients meeting the inclusion criteria participated in this study; 43 patients completed the two-week treatment and assessment. The mean scores of patient＇s ＂worst＂ and ＂least＂ pain intensity assessed with BPI-C decreased significantly on d 8 and d 15; the therapeutic frequency of BP also significantly decreased; but the average daily dose of opioids did not change significantly. For the nine symptoms in EORTC QLQ-C30 assessment, the mean scores of pain, fatigue, constipation and insomnia were significantly lower on d 8 and d 15 compared with baseline; the mean scores of the overall health status, nausea/vomiting and the incidence rates of both anxiety and depression also decreased significantly on d 15. Conclusions： To opioid tolerant patients with cancer pain, adjuvant treatment with HANS could improve pain release and patients＇ QOL by decreasing the severity of pain, fatigue, constipation, insomnia and other concomitant symptoms; it could also decrease the incidence rates of anxiety and depression.

A single nucleotide polymorphism in the IL1RL1 gene is associated with Behcet's disease in a Chinese Han population

AIM:To explore the association of single nucleotide polymorphisms(SNPs)in the IL33/IL1RL1 gene region with the susceptibility to Behcet’s disease(BD)in a Chinese Han population.METHODS:A total of eight SNPs in the candidate gene region(rs11792633,rs7025417,rs10975519 and rs1048274 in IL33;rs2310220,rs12712142,rs13424006 and rs3821204 in IL1RL1)were genotyped in783 BD patients and 701 healthy controls by the Sequenom Mass Array i PLEX platform.RESULTS:A statistically significant association was observed between IL1RL1 rs12712142 and BD patients.The frequency of IL1RL1 rs12712142 variant allele A was significantly lower in BD patients than that in controls(OR=0.8,95%CI:0.69-0.94,Pc=0.039);the genotype distribution(Pc=0.043)and additive and dominant genetic model analyses(OR=0.8,95%CI:0.69-0.94,Pc=0.040 and OR=0.72,95%CI:0.58-0.88,Pc=0.011)also indicated a strong association between rs12712142 and BD patients.CONCLUSION:This is the first study to reveal the association between IL1RL1 rs12712142 variant allele A and the decreased risk of BD in the Chinese Han population,indicating a protective role of IL1RL1 in the pathogenesis of BD.

SLC26A4 gene polymorphism and late-onset Alzheimer’s disease in a Han Chinese population from Qingdao,China

In a recent genome-wide association study, the SLC26A4 gene rs2072064 polymorphism was found to be associated with late-onset Alzheimer＇s disease in Caucasians. Here, we investigated this association in a large Northern Han Chinese cohort consisting of 599 sporadic late-onset Alzheimer＇s disease patients and 598 healthy controls matched for sex and age in a Northern Han Chinese population from Qingdao, China. Genotyping by the polymerase chain reaction-ligase detection reaction revealed that there were significant differences in the genotype （P = 0.017） and allele （P = 0.007） frequencies of the rs2072064 polymorphism between late-onset Alzheimer＇s disease patients and controls. The A allele of this polymorphism was significantly associated with a reduced risk of late-onset Alzheimer＇s disease （odds ratio （OR） = 0.792, 95% confidence interval （CI） = 0.670-0.937, P = 0.007）. When the data were stratified by the apolipoprotein E E4 status, there was a significant difference only among apolipoprotein E E4 non-carriers （genotypic P = 0.001, allelic P = 0.001）. Furthermore, the association between rs2072064 and late-onset Alzheimer＇s disease remained significant by logistic regression analysis after adjustment for age, gender, and the apolipoprotein E E4 carrier status （dominant model： OR = 0.787, 95% CI = 0.619-1.000, P = 0.050; recessive model： OR = 0.655, 95% CI = 0.448-0.959, P= 0.030; additive model： OR = 0.792, 95% CI = 0.661-0.950, P = 0.012）. These findings suggest that SLC26A4 is a susceptibility gene for late-onset Alzheimer＇s disease in a Northern Han Chinese population from the Qingdao area.

Pain management using Han’s acupoint nerve stimulator combined with patient-controlled analgesia following neurosurgery A randomized case control study

BACKGROUND： Han＇s acupoint nerve stimulator （HANS） has been frequently used to relieve pain by promoting the central nerve system＇s release of endogenous opioid peptides through electric stimulation to the body surface. OBJECTIVE： To investigate the pain-relieving effects of HANS, combined with patient-controlled analgesia, following neurosurgery, and to observe adverse reactions and effects. DESIGN, TIME AND SETTING： A randomized control observation was performed at the Department of Neurology in the First Affiliated Hospital of Gannan Medical College （Ganzhou, Jiangxi Province, China） from January 2005 to February 2006. PARTICIPANTS： Forty patients, who were selected for craniotomy and required pain relief following surgery at the Department of Neurology in the First Affiliated Hospital of Gannan Medical College （China）, were included in this study. METHODS： Forty patients underwent neurosurgery and were randomly divided into two groups： patient-controlled analgesia plus HANS （＋HANS, n = 20） and patient-controlled analgesia （-HANS, n = 20）. Both groups were well matched in baseline data. Automatic syringe infusion pump ZZB-150 was the product of Nantong Aipeng Medical Instruments Co., Ltd. （China）. Patient-controlled analgesia consisted of 100 mL 0.02% lappaconitine/0.02% metoclopramide. LH-402 HANS instrument was produced in Beijing （China）, with a serial number of 402183. The HANS instrumentation was used to stimulate the Hegu-Laogong acupoint on one side and Jiaogan, Shenmen penetrating Shen, Waifei, Naogan penetrating Pizhixia ear acupoints on the affected side for one hour, with 2-hour intervals. The disperse-dense wave was alternating, with a 2/100 Hz frequency of electrical stimulation. MAIN OUTCOME MEASURE： The scores of visual analogue scale and incidence of adverse reaction were observed in two groups following surgery. RESULTS： Compared with the HANS group, the visual analogue scale scores were remarkably lower in the ＋HANS group six hours after surgery （P 〈 0.01）, and the incidence rate of adverse reactions, such as nausea and vomiting, was also decreased （P 〈 0.05）.CONCLUSION： The application of HANS to induce body surface stimulation can enhance the effect of pain relief and reduce adverse reactions when used in combination with patient-controlled analgesia following neurosurgery. The effect of combined therapy is superior to patient-controlled analgesia alone.

Genetic association of urokinase-type plasminogen activator gene rs2227564 site polymorphism with sporadic Alzheimer's disease in the Han Chinese population

A missense C/T polymorphism in exon 6 （the NCBI rslD is rs2227564） of the urokinase-type plasminogen activator gene has been identified as a possible hot spot for Alzheimer＇s disease risk. The present study analyzed urokinase-type plasminogen gene polymorphisms of rs2227564 with sporadic Alzheimer＇s disease by PCR-restriction fragment length polymorphism. Results showed that CC, CT and TT genotype distribution frequencies had significant differences between sporadic Aizheimer＇s disease patients and healthy controls, in-depth analysis of the association between urokinase-type plasminogen gene rs2227564 polymorphisms and sporadic Alzheimer＇s disease indicated that people with the C-positive genotype CC ＋ CT were at a higher risk for developing sporadic Alzheimer＇s disease. These results support the contribution of the polymorphisms of rs2227564 in the urokinase-type plasminogen gene to the pathogenesis of sporadicAIzheimer＇s disease in the Han Chinese population.

龙江韩氏妇科对“肝肾同源”理论的传承应用

“肝肾同源”最早见于《易经》,医学概念源自《黄帝内经》。五行中肝属木,肾属水,水生木,肾为肝之母,肝为肾之子,肝肾同源,乙癸同源,精血互生互化,二者在生理上互相联系,病理上互相影响。龙江韩氏妇科历代医家重视“肝肾同源”理论,发展并应用于指导临床。龙江韩式妇科奠基人韩百灵教授,最早提出“肝肾学说”,其子韩延华教授作为代表性传承人,在韩百灵教授的理论思想指导下,创新性提出“肝主冲任”理论,并创立百灵育阴汤、补肾活血调经汤和百灵调肝汤等代表性方剂,运用于临床不孕症、闭经和月经先后不定期的治疗中,取得良效。本文围绕“肝肾同源”理论,追溯其起源,阐述韩氏妇科对其传承及应用,体现中医理论的传承和创新,为妇科同行提供借鉴。

龙江韩氏妇科诊治PCOS临证经验探析

多囊卵巢综合征(polycysticovariansyndrome,PCOS)是一种极为复杂的内分泌与代谢紊乱性疾病。西医认为该病病因不明,中医认为,肾精不足是引发本病的核心病机。龙江韩氏妇科韩延华教授对该病的认识有着独到的见解,认为该病的发生多责之于肝肾二脏,因此,从肝肾论治PCOS,临床往往取得良好效果。

GSTM1与GSTP1基因多态性对红细胞GST酶活性的影响

目的研究单独或结合GSTM1纯合缺失基因型时,不同GSTP1基因型对红细胞GST酶活性的影响。方法GST酶活性参照Habig等报道的方法用紫外分光光度法测定。用多重PCR分析GSTM1基因多态性,PCRRFLP检测GSTP15号外显子105位密码子基因多态性。结果汉族人的GSTM1纯合缺失频率为56.1%,GSTP1105I/I、I/V和V/V基因型频率分别为60.7%、35.2%和4.1%。杂合I/V基因型组的平均GST酶活性(3.53±0.63U·g-1Hb)比野生I/I基因型的GST酶活性低(4.25±1.07U·g-1Hb,P=0.000),比突变V/V基因型的GST酶活性高(2.44±0.67U·g-1Hb,P=0.004)。在GSTM1(-)基因组,GSTM1(-)/GSTP1I/I基因型携带者的GST酶活性比GSTM1(-)/GSTP1I/V或V/V携带者的高,而在GSTM1(+)组,两组间的酶活性无差异。不同年龄组平均GSTs活性无差异,而女性的平均GSTs活性比男性的平均值高,但差异无显著性。结论尽管其它GST酶可能会稀释GSTP1基因型对GST酶活性的效果,GST酶活性仍与GSTP1105Val基因型呈很强的相关性。

龙江韩氏妇科从脾肾论治低置胎盘

龙江韩氏妇科是国家中医药管理局首批中医学术流派传承建设单位,在全国中医妇科学术界享有盛誉,韩氏妇科在中医理论上守正创新,临证上颇有建树。本文仅对韩氏妇科治疗低置胎盘进行阐释,韩氏认为造成低置胎盘的原因主要是脾肾两虚,治疗上提出固护脾肾,补母体而调胎运,坚持“治病与安胎并举”的原则。临证中常以韩氏经验方“加味补肾安胎饮”加减化裁,补肾填精以养冲任气血,健脾益气以升举脏器,精血旺盛胎元得养,低置胎盘得以升举,从而提高妊娠成功率,临证屡获良效。并附验案一则,以飨读者。

中国汉族人群hGSTA1基因C-69T多态性分析

目的 研究中国汉族人群中人谷胱甘肽S 转移酶(hGSTA1 )C-69T基因多态性的分布。方法1 4 0例血样本来自中国2 5个省份的汉族人口,用聚合酶链反应 限制性片段长度多态性方法检测hGSTA1 69位点的变异。结果 中国汉族人群GSTA1基因 69位点的野生型纯合子(CC)基因型的分布频率为75 .0 %,突变型纯合子(TT)基因型为0 .7%,杂合子(CT)基因型为2 4 .3 %;C及T两种等位基因的频率分别为87.1 %及1 2 .9%。结论中国汉族人群GSTA1基因呈多态性分布。

谷胱甘肽硫转移酶基因GSTM1基因多态性与东北地区汉族人群肺癌易感性的相关性及其临床应用创新

目的:探究谷胱甘肽硫转移酶基因GSTM1基因多态性与东北地区汉族人群肺癌易感性的相关性及其临床应用创新。方法:选取2016年1月-2017年1月本院收治的肺癌患者中408例为研究组,选取同期健康体检人员303例为对照组,同组对象之间不存在血缘关系。以盐析法从支气管肺泡灌洗液或血凝块残留液中提取基因组DNA,采用PCR法及基于PCR基础上的限制性片段多态检测法(PCRRFLP),对各基因型进行检验和区分。采用回顾性"病例-对照"试验设计,危险度计算采用非条件性逻辑斯谛回归模型(Unconditional logistic regression models)分别对年龄、性别进行校正后计算比数比(Odds Ratios,OR)及95%可信区间(Confidential Intervals,CI)。结果:研究组GSTM1缺陷型基因频率为0.61,对照组为0.44,两组比较差异有统计学意义(P<0.05);GSTM1缺陷型与GSTM1功能型基因相比,缺陷型基因携带者患肺癌的危险升高2.084倍。结论:GSTM1缺陷型基因是导致东北地区汉族人群易感肺癌的主要因素,烟草致癌代谢活化是导致癌变的重要途径。

国医大师韩明向辨治气郁化火型郁证经验

郁证之气郁化火证是中医学常见证候之一,多表现为胸闷痞塞、烦躁易怒、口干口苦、头晕失眠等,主要见于西医学神经衰弱、癔症及焦虑症等。韩明向教授作为全国第四届国医大师,对郁证的治疗有着丰富的经验,尤其擅长运用“气郁化火”理论辨证论治。韩老认为“气郁化火”证是由内因和外因共同作用而成,因此不仅要“治病求于本”,还应根据外因进行个体化治疗。对于气郁化火型郁证的辨证用药,韩老从气、火、肝三个方面,以“行气解郁,疏肝泻火”为治疗准则,使用“丹栀逍遥散”为基本方,形成肝脾同调,甘苦并用,兼顾扶正的治疗特色。结合临证医案,阐述名中医韩明向教授的学术思想和临床经验,为指导临床实践提供帮助。

GSTP1基因多态性与新疆维、汉肺癌易感性的关系

目的探讨谷胱甘肽S转移酶P1基因（glutathione S-transferase P1,GSTP1）rs1695位点多态性与新疆地区维吾尔族（维族）和汉族肺癌患者的相关性。方法采用病例—对照研究方法,选取维族、汉族肺癌患者各80例作为病例组,另以维族、汉族健康人群各80例为对照组,运用限制性片段长度多态性聚合酶链反应（PCRrestriction fragment length polymorphism,PCR-RFLP）技术检测GSTP1基因Ile105Val多态性,分析其基因型频率在2个民族间分布的差异。结果 （1）GSTP1基因rs1695位点多态性在对照组与病例组中的分布均符合HardyWeinberg平衡;（2）在维族人群中,GSTP1基因rs1695位点基因型在病例组与对照组中的分布频率差异无统计学意义（P〉0.05）。在汉族人群中,携带G等位基因者发生肺癌的风险增加（OR=2.170,95%CI：1.146~4.107,P〈0.05）;（3）维族人群突变型杂合子AG和纯合子GG基因型频率均高于汉族,其中在对照组中维族GSTP1（GG）基因型频率较汉族高1.3倍（8.8%vs 3.8%）,但差异均无统计学意义（均P〉0.05）。结论 GSTP1基因rs1695多态性与汉族人群肺癌发病风险相关,与维吾尔族人群无关,其相关性具有民族差异。

北京协和医院面向全科医师的女性健康管理MOOCs建设

为响应国家政策的号召及基层全科医师培养的需求,北京协和医院(PUMCH)将线上课程(MOOCs)教学模式引入全科医师女性健康管理,进行了一次大胆的尝试。通过对项目的背景、过程、优势、展望等的分析,以期由一次小规模尝试的成功来使这种教学模式得以逐步推广,并最终使基层全科医生女性健康管理水平得以逐步提升。

河北健康汉族人群GSTO2基因多态性研究

目的探讨河北汉族人群谷胱甘肽硫-转移酶O2(GSTO2)基因多态性的分布情况。方法应用聚合酶链式反应-限制性酶切片段长度多态性(PCR-RFLP)方法对210例河北汉族正常人进行GSTO2N142D和GSTO2 A183G基因多态性分析。结果河北汉族人群GSTO2 N142D和GSTO2 A183G基因多态性符合Hardy-Weinberg遗传平衡定律。河北汉族人群GSTO2 N142D基因型频率分布和等位基因频率分布与贵州汉族人群、台湾地区人群、泰国人群、伊朗人群、意大利人群、美国人群有显著差异(P<0.05)。河北汉族人群GSTO2 A183G基因型频率分布与台湾地区人群、德国人群、美国人群有显著差异(P<0.05),而与日本人群无显著差异(P>0.05);但其等位基因频率与台湾地区人群、日本人群、德国人群、美国人群有显著差异(P<0.05)。结论河北汉族人群GSTO2基因存在多态性,具有特异性。

上海地区汉族人谷胱甘肽S转移酶基因多态性分析(英文)

目的 测定GST基因在上海地区健康汉族人中的遗传多态性 ,筛选出汉族人的GST候选单核苷酸多态性 (SNP)位点 ,为开展GST基因多态性与汉族人群肿瘤易感性及治疗相关性研究作一初步探索。方法 采用荧光标记自动测序法 ,筛选GSTT1,GSTM1基因在 2 0名上海地区的汉族健康志愿者中的候选SNP位点。结果4例受检者在GSTT1外显子 4和 3之间的第 86 0 5 7位点发生点突变 ,由腺嘌呤A取代鸟嘌呤G ,经与Genebank中SNP数据库比对 ,可能为一新的GSTT1基因候选SNP位点 ;在外显子 5的第 793位点和 92 1位点 ,所有受检者均为G&A的杂合子。GSTM 1在 8个外显子中均发现有候选SNP位点 ,但多为单核苷酸的杂合子。约 4 0 %受检者的外显子 2出现腺嘌呤A缺失 ,所有受检者在第 1383位点和 1385位点分别是A&G受C&G杂合子 ;在第 10 1位点 6 0 %个体为A&T杂合 ,4 0 %个体为腺嘌呤A的纯合子。我们还初步发现在外显子 2的 190bp以后可能存在多个碱基或小片段缺失。结论 上海地区健康汉族人的GST基因具有丰富的遗传多态性。这些多态性是否为汉族人所特有、与肿瘤易感性的关系 ,以及这些可能的候选SNP位点是否会造成其编码氨基酸的改变并引起产物蛋白一级结构的变化、进而导致GST酶活性发生改变而表现为具有不同的表型及基因型 ,尚需深入?

Skp2在人类及妇科肿瘤中作用的研究进展

肿瘤是一种细胞周期调控异常性疾病。细胞S期激酶相关蛋白2（Skp2）是一种与肿瘤的发生发展密切相关的细胞因子。是F-box蛋白家族成员之一；Skp2是泛素连接酶复合物的底物识别蛋白，通过泛素蛋白酶体途径降解p27、p21、p130等多种细胞周期调节因子，在多数恶性肿瘤中表达增高。Skp2基因被认为是一种原癌基因，具有癌基因功能，在人类肿瘤的发生、发展和生物学特性及转归中发挥着不可忽视的作用，具有潜在的诊断和治疗价值。该文总结了Skp2在人类及妇科肿瘤发生发展机制中的调控作用及其基因治疗现状的研究进展。

青海地区汉族胃癌患者血清P53、sFas蛋白表达

目的测定青海地区汉族胃癌(GC)、慢性萎缩性胃炎(CAG)、慢性浅表性胃炎(CSG)患者血清中P53蛋白、可溶性Fas蛋白(sFas)水平,明晰青海地区汉族胃癌患者血清P53、sFas蛋白表达特点。方法收集世居青海地区因消化道症状前来青海大学附属医院诊治的汉族GC、CAG、CSG患者,采用酶联免疫吸附法(ELISA)检测血清P53蛋白、sFas水平,并进行相关分析。结果 1.血清P53蛋白水平在GC组、CAG组、CSG组依次降低,差异具有统计学意义(P<0.05);2.血清sFas水平GC组较CAG组、CSG组明显降低(P<0.05);3.GC组血清P53蛋白与sFas间呈负相关,r=-0.543,P<0.05。结论青海地区汉族GC患者血清中P53蛋白显著升高、sFas显著性降低,二者联合检测有望作为胃癌诊断的一种新型的简单易行的检测指标。