1.常规检查的必要性 对住院患者进行一些常规检查和必要的辅助检查是正当的、正确的,也是可以很容易让人理解。 目前比较公认的常规检查包括血压、脉搏、血常规、粪常规、尿常规、胸部 X 线透视和心电图,这些检查涵盖了人体的五个重要系统或器官,可以对血液、消化道、泌尿系、心肺的状况进行初步的确认,在没有明确相关症状和体征的情况下,检查结果正常,可以让我们对相应的系统和器官多一份放心,这份放心是必要的,因为在疾病的最早期,并不一定首先出现相应的症状和体征,如果检查中有不正常的情况,无疑对我们的诊疗工作十分有价值。 在我们的实际临床工作中,疾病初步诊断相关以外的常规检查常常是正常的,有部分的不正常也并不一定有助于我们发现某种潜在的疾病。但我们确实通过这些常规检查发现了许多。我在十多年的临床工作中,患者大多数因为骨科疾病要进行手术治疗,有一些因为血压高发现了高血压病、有一些因为尿糖高发现了糖尿病。从这个角度讲,这些常规检查的必要性是可以支持的。 2.常规检查受到社会经济水平或支付者经济能力的制约 通常,这些检查十分廉价。以我们现在普遍的社会经济水平,这些成本是可以承受的。但,在我国和世界上一些贫困的民众,倘若全部或部分医疗费需要他们自己承担,那么,即使一项心电图检查,也会成为他们的重要经济负担。所以,每一项再廉价的检查,只要存在成本和支付(不管是谁支付),都要对检查的必要性和成本控制问题进行权衡。 我们要实现完美医疗,医疗费用的控制是一项十分艰巨的任务。完美医疗认为,在制定诊疗计划时,需要考虑检查成本的问题,检查的选择和医疗费用的控制之间的最佳点,应该可以达到一个当前社会经济状况允许、或者基本医疗允许的水平。如果一个国家或地区的社会经济水平不允许对上述提及的常规检查进行全部检查,可以给予一定条件进行限制,比如:脉搏不正常或有胸闷、心慌症状的患者,才给予心电图检查,这样就可以节约大量的心电图检查费用。相反,如果那个国家或地区足够发达,不仅可以给予她的民众全部的检查,还可以增加血液生化、重要脏器的 B 超检查等。 常规检查项目的确定,或者制约条件,完全可以通过政策制定加以规范,甚至可以通过在民众中进行普及宣传,群众的监督是最可以达到普遍严格执行的手段之一。所以,有关规则的执行并非不可行。 我们可以得出结论:常规检查的必要性是因为疾病诊疗的需要,但是受到社会经济水平,特别是支付者经济能力的制约;常规检查可以通过设定条件予以限制,这样可以节约医疗费用。 3. HIV 检查的谎言 在有的医院,把一些很特殊的检查也作为住院患者的常规检查,比如艾滋病病毒抗体( HIV )的检测。进行这种检查的理由主要包括如下两种: 1 .保护医护人员免受感染。 2 .避免今后患者罹患 HIV 引起的纠纷。 这两种理由都是站不住脚的。 一个需要急诊进行手术的患者,迅速抽取的血样,送出去进行检测,初步检测结果回报到医护人员处,需要 1~3 天时间,此时手术早已经结束。无论检测出 HIV 抗体阳性还是阴性,对于医护人员防护都没有实际意义,何况,检测结果存在假阳性或假阴性的可能,需要进行进一步的检测才能最终找出真相。显然,为保障医护人员免受患者携带病毒、细菌感染的唯一办法就是严格执行必须的无菌制度、隔离制度等相应的操作规程。 有人认为,住院期间检测 HIV 抗体,可以避免今后患者的纠纷。我们假设,检测结果是阴性的,出院以后若干时间,患者检测阳性,是不是就可以避免住院期间感染的可能性?当然不能。如果住院期间由于输血等原因感染,因为潜伏期等原因,并不能立即检测出,也是十分正常;而且,时下的检查常常是在入院初期就检查了,关键的治疗还没有给予,出院的时候也不会复查。避免这样的纠纷,关键是血源的规范与医院消毒的规范( 这其它章节详述) 。 如果住院期间,检测结果是阳性的,有人认为可以警示保护医务人员。这个说法看似很有道理,其实也只是借口而已。医护人员的职业保护,需要在平时工作的规范上下功夫,而不是检测出阳性就严格规范,未检测阳性,就可以放松而不严格规范。 HIV 的检测如果作为普查、筛查,应该由科研机构或公益资金承担,并且也要在征得当事人的同意。如果患者有诉求,即是按照规范要开展的诊疗行为;如果没有相应的诉求,则不应该以避免纠纷、保护医务人员等借口给患者检测,并要其承担费用。 医院常规检测 HIV 只是一个谎言。
美国Rosas HG在2009年6月的《Top Magn Reson Imaging》(核磁共振专题)杂志上撰文,总结了膝关节半月板的核磁共振MRI影像学。 文中称:在诊断膝关节半月板损伤上,膝关节核磁共振影像学技术已经发展成为一项具有高精确性的方法。膝关节核磁共振片子上可以显示出必要的解剖学细节。在这个保留半月板为导向的年代,膝关节核磁共振可以帮助我们选择相应的治疗策略。若想很准确的解读膝关节核磁共振片子,需要对半月板解剖学、半月板功能、半月板解剖变异、核磁共振技术、膝关节半月板撕裂的核磁共振表现、伴发的膝关节韧带损伤、膝关节半月板误诊的原因以及联合临床体格检查的重要性有全面的理解和把握。 Pubmed相应链接: http://www.ncbi.nlm.nih.gov/pubmed/20410803 Top Magn Reson Imaging. 2009 Jun;20(3):151-73. Magnetic resonance imaging of the meniscus. Rosas HG, De Smet AA. Department of Radiology, University of Wisconsin, Madison, WI 53792, USA. 启示:随着我国人民生活水平的提高,体育运动的增加,膝关节半月板损伤的患者也越来越多。膝关节核磁共振检查是一项很好的无创检查膝关节半月板损伤情况的手段和方法。但是,为了能够更好地解释膝关节核磁共振片子的病理意义,我们需要进一步提高对半月板解剖学、半月板功能、半月板解剖变异、核磁共振技术、膝关节半月板撕裂的核磁共振表现、伴发的膝关节韧带损伤、膝关节半月板误诊的原因以及联合临床体格检查的重要性的理解和把握。 (江苏省徐州医学院附属医院骨科 膝关节方向 高绪仁 编译)
Submitting your paper: final checks If you have written your paper, critically self-evaluated it and/or asked a colleague to evaluate it, and believe it to be as scientifically robust and well written as possible, you are ready to submit it to your target journal. You should by now have selected the most appropriate journal for your paper and written a convincing cover letter to the editor. Check that all of the instructions in the target journals Guide for Authors are complied withif any are not, then these should be addressed before the paper is submitted or they could cause delays later on. This includes ensuring that the manuscript and any figure files are saved in the appropriate file format and of the requested resolution. Most journals encourage online submission, which usually requires registering with the target journal and setting up a submission account. This is a step-by-step procedure in which details such as full names, departmental addresses, highest degrees awarded and full contact information for all authors, not just the corresponding author, are usually requested. Following registration of an account, the submitting author will be able to upload all relevant files, including manuscript file, cover letter, separate figure files and any supplementary material files, to the journals online submission system. Some journals request submission by post, which requires posting the requested number of identical printed copies of the manuscript along with an electronic copy of all files on a CD. Frequently, each author is required to sign a declaration agreeing to the submission to the journal of a paper bearing their name, although some journals now verify this by e-mail. During the submission process, there might be a requirement to pay any submission costs, although publication costs are not usually requested until after a manuscript is accepted. Any figures or other content that are being reproduced or modified from previously published work will require the appropriate permissions, and these are sometimes requested at the time of submission. If a manuscript is accepted, the copyrights to the manuscript will need to be transferred to the publisher; the relevant forms for copyright transfer are sometimes made available during the submission process. The submission process sometimes allows you to recommend or exclude potential reviewers of your manuscript. If not, it is usually worthwhile doing so in your cover letter. The journal editors will try to appoint independent experts as reviewers, but will also be aware that many fields are intensely competitive among labs. They will also appreciate that your unpublished data needs to be treated sensitively, and that it might not be appropriate to put that in the hands of a competitor working on the same thing. Thus, it will help them to know who might be a friendly reviewer and who might be less friendly. The editors will almost certainly not appoint only the reviewers you suggest and exclude all those you ask to be excluded, but they will use the information you provide to make an objective decision about who should and who should not review your paper. In choosing who to recommend as a potential peer reviewer, you should consider any researchers whose hypotheses and ideas your work supports; for example, if your work builds on previously published work, extending or confirming the findings of that work, then the senior author(s) on such a study would likely be a good candidate reviewer. A look through your reference list will help you to identify such candidates, and reading their papers closely will give you an idea of whether their thoughts are in line with your own, or perhaps opposed to them. Ideally, recommend senior researchers in the field who have propounded ideas that would be supported by the findings of your study. International collaborators in the same field also represent potential friendly reviewers, although if you have previously co-published work with those researchers the journal editors might exclude them for potentially being bias. Working out who to exclude can be more difficult, but if you know that some other lab is working closely on the same thing, perhaps because you have seen researchers from that lab speak or present a poster at a recent meeting, it would be a good idea to ask the editors to exclude the Principle Investigator of that lab as a candidate reviewer. Also ask the editors to exclude researchers whose hypotheses or ideas are known to run counter to those suggested in your manuscript. Of course, any reviewers that are appointed will be asked to be completely objective in their assessment of your manuscript. Moreover, the editors will also be able to assess your manuscript to some degree and identify if the points raised by the reviewers are fair or not. If completely polarized reports (for example, one very positive and one very negative) are received, the editors may choose to appoint additional reviewers and delay a decision on your manuscript until they are satisfied with the reports they receive. Ultimately, if you have designed and executed your study well, show something novel and interesting, and written a clear and concise manuscript complying with the instructions for authors, you will have maximized your chances of getting over the final hurdle before acceptance. 投稿:最后检查 论文写完之后,要严格自查并/或找一位同事评价一下,尽可能确保文章具有很强的科学性和良好的撰写方式,然后就可以投向目标期刊了。此时你应该已经 挑选出最合适的期刊 ,并已经写出一份有说服力的 投稿信 给编辑。检查目标期刊的《稿约》,确保遵循了所有要求;如果没有,那就要在投稿前做相应改正以免将来造成延误。其中包括稿件和所有插图都保存为正确格式和所要求的分辨率。 多数期刊鼓励在线投稿,这通常需要在目标期刊注册一个投稿帐户。这是一个分步过程,通常要求输入全名、单位地址、最高学位和所有作者的详细联系信息(不仅是通讯作者)。注册之后,投稿作者把所有相关文件(包括正文、投稿信、插图文件和补充材料)上传到期刊的网上投稿系统。 一些期刊规定以邮递方式投稿,要求提交规定数量的论文打印件和含所有文件的光盘。通常每个作者都要签署声明表示同意向杂志投稿并在论文上署名,不过有些杂志现在也通过电子邮件进行确认。投稿过程中可能需要交纳投稿费,但是大多数情况下出版费都是论文被录用之后才会征收。任何从已发表的文献中转载插图或其他内容都要获得许可,有时在投稿时杂志社就会要求你提交此类许可证明。若论文被录用,论文的版权就要转让给出版商;有时,在投稿时就要填写一份版权转让表。 投稿过程有时允许你推荐或排除潜在的论文审稿人。如果没有这个过程,你也可以在投稿信中推荐或排除。期刊编辑会尽力任命独立专家为审稿人,但也知道许多领域的实验室之间存在激烈竞争。他们很清楚:你尚未公开发表的数据具有敏感性,把它交给直接竞争对手有可能不合适。所以,他们愿意知道谁可能是友好的审稿人,谁可能不那么友好。编辑们几乎肯定不会只任命你推荐的审稿人或排除所有你请求排除的人。他们会用你提供的信息来客观地决定谁应该和不应该审读你的稿件。 在选择哪些专家可列入推荐审稿人时,你应该考虑那些你论文所赞成的研究或观点的作者;比如,若你的工作基于之前发表的一篇文献并发展或确认了其结果,则该文献的资深作者就是好的候选人。你的参考文献可以帮你找出这些候选人,仔细阅读他们的论文就能知道他们的观点是否与你相符或相反。在理想状态下,你的研究发现能支持你所推荐的本领域资深研究者所提出的观点。相同领域内的国际合作者也可成为友好的审稿人,不过如果你们之前共同发表过论文可能会被编辑以偏向性理由排除。 确定谁应该被排除出审稿人行列要更为困难。但是,如果你知道有另一实验室在做同样的工作(也许你在最近召开的一次会议上听过该实验室成员做的报告或张贴的壁报),就可以请编辑把该实验室的主要研究者排除出审稿人行列。此外,也要请编辑把观点或假设与你相反的研究者排除在外。 当然,期刊会要求任何审稿人完全客观地评议你的稿件。而且,编辑也会在一定程度上评估你的稿件来判断审稿人的意见是否公正。如果收到的审稿意见完全相互矛盾(如一个非常正面,另一非常负面),编辑可能会再找一个审稿人来评议直至对审稿意见满意,这会推迟你投稿的决定意见。归根结底,只要研究的设计和实施都没有问题,结果有新颖和有趣之处,行文清楚简洁并符合《稿约》,你的论文就有最大的机会能逾越这些障碍并最终被录用。 在这里还需提请各位注意,Dr. McGowan 的母语是英语,无法阅读中文,因此请大家尽量使用英文回帖,如有任何需要与他沟通的学术和语言问题也请使用英语,Dr. McGowan 会及时回复大家的。 Dr. Daniel McGowan 曾任 Nature Reviews Neuroscience 副编辑,负责约稿,管理和撰写期刊内容。于2006年加入理文编辑(Edanz Group) 并从2008年起担任学术总监。Dr. Daniel McGowan 有超过十年的博士后和研究生阶段实验室研究经验,主要致力于神经退化疾病、分子及细胞生物学、蛋白质生物化学、蛋白质组学和基因组学。