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新形势下医学科研选题的原则和方法

2018-02-01  921

摘 要 随着我国科技工作的迅猛发展,科研选题愈发成为整个科研工作的关键环节。新形势下,医学科研选题要遵循创新性、实用性、科学性、可行性等原则,还应该掌握一些基本的选题方法:从各级科研课题申报指南中获得启发;博览文献,捕捉灵感;结合特色,从临床实践中挖掘新课题;借鉴中发展提高;交流协作中学习、进步。关键词 医学科研选题;原则;方法  科研选题是科研工作的起点和关键环节,关系到整项科研工作的成败和科研成果的大小,这正如爱因斯坦所言“提出一个问题往往比解决一个问题更重要”,也是每个科研工作者的亲身体验。自20 世纪80 年代以来,包括临床一线、科研管理部门、期刊界等多个行业在内的专家学者对医学科研选题的原则和技巧进行了有益的总结和报道,对科研工作的开展起到了较好的引导作用。近年来,随着我国医学科技工作的迅猛发展,很多领域尤其是常见病、疑难病的诊治方面都有了突破性进展,然而一些科研人员却产生了“山重水复疑无路”的感觉,一不小心就会落入“重复”的陷阱。另外,随着科研工作受关注程度的提高,经验不足的科研人员“跟风”或“被迫”搞科研,导致很多科研工作无疾而终。可见,在新形势下,医学科研选题的原则仍然要遵循,方法也更应该被不断总结和运用,从而达到事半功倍、举一反三的效果。1 新形势下医学科研选题的原则 医学科研选题的原则主要包括创新性、实用性、科学性、可行性。本文结合《山东医药》杂志于2011 年10 月与北京积水潭医院联合策划出版这一实例,对以上原则进行解读。1.1创新性原则科研的本质和灵魂是创新,能否在选题环节充分体现创新性,是科研工作成败的关键。北京积水潭医院是我国最早创建骨肿瘤专业的医院,历经几十年的专业拓展,他们自有过人之处。首先,在技术上,国内使用计算机辅助手术导航系统的医院屈指可数,而北京积水潭医院已把该技术从脊柱外科拓展到了骨肿瘤科,不仅在复杂手术中取得较好的临床效果,而且对该系统的误差、与其他影像技术的结合等方面进行了深入研究;其次,在思路上,当国内很多单位还处于通过单一的手术方法治疗疾病时,北京积水潭医院骨肿瘤科已经过渡到了疾病的综合治疗期和反思期,所以专题主旨就是探讨“骨与软组织肿瘤的规范化治疗”,从骨与软组织肿瘤专业的特点分析出发,得出了肿瘤与骨科手术结合的规范化治疗的主张;最后,专题中的临床经验性稿件也均有新意,有对高难度手术的挑战,有对罕见病例的总结,还有对临床常用方法的改良等。可见,科研工作的创新并不局限,可以是大创新,也可以是小创新;可以是整体创新,也可以是局部创新;可以是理论创新,也可以是实践创新。只要有所创新,科研工作就有了生命力。1.2实用性原则这一原则包括前人提到的需要性和效益性两方面。需要性是科研工作的目的和意义所在。医学科研选题肩负着“救死扶伤”的重要意义,临床科研重点要解决疾病的发病机制、诊断方法、预防和治疗手段、预后等有关问题。由于骨肿瘤科是从骨科专业中独立出来的,所以临 床普遍存在重视骨科治疗而忽略肿瘤治疗的问题,突出表现在恶性骨肿瘤的治疗上,所以北京积水潭医院近年来把科研方向定位于各种骨与软组织肿瘤的规范化治疗,以真正提高该疾病的诊治水平。所有科研工作都必须产生社会效益和经济效益,总的原则是投入少、成本低、见效快、收效大。临床工作者应致力于具有临床实用价值的课题开发,而不能一味追求“高、精、尖”的基础课题,以免“剑走偏锋”,将研究方向引入误区。正如北京积水潭医院田伟院长所言,对于骨肿瘤来说,手术就像打开一个魔盒的钥匙,今天的医生不要过于自信地随意使用这把钥匙,以免花了很多钱买了金钥匙,结果却是还不如不开这把锁 。1.3科学性原则科研选题要符合客观规律,合乎逻辑,实事求是,观点新颖,论据充分,内容具体,方案切实可行。专题的作者均为临床一线的专家或医生,实验设计合理,研究方法和统计学方法可靠,大都符合对照、随机、盲法和重复的原则,而且临床资料和数据真实可信,所以得出的结论和经验经得起检验、推敲、重复和历史的证实,具有普遍性意义。1.4可行性原则科研人员要从实际出发,充分考虑自身所具备的主观条件和客观条件,保证课题按期进行。主观条件包括课题参与者的学历和资历、研究方向、专业特长、知识积累;客观条件主要包括科研经费是否有保障,是否有实验场所和研究所需仪器、设备,临床课题还应考虑是否能收集到足够的病例资料等。北京积水潭医院骨肿瘤科成功把计算机辅助手术导航系统应用于骨与软组织肿瘤的治疗上,得益于脊柱外科多年来的经验和体会,该课题得到了国家自然科学基金和首都医学发展科研基金等项目支持,而且也得到了清华大学电子工程系在技术上的指导和支持。可见,要结合个人优势,扬长避短,必要时组织科研协作,力争在“量力而行”的基础上使选题达到一定的高度。 2 新形势下医学科研选题的主要方法 新形势下,应当对医学科研选题的方法和技巧不断加以总结和更新,现结合工作体会,对主要方法总结如下。2.1 从各级科研课题申报指南中获得启发各级科研课题申报指南都会明确提出鼓励研究的领域和重点资助范围,科研人员应视其为良师益友,认真解读和领会,以准确掌握科研方向和动态。例如,2010 年度江苏省预防医学科研课题申报指南明确划定重点传染病研究范围包括流感、手足口病、霍乱、结核病、艾滋病、性病、病毒性肝炎等。当然,申报指南所列内容和范围都比较宏观、笼统,科研人员从中得到启发后,应结合自己的工作领域,从某一方面提出创意、见解并实现突破。2.2 博览文献,捕捉灵感文献是对前人研究和工作的总结和经验,蕴藏了大量的科研信息或选题来源。临床工作者和科研人员应定期、尽可能多地检索行业内文献,通过网络、报纸、期刊跟踪国内外医学新进展。尚无选题目标的科研人员应在浏览文献的过程中发现空白点,并对其相关研究进行系统了解和分析,确认前人没有做过此项工作且确有研究的必要和可能,从而可作为选题的参考。已有选题方向的科研人员,一方面可以通过自己查阅文献或由情报部门科研查新,验证选题的创新性,避免低水平的重复;另一方面也能在查阅文献时受到启发,发现新问题,提出新见解,增加新亮点,作为已有选题的有益补充。在检索和浏览文献的过程中,科研人员应随身备有专门记录科研题目的卡片或笔记本,以收集瞬间闪现的灵感,当然,所有的灵感都来自雄厚的理论和丰富的实践经验。选题确定后,应系统梳理相关文献资料,书写综述文章,作为选题的理论依据。2.3 结合特色,从临床实践中挖掘新课题很多临床一线工作者都会抱怨工作太忙,没有时间搞科研,尤其是在基层医院,手头素材太少,巧妇难为无米之炊。实际上,临床实践中的选题来源非常丰富,同种疾病患者的个体差异导致病情千变万化,工作中总会遇到各种各样技术和理论上的难题,只要多加留心观察和分析,都会成为好的科研选题。比如,发现疾病新的症状、病因、诊断指标,对疾病流行病学进行调查,改进药物的使用方法或剂量以提高疗效或降低不良反应,总结误诊、误治的经验教训,探讨手术时机的选择对预后的影响等,诸如此类,不胜枚举。偏远或基层地区的科研人员若结合当地特色,则能将劣势转换为优势。比如,青海、西藏等地可以研究高原缺氧对心血管疾病或呼吸系统疾病的影响;可能受遗传学因素影响的所有疾病或指标的研究均可在少数民资地区“照葫芦画瓢”;癌症的集中地、中药的种植地均可作为科研选题的对象并受到重视。2.4 借鉴中发展提高科研人员都希望自己的选题标新立异,甚至具有划时代的意义,但这并非易事,相对独立、与众不同的选题往往缺乏理论基础,经受压力和失败的可能性也比较大。科研工作还是要脚踏实地,站在巨人的肩膀上,通过借鉴别人的选题升华自己的构思是获得成功的捷径。借鉴移植是科研工作的重要方法,它把应用于某些疾病、学科、专业领域的先进方法、技术等移植应用于另外一些疾病、学科、专业领域,为己所用。常用的学科交叉区的立题方法主要是相互移植各学科领域的新概念、新成果、新技术。例如,有研究发现,胃癌、肺癌中血管内皮细胞因子(VEGF-C)的表达与淋巴管生成或淋巴结转移有关,刘天舟等据此进一步研究发现,VEGF-C 也可作为乳腺癌淋巴道转移和预后判断的指标之一;王立祥在介绍自己科研和发明技巧时提到的“以新带老、以老求新、借鸡生蛋、节外生枝、玩滚雪球”等方法也多为借鉴中创新。科研设计的三要素包括处理因素、受试对象和实验效应,在前人研究的基础上,试着改变其中任一因素,都可以形成一个新的选题。例如,对抗癌新药多西紫杉醇的应用,既可以改变受试对象,分别探讨其在乳腺癌、卵巢癌、前列腺癌中的应用;又可以改变用药方法,如单用或与顺铂、泼尼松等联合应用;还可以改变观察指标,如短期疗效、长期疗效、不良反应、抑瘤率、蛋白表达等。2.5 交流协作中学习、进步科研工作不是闭门造车,要广泛交流。临床医生要尽可能多地参加国内和国际的学术会议、病例讨论、专题研讨会、专家讲座等。一方面,可以从学术争论中受到启发,发掘选题;另一方面,可以勇于提出自己的选题,请行业内权威专家论证和把关;另外,还可以借机寻求单位或个人间的合作,取长补短,解决选题中的难点,以免好的选题因某些难点而被迫放弃或降低水平。科研协作是一种观念,贯穿科研工作始终,科研人员在选题阶段就要立足于协作[6]。走跨学科的科研大协作的路子,使基础医学与临床医学、中医和西医、军事医学和预防医学、药学和生物高技术等方面有机结合。通过积极协作、互通有无,节省人力、物力、财力,缩短研究周期,提高科研效率,高水平、高质量地完成科研选题和整个科研任务。总之,医学科研工作任重而道远,我们要在不断的临床实践中开动脑筋、积累经验、寻求技巧,通过高水平的科研选题为医学进步和人类健康作出应有的贡献。 

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Meta 分析:最贴近医患的科学研究

2018-02-01  902

最近,Meta 分析和临床试验频繁出现在临床热门问题的讨论中,每每抛出颠覆性观点,引起轩然大波。 2017 年 12 月,《柳叶刀》杂志刊出的一篇临床试验表明,不用吃药,控制体重、生活方式干预就可以控制早期糖尿病。同月,《美国医学会杂志》一篇 Meta 分析,挑战补钙的作用。2018 年1 月,《美国医学会杂志·心脏病学子刊》又一篇 Meta 分析质疑深海鱼油的效果。在这些争议里, Meta 分析和临床试验俨然判官,对过去做法或常识一一予以否定。 从科学理论探索到医学实践应用,这是一条漫长的链条,临床试验的 Meta 分析位于终端,构成了临床实践最坚实可靠的证据。 临床效果是最终的裁判员 医学存在的理由是疗效,而不是原理。牛痘接种、青霉素等,都是先有应用,而后才探究原理。但是,现代西药开发主要走的是一条相反的路,从原理到疗效。 例如,最近,阿尔茨海默症新药茄尼醇单抗(Solanezumab),经过近 20 年研发,最终证明无效。1984 年发现β-淀粉样蛋白,1985 年发现该蛋白可能与阿尔茨海默病有关,之后《自然》杂志和《科学》杂志以β-淀粉样蛋白为主题,共发表了逾百篇文章。2002 年美国礼来制药公司研发出茄尼醇单克隆抗体,可以清除β-淀粉样蛋白,有望治疗阿尔茨海默病,并通过了小鼠实验,以及人群中的Ⅰ期和Ⅱ期临床试验。但是,2014 年 1 月 23 日,《新英格兰医学杂志》发表了一项纳入 2000 多例阿尔茨海默病患者的Ⅲ期随机对照临床试验,结果显示茄尼醇治疗组与安慰剂组相比没有显著差异。这意味着近 20 年的研发功亏一篑。 为什么这个依据生物医学原理设计出来的药物在临床上无效呢?而且,这样“临门一脚”败下阵来的设计药物并不是个案,每一个成功的新药都有成百上千个没有走到终点的陪跑者。这只能说明,这些药物并不是离成功一步之遥,而是过去很多路可能都走错了,这些药物依据的生物医学理论可能是片面的,甚至是错误的。 针对人体内任何生理、病理现象,人们都可以提出很多貌似合理的机制或假说。但究竟哪个是对的,去证明它的路很长,而临床疗效是最后裁决的标尺:疗效不存在,理论都是浮云。 评估疗效 随机对照试验最可靠 一项治疗的临床价值,最终必须通过在人群中的临床测试来检验,这种测试叫作临床试验。临床经验、观察性研究和随机对照试验(实验性研究)都可以用来测试药物的临床效果,但是它们的结果不是同等可靠的。一般来讲,其科学性从高到低依次为随机对照试验、观察性研究和临床经验。 随机对照试验科学性最高,控制“噪音”的能力最强,能探测到很小的疗效信号。但是,在疗效十分明显时,如白内障手术、断肢再植、抗生素、麻醉、输血等,治疗几个或几十个病人的临床经验或者观察性研究,就足以证明疗效的存在,不需要随机对照试验。然而,如此特效的治疗并不多见,大部分治疗的效果并不那么明显。 例如,用降血压药物治疗 100 个病人,5 年之内,大概有 3 人会因为吃药而预防冠心病或脑卒中的发生,7 人即使吃药也照样发生心血管事件,另外 90 人即使不吃药也不会发生心血管事件。降血脂药、降血糖药、叶酸、阿司匹林等预防心血管病的药物,以及很多抗癌药等,效果都不那么显而易见。确定它们疗效存在与否,必须依靠严谨的随机对照试验。 因此,在治疗效果的问题上,尤其当疗效不大时,一般不能仅仅拿临床经验和观察性研究的结果来评判。 效果重要性主要看终末结局 随机对照试验也不都能提供有助于实际临床决策的信息。比如,大量随机对照试验显示,利多卡因可以改善急性心肌梗死后的室性心律失常,曾在临床上广泛使用,但如果用死亡作为衡量效果的结局指标,利多卡因可能增加死亡风险。又如,降压药可以降低血压,降血脂药可以降低血脂,降糖药可以降低血糖,但是这不是这些药物的最终目的,不能只盯着它们在这些指标上的作用,这些药物能否降低心血管病事件的风险,才是我们最关心的。同理,补钙可以提高血钙水平,增强骨质密度,但是否可以预防严重骨折才是最重要的。抗癌药也一样,它们可能会抑制肿瘤的生长,但如果不能提高生存时间和生活质量,仅抑制肿瘤生长的临床意义就小得多。 在上述例子中,心率、血压、血脂、血糖、骨质密度和肿瘤大小均属于中间替代结局,而死亡、心血管事件和严重骨折则属于终末结局。在评估药物疗效时,经常会使用替代结局,而不是更重要的终末结局,因为这样做可以节省时间和资源。终末结局发生很缓慢且频率很低,需要时间长、样本量大的随机对照试验才可以证明,这样的研究只有在最后确认疗效阶段,甚至药物上市后才会进行。但凡需以慢性终末结局为最终治疗目的的药物,评估过程多是如此。 因此,在疗效问题上,只拿中间替代结局上的效果说事,有时是靠不住的,而且也不能体现出治疗在终末临床结局上效果的大小。一定要追问终末临床结局上的效果。一般来讲,仪器测量的指标都是中间替代结局,如血压、血糖和影像,而病人可以直接感受到的,或理解其意义的指标则属于终末结局,如瘙痒和疼痛,又如失明、失聪和死亡。很多药物上市后受到质疑,不少是因为早期在替代结局上显示的效果,在终末结局上未得到确认,有些则是因为后来的研究发现,其慢性毒副作用远大于治疗带来的好处。 疗效评估时 Meta 分析不能缺席 理论、机理、学说以及基础研究和人群观察性研究的发现,往往不足以证明临床疗效,使用终末结局的随机对照试验,才是测试治疗效果相对可靠的方法。 但是,单个随机对照试验可能样本量太小,不能确定效果真实存在。也可能在研究纳入的病人中无效,而在其他病人中有效,反之亦然。还可能研究存在严重偏倚,无论显示有效或无效,都是错误的。所以,把所有已完成的随机对照试验都找来,并把它们的结果综合比较,考量所有相关信息后得出结论,这个方法就是 Meta 分析。 Meta 分析现在一般称为系统综述(systematic review),目前 Meta 分析专指系统综述里整合结果的统计方法。总结了有关一项治疗所有随机对照试验结果的 Meta 分析,就是该治疗效果的最全面、权威的证据。 由此可见,在日新月异的医学突破中,在精彩纷呈的医学信息里,随机对照试验的 Meta 分析呈现的结论,才是医生和患者最值得信赖的科学发现和决策依据。在有关疗效的争议中,任何 Meta 分析的缺席,都可能使论战“说不清,道不明”。例如,最近登榜的苄达赖氨酸滴眼液,就是一个 Meta 分析和临床试验双双缺席的讨论。 不过,有很多粗制滥造的 Meta 分析,也应充分警惕。Meta 分析自身可能存在的最大问题是漏掉了重要研究,尤其是漏掉了无效的研究,会造成高估治疗效果。一般来讲,除非蓄意,否则一个 Meta 分析漏掉重要大型研究的可能性很小。另外,漏掉几个小型研究对最终结论一般影响不大。但是,我们偏向于选择性地发表阳性结果的研究,很多小型阴性研究没有发表,那么,一项仅总结了已发表研究的 Meta 分析,可能会夸大实际的效果。 即使如此,任何关于临床疗效的争议,都需 Meta 分析的出席。如果总结了大量随机对照试验的 Meta 分析都说不清楚、争议不断,即便该治疗有效,效果也不会大,这时的决策一定要慎之又慎。

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Optimization of the blood culture pathway: a template for improved sepsis management and diagnostic antimicrobial stewardship

2018-02-01  804

Introduction Turnaround times of pathology results (from collection through to clinical interaction/issuing a report) have a significant impact on individual patient management, but also have a wider bearing on infection control/public health, hospital patient flows and antibiotic stewardship. Although blood cultures are collected from among the sickest patients, they are rarely treated as urgent. Without audit of the blood culture pathway (using specimen collection as the starting point), microbiologists and clinicians are unaware of significant preventable delays in obtaining results. Over 30 years ago, Holliman et al. highlighted the need for rapid microbiology results, reporting that antibiotic treatment was either initiated or altered on the basis of laboratory results in half of patients with significant positive cultures [1]. This was in an era where resistance to third-generation cephalo-sporins, quinolones and aminoglycosides was uncommon. Since then, antibiotic resistance rates have increased in clinical isolates, culminating in the emergence of carbapenamase-resistant Enterobacteriaceae. Blood culture technology has improved over the past decades, with laboratories now using analysers that monitor samples every 10e15 min and detect positive cultures 24 h/day. However, these developments have not been matched by changes in laboratory practice. The present-day convergence of the need for improved recognition and management of sepsis, increasing antibiotic resistance, and the need for enhanced antibiotic stewardship places greater demands on the laboratory for improved turn-around times of blood cultures, with both positive and negative cultures having an impact on patient management. The authors devised an optimized blood culture pathway in the study hospital. This study investigated the impact of this pathway on the turnaround times of results, and compared the blood culture turnaround times at the study hospital with those of five other laboratories that had not optimized their path-ways, and one laboratory that had taken some steps to improve blood culture handling and processing. Methods Optimization of the blood culture pathway Addressing load delays The guidelines of the UK Standards for Microbiology In-vestigations indicate that 100% of blood cultures should be loaded within 4 h of collection [2]. A baseline audit prior to the intervention revealed that more than 60% of blood cultures were taking >4 h to be loaded at the study hospital. This was corrected in three stages: Moving the FX blood culture analyser (Becton Dickinson, Oxford, UK) from microbiology into the blood sciences laboratory, allowed blood cultures to be loaded 24 h/day. Replacing glass bottles with plastic blood culture bottles, allowing samples to be sent via the hospital air tube system. Education of clinical staff on the importance of collecting and sending blood cultures to the laboratory without delay. Addressing unload delays Blood sciences staff processed blood cultures, flagging positive cultures outside of routine microbiology hours (08:30e20:00 h). Samples were plated on to routine laboratory media, including plates for direct Gram-negative sensitivity testing, extended-spectrum beta-lactamase testing and genta-micin minimum inhibitory concentration determination, in a portable class I safety cabinet. A Gram stain was not performed. Audit of blood culture processing in other centres     Audit of other hospitals Laboratories serving five other hospitals (teaching and non-teaching, some off-site) in the same health region as the study hospital provided the following data points on 27 consecutive Escherichia coli-positive blood cultures: time when blood culture collected; time when loaded on the analyser; time when flagged positive; andtime when removed from the analyser. None of these laboratories had optimized their blood cul-ture pathways. In addition, the same data set was collected for 50 consecutive blood cultures positive for E. coli at one other hospital (with an on-site laboratory) in another health region; a further data point (time when sensitivity data were inputted into the laboratory information management system) was also measured. These data were compared with the same time points in the study hospital.  Appropriateness of empirical antibiotic therapy Using a pro forma, the initial antibiotic therapy of 106 consecutive patients with significant positive blood cultures was reviewed. Antibiotic therapy was considered to be appropriate if the patient was prescribed at least one agent that was active against the blood culture isolate based on in-vitro antibiotic susceptibility testing. For deep-seated in-fections due to Staphylococcus aureus, agents with modest activity (e.g. co-amoxiclav) were considered as partial ther-apy. Inappropriate therapy was defined as no antibiotic treat-ment, any oral antibiotic therapy in a patient who was septic, or parenteral treatment with antibiotics to which the pathogen was resistant. The authors also considered whether Gram stain results, or identity of the organism, before antibiotic suscep-tibilities were available could have corrected inappropriate empirical therapy.  Results Blood cultures positive for E. coli Ninety-five percent of blood cultures were loaded within 2 h at the study hospital. In contrast, in the non-optimized hospi-tals, blood culture samples sometimes took over 24 h to load after collection 95% of bottles, with a range of 16e26 h (Figure 1). Ninety-seven percent of cultures positive for E. coli at the study hospital were removed from the analyser within 18 h of collection, compared with 42e56 h in the other hospitals (Figure 1). The average time from collection to unloading at the study hospital was 12.79 h, compared with 18.87e30.28 h in the other hospitals. The study hospital was also substantially quicker than the comparator hospital that had optimized its blood culture pathway at three defined time points. The overall impact of this was that >85% of blood cultures positive for E. coli had antibiotic susceptibilities reported within 36 h of specimen collection at the study hospital, compared with 66 h at the comparator hospital (Figure 2). Appropriateness of empirical antibiotic therapy Of 106 consecutive significant positive blood cultures, almost one-third (N¼34) of patients did not receive appro-priate empiric antibiotic therapy. Analysis of failure of initial empirical therapy showed that a Gram stain result could have corrected treatment in 19 (55.9%) cases, and enabled early identification of the organism in a further five (14.7%) cases. Early availability of antibiotic susceptibilities would have influenced treatment in 10 (29.4%) cases. Discussion Optimization of the blood culture pathway reduced turn-around times substantially. By optimizing the pathway, the authors were able to report 36-h negative blood cultures for neonates, in accordance with National Institute for Health and Care Excellence guidance [3]. This contrasts with the experi-ence in one UK region, where no laboratory could consistently provide real-time 36-h negative reports [4]. Reduction in load delays was achieved with minimal in-vestment because, as in most hospitals, blood sciences staff at the study hospital operate a 24-h shift system. Also, although the blood science staff at the study hospital entered complete patient demographics into the microbiology laboratory infor-mation management system, modern analysers allow anony-mous loading, so this step could be eliminated. Unload delays can be at least as long as load delays if blood cultures flagging positive outside routine hours remain on the analyser until the next working day. A national survey in 2012 found that some laboratories stopped processing positive blood cultures after 16:00 h during the working week and 12.00 at weekends [3]. Five years later, these practices continue in some UK laboratories. One potential impact of delays at this stage is that some bacteria, most notoriously Streptococcus pneumoniae, may complete their growth cycle and autolyse so that subcultures are negative. However, the main benefit of early results availability is facilitating appropriate antibiotic therapy. This study found that empiric antibiotic treatment was inappropriate in almost one-third of cases of true blood-stream infection, although, perhaps surprisingly, early anti-biotic susceptibility data influenced treatment in only 10 out of 106 cases. However, this study did not evaluate the impact of earlier blood culture results on rationalizing or stopping antibiotic therapy. There is a belief that all patients with positive blood cul-tures are on appropriate antibiotics, thereby mitigating the impact of delays. Such confidence is misplaced, as intrinsic to any antibiotic policy is the inevitability that it will not provide 100% activity against Gram-negative pathogens. Other studies, including a recent UK multi-centre study of blood-culture-confirmed Gram-negative sepsis, have found that approxi-mately one-third of patients do not receive appropriate empiric therapy [5,6] The present study, based in a district general hospital, may understate the size of the problem in other hospitals where patients may have infection with a wider range of micro-organisms, and where antibiotic susceptibilities may be more unpredictable. In the study hospital, making an incorrect initial diagnosis or failing to follow antibiotic pre-scribing guidelines were more common reasons for the inap-propriateness of empiric antibiotic therapy than unexpected antibiotic resistance. 

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浅谈临床医师的科研选题(节选)

2018-02-27  535

近年来, 国家对临床医学的科学研究投入逐渐加大,医疗界备受关注的各种医学院校、 医院及专科排名的公布,以及医务工作者自身晋升及提高所属医院及专科知名度等各种原因的激励下,各级单位乃至各级医师从事科学研究的热情高涨,对科研选题及申请基金资助的需求更加迫切。然而,对于多数非研究型大学附属医院的医学影像科医师而言, 首先由于临床工作十分繁忙, 难以有足够的时间充分审视、 回顾、 总结和规划自己的科研工作; 其次, 缺乏系统的科研培训也限制了自己科研规划能力; 再次, 所属单位的各个学科综合条件及其自身缺乏研究积累, 这些原因导致很多医师在投入科研工作及面对各级科研基金申请时,面对越来越激烈的竞争, 虽然满腔热情, 却又深感艰难, 无从下手, 难以施展拳脚, 甚至产生抵触, 认为临床和科研工作是相矛盾的, 临床和科研工作的基本层面是互通的、 互相促进并可以互相借鉴, 产生正反馈, 如果有矛盾,那就是一点,时间的冲突性,一个人花费大量时间在临床上 , 科研方面的投入必然减少 。 笔者自 1997 年至 2002 年在中山大学影像医学与核医学攻读硕士、 博士期间,从事白血病及地中海贫血骨髓 MRI 的临床研究 , 自 2003 年开始从事周围神经损伤及分子影像学的应用基础研究,这期间一直在国内独立开展自己的研究工作 , 自 2003 年首次获得国家自然科学基金青年基金后, 已陆续获得了五项国家自然科学基金面上项目的资助, 两项广东省自然科学基金向上项目资助 , 研究成果以通讯作者发表 SCI 论文 29 篇 , 包 括 《ASC Nano》、《Radiology》、 《Sci Rep》、 《J Mater Chem》、《Eur Radiol》、《AJNR》、《AJR》、《BJR》 等权威期刊 。随着研究成果的积累, 近年来获得了一些较大项目的资助 , 如广东省自然科学基金团队项目 , 并参与了国家 973 计划的子课题。 在这十几年的专业生涯中,深感对于一名临床医师进行科研工作十分的不容易,尤其是起步阶段倍感艰辛,但是一旦投入其中,取得一定的研究成果后, 就会发现科研工作也是内容丰富,对自己的临床工作思维及对疾病的理解有更深层次的理解,从事科研的兴趣也会养成并得到加强。在此, 笔者将其中一些自己的经验、 体会, 简述一二,希望能对正在从事或未来将要从事科研工作的年青医师有所启发或帮助。 以下所述均为结合本人自身经验所写,由于学识水平所限, 难免有偏颇之处, 还望各位读者阅后给予批评指正。 基金申请选对合适类别进行申报 国家及政府对科学研究及创新十分重视,对医学的科学研究投入越来越多, 相应的可供申报的科研基金项目门类比较多 。 按照研究内容来看 ,大致可分为 :(1)基础研究 ;(2)应用基础研究 ;(3)应用研究 。基础研究关注的是生命科学中关于生命, 如细胞、 基因、蛋白等基本生命单元的结构、 功能及作用机制等,是解开生命之谜,提高生命的质量等长远课题。 应用基础研究关注的是疾病过程中一些细胞、 基因、 蛋白等功能作用及其机制, 应用研究关注的是临床疾病领域中的诊断、 治疗及预防的新技术、新方法等,偏向于临床应用,主要是解决威胁人类健康和生命最大的疾病防诊治问题,比较适合临床医师进行申请, 这方面近年来关注的热点是大数据、 精准医学及转化医学研究。 一般而言, 省市厅级科技基金项目的着重支持应用研究, 如省市级卫生厅支持的科研项目,一些科技计划的社会发展项目。 而省级及国家级自然科学类基金, 对于临床医学而言, 资助的多为应用基础研究,在申请内容方面往往涉及大量实验内容。 近年来即使在省厅级科技项目方面,已有很多应用基础研究内容参与竞争并获得资助, 这反映了基金申请的竞争越来越大,获得资助的难度越来越高。 相反, 地市级基金, 竞争相对较弱,有良好研究基础的申请者不多, 水平相差也不大,比较容易申请到。除了这些常规的面上项目, 当个人的研究积累取得优异成绩后,可申请一些人才项目, 比如省级、 国家级杰出青年基金、优秀青年基金。 多个优秀的研究者可以组成团队,申请加入创新团队,科研平台、基地建设项目等。 这些不同层次的科研基金, 支持的对象及内容侧重点不同, 在申请科研基金项目时, 应做到心中有数, 目标明确, 从易到难,逐步提升。 对于广大临床医师而言,长期接触临床,具有丰富的疾病诊治的经验和病例资源, 较为合适的从应用研究开始, 再深入探索, 到应用基础研究, 当积累到一定程度,取得优异成绩后, 再申请各级人才项目资助, 逐渐形成自己的研究特色和体系。 基金申请需要平时多方面的积累 基金申请, 正如一座高楼, 没有牢固的地基是很难申请成功的。 除了申请资助内容具有创新性、 明确的科学意义或临床价值外,申请者必需具备相应的研究能力和研究经历, 掌握课题涉及的各项关键理论技术, 能够保证在基金获得资助后能够得以顺利完成。 这方面除申请者自身的教育经历、 研究经历外, 主要从以下几个方面进行考察和积累 :(1)研究论文 ,如发表在 SCI 收录期刊 ,中华 、 中国系列中文期刊的文章 ;(2)各级科技成果 ;(3)各项发明专利 ;(4)专著 。 这四方面是获得基金资助的有力支撑 ,和基金项目获得资助是正循环、 相互促进的关系。 对于缺乏基础的临床医师, 在准备申请科研基金之前, 最容易的是从积累论文开始, 不能等待, 其他三个方面的积累需进阶到一定水平方能做到。 申请者发表论文如果觉得难以着手,可尝试从发表本领域的中文核心期刊,到中华、 中国系列期刊,SCI 收录期刊 ,循序渐进 ,逐渐过渡 。 发表的论文数量越多,发表的期刊档次越高、越权威, 越有利于自己的申请获得评审专家认可,获得资助的可能性就越大。 需要提醒的是, 由于基金申请者水平近年来水涨船高, 评审者往往会关注发表的文章是否围绕申请人申请的课题方向,用不相关的论文进行凑数也难以获得评审者的肯定,因此发表的论文研究方向越集中越好。 这一点对于年青医师特别重要, 不围绕一个方向进行准备, 在基金申请中研究基础竞争力不强, 且在以后的可持续性发展方面也会受到限制。比如, 如有人要申请帕金森病的早期影像学诊断手段, 那么之前,申请者应尽量在帕金森病诊断方面发表多点好文章,在影像学新技术方面发表多点好文章。 科研选题应围绕临床实践 临床医师的大量时间为临床日常工作所占据,这对科研工作而言是不利因素,但对于科研选题是有利因素。 临床医师每天在日常工作中, 接触到很多实际病人, 遇到很多疑难病例,每一个临床医师内心都拥有去解决这些问题的原动力,这些疑难病例往往可成为自己科研选题的线索来源。 对于应用基础研究及应用研究而言, 选题的思路首选基本是从大到小逐渐聚焦过程, 即由疾病领域到临床问题到研究手段三个方面。首先是需要确定研究的疾病领域, 科研选题需要选择一些国家关注的重大疾病,如肿瘤、 心脑血管病、 自身免疫性疾病、 糖尿病、 慢性不可控性炎症等这些严重影响人们生命及健康的疾病, 其次是地方特色疾病, 如广东省较为常见的肝癌、 肝硬化、 鼻咽癌、 食道癌等, 再次是社会发展带来的一些人口问题, 比如由于人口老龄化, 一些神经退行性疾病发病率逐渐增高, 而治疗方面又存在困难, 这些疾病如帕金森病,早老性痴呆等。 选择这些疾病进行研究,那么在研究的意义和重要性方面已略胜一筹了。 在确定好疾病领域后, 其次是临床问题或者说是科学问题, 这些问题离不开疾病的三个方面,即预防、 诊断和治疗, 围绕疾病的防、 诊、 治目前存在的难点, 选择临床问题或者科学问题,进行研究。 比如疾病的诊断方面,如何进行某个重大疾病的早期诊断、精准诊断;治疗方面, 如何研发新的治疗方法;如何提供更优的治疗方法;预防方面,何种策略可进行疾病预防。 确定好疾病领域及临床问题后,接下来要考虑的是研究手段了。 历年来, 各项基金资助的内容其实围绕的疾病诊治内容变化并不大, 申请者需要从研究手段上挖掘自身的特色,申请者需要关注前沿、 热点研究技术手段,保证申请的项目里面才应用的研究手段具有先进性。 这是因为,不断出现的新的实验技术、 新的影像学技术, 可能会给我们对疾病发病机制、 发生发展过程带来新的认识, 从而可能给疾病的诊治带来新的突破。 医学影像学专业医师选题思路, 可首选关注于疾病的诊断领域, 这是医学影像学专业医师的擅长领域, 当今影像学新技术层出不穷, 如IVIM,ASL,DTI、 能谱 CT、fMRI, 静息态 MRI 等等 , 这些新技术能否给疾病的早期诊断和精确诊断带来帮助都是值得研究的问题,比如脑胶质浸润边界哪种影像学技术能够给予精确勾画;其次,是通过应用这些新的影像学技术, 能否帮助临床研发新的治疗手段和方法,比如哪些影像学新技术能够确定脑梗死溶栓治疗最佳时间窗。 科研选题的一些实际建议 尽管在以上方面讲了很多,到具体进行科研选题的时候,很多基层单位临床医师还是颇费周折, 倍感困难,主要集中体现在两个方面, 即难找科研题目, 其次是缺乏研究积累。 接下来,笔者将介绍一些具体做法,对于解决这两方面问题可能具有一定的帮助。由于基金申请的选题, 往往注重创新性, 很多人在选题时常感到没有什么好的新奇的想法。 对此首先要对创新性有所认识。 创新是科研的生命线,缺乏创新性,就会失去科研立题的前提。 就创新性而言, 有几个层次的创新,如:1)原始创新 ,即所选的课题是前人或他人尚未涉足的 ,当然也非天马行空想象出来的, 必须有理论基础的原始创新 ,这是最强的创新 ,也是最难做到的 。(2)自主创新 ,以往对某一课题作过研究, 但现在发现新问题、 新试验依据及新理论 , 促使该课题有新的发展 、 补充或修正 ;(3) 二次创新, 国外已有研究, 但尚需结合我国临床实际情况进行研究,填补国内此领域的空白。 不同级别的基金项目,对于创新的水平也有不同要求。 目前,在省市级别的基金申请中,大多数是自主创新和二次创新。 对于国家级别的重大重点项目,对项目的原始创新要求更高。在明确创新性要求之后, 就应思考如何科研选题了,科研选题不会凭空产生不会从天而降, 而是来自勤奋实践和反复思考 , 并采取有效的方法 , 如 :(1) 密切注意临床中发现的一些特别现象, 需要注意临床出现的偶然现象、 反常现象,也就是有些病人出现了并非预期的一些影像学特点或表现,留心到此现象,寻找原因,通过书本或者文献检索无法寻找到原因时,就可能成为一个课题,接下来通过思考,进行课题设计,申请基金,收集更多样本,进行观察,总结规律,寻找到原因。(2)注意临床各学科中关于疑难病例的诊治问题,寻找临床学科的关注点,由于各专科医师对其他学科的新进展和新技术往往并不熟悉,而临床医师在疾病的诊治中往往会提出一些问题,需要别的学科进行解答或者帮助,这也是科研选题的切入点。(3)积极开展并参加多学科会诊讨论,现在很多大型医院科室间开展了很多多学科会诊讨论,医学影像学科往往是多学科会诊必不可少的一个学科,在这些多学科会诊中,不同学科的专家围绕疾病的诊断和治疗进行深入分析,往往会产生一些新的想法。比如,笔者在参加内分泌科多学科会诊时,内分泌科专家提到糖尿病足的夏科关节早期诊断十分重要,早期诊断便于采取措施最大程度保留关节功能避免患者残疾,而临床对于糖尿病夏科关节无统一的早期的诊断标准,由于笔者在周围神经病方面研究较多,因此就提出可否利用周围神经磁共振成像术来作为糖尿病夏科关节的早期诊断手段,就此,笔者的学生申请了广东省卫生厅基金项目,成功获得资助。这说明,在临床实际工作中,有大量未解之谜,或者有待改善的疾病诊治方面问题,只要我们留心,多学科多交流,可能就会发现科研选题的切入点。(4)积极参加高端学术研讨会议, 多参加有专家互动讨论的环节,这些交流中,专家互动提出的一些问题,也可能是科研选题的切入点。(5)定期阅读本专业中文或者英文权威期刊发表的综述性文章、述评性文章,在这些文章中,作者往往会在结束段提出一些问题和展望,这部分可能列出了当前相应领域存在的各种问题, 采取何种手段解决这些问题,这是最为便捷的获取科研选题思路的方法。通过专家的总结, 获得启发,作为自己的选题,这类课题往往具有先进性,有可能在前人或他人研究的基础上提出新观点、新论点和新方法。(6)对于科室负责人来说,要力求能够自己科室拥有先进的设备和技术, 影像医学学科各项科研工作,离不开设备和技术,拥有先进的技术手段,科研选题就比较容易,可利用掌握和获得的新技术围绕重大疾病的热点问题进行选题,申报基金。有了好的科研选题,却又缺乏研究基础,这又如何解决呢? 除了前面所述平时就要尽量多发表文章外,在申请基金项目的时候,可采取临时手段,借助一定的外力。这些外力,来自于两个方面,一个是本院的优势学科, 申请者一定首先要梳理本院的优势学科, 寻找到自己意愿的优势学科有哪些,和他们进行合作,利用和优势学科的科研积累,提高自己基金项目获得资助的可能性。如果医院的心内科比较强,病例多,心内科医师在临床医学方面文章多,在科研选题时,可有意识地选择心血管疾病方面的热点问题,比如斑块活动性影像学评价等,在申请时将心内科有实力的专家作为项目组成员,在研究基础中,放入他们的研究基础,也不失为一个办法。另外一个方面是合作医院, 现在很多基层医院都与大学附属医院建立了合作、协作关系,申请者可将合作医院的专家作为项目组成员,借助合作医院专家的研究基础,提高基金项目申请成功的可能性。需要注意的是,这些措施,在申请者与竞争者处于同一水平的情况下,有大型合作医院的基础会提高自己的竞争力,但是如果竞争者水平和实力明显高于自己一筹,即便有大型合作医院的基础,也未必能够胜出。总而言之,临床医学中有很多待解之谜,新技术的开发与应用,又产生了很多新的问题。临床工作是临床医师科研选题之源,在进行科研选题时围绕危害人类健康和生命的重大疾病中诊断与治疗面临的各种有待解决的问题,采用先进的手段进行研究,加以解决。在实际工作中,应积极开展多学科合作交流,积极跟进最新的前沿知识进展,勤奋思考,留心观察,采取多种手段寻找并选取适合自己的科研选题,并采取一定的技巧,提升自己课题申报成功的可能性。

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Graduate Theses and Dissertations

2018-02-01  393

  6. Graduate Theses and Dissertations   Camante, no hay camino, / Se hace camino al andar. (Traveler, there is no path, / Paths are made by walking.) —Antonio Machado 6.1  THE THESIS AND YOUR GRADUATE PROGRAM Except for works of rare genius, a thesis or dissertation cannot be produced in a week or even a month. (I will use thesis to mean either thesis or disser-tation unless it is preceded by master’s.) The thesis is the final report on the research that you pursue throughout your graduate program. To make the most conservative use of time, coordinate the writing with activities such as course work and professional meetings as well as the research itself. Drafts of litera-ture review, methods, results of individual experiments, and preliminary con-clusions can all be written as your work progresses. Any drafts that you have started or completed early will make those last months of your program a great deal easier. As you get into your graduate program, develop a tentative time line with dates of proposed milestones from the beginning to your expected graduation date. Be sure to review the policies of your institution regarding due dates, committee requirements, and other procedural issues that can impact your time line. Along the line will be as much detail as you can enter, and you will revise it as you proceed through your degree program. Figure A6.1 in Appendix 6 is a hypothetical time line that can serve only as a model. Yours must be indi-vidualized and will include a greater number of specific details. Coordinate the milestones with times for course work, the steps in the research itself, gradu-ate exams, job search, making presentations at meetings or in your department, and whatever else fits your individual program. If you find it difficult to jug-gle all these activities, read Molly Stock’s (1985) book, A Practical Guide to Graduate Research. The thesis is the document that records your research efforts and the results of them and reflects what you learn along the way. Characteristically, your thesis should be built upon knowledge you have gained from the following: A complete review of literature—on what has been done on your specific research topic and closely related subjects Your original research or professional project—field and laboratory experi-ments based on a research proposal or project as approved by your advisor and graduate committee Your syntheses—putting together and deriving meaning from your data, ideas from others, and your own conclusions. Neglecting any one of these foundations for your thesis will limit the quality of your work. Success depends on your knowledge of the literature, meticulous work with your own research, and your efforts to give a clear, accurate perspec-tive to the entire study. When these points have been given appropriate atten-tion, the other criterion for success is communication—the writing itself. Expectations for both master’s and doctoral theses are inconsistent even in the same discipline. Common requirements are set forth by the department, the college, and the graduate school from which you get your degree, but your advi-sor, your committee, and your degree program may specify other expectations. As you begin your graduate project, check on any criteria for theses from your grad-uate school and department, talk with your advisor and committee members, and peruse several theses that have been produced in recent years by respected gradu-ates from your department. In other words, get a clear feel for what your thesis should be long before you write it. What you do during the first few weeks of your graduate program to understand what is ahead can make a major difference in the time it takes you to finish the degree. The format your thesis takes may be one or more journal manuscripts with or without additions such as a general introduction, proposal, appendices, and an overall abstract. The thesis can also be a traditional form not designed for immediate publication. Whatever the form or style, the contents of your thesis will typically include the following: Introduction—general justification for the study, the hypothesis or question behind the research, and a specific statement of objectives Literature review—a detailed report of what has already been done on your subject (sometimes combined with the introduction and included as content in journal manuscripts) Materials and methods—an account of the specific techniques used in the study, including materials needed, procedures, statistical design, and data collection and analyses Results—a presentation and meaning of the data acquired from your research Discussion—significance of your own data as well as the relationship between your work and the findings of others (results and discussion are sometimes combined) Conclusions—a summary of your findings and their significance and perhaps suggestions for further research or applications for the findings Bibliography—references to the literature used Appendices—related material that supports a point and provides additional information but is not essential for understanding the thesis itself Abstract—required for doctoral dissertations and may be needed for master’s theses. Writing the thesis will be easier when you visualize a clear picture of the content and organization involved. As with your proposal, the content of your thesis will present a question or questions to answer or a problem to solve. You will establish objectives for your study by talking with advisors, reviewing the literature, and suggesting a hypothesis or answers to the questions involved. (See Chapter 5 for distinctions between hypothesis and objective.) If your proposal is carefully written and followed, it can become a foundation for the introduc-tion, literature review, and methods sections of the thesis. Once you have tested your hypothesis with your methods, you can report and interpret results relative to the original questions or objectives. With a vision for the format and contents of your thesis in mind, consider use of the following resources. 6.1.1   Graduate College Requirements Most graduate schools furnish information on requirements for graduation in a published or online catalog or in a guide for preparing theses. Keep these instructions handy and check for updates periodically. There are deadlines to meet and fees to pay. Requirements for both the college and your department include deadlines; committee composition; and technical details for the thesis, such as margins, type font, spacing, and the kind of paper required. Knowing these things ahead of time or having a guide to refer to will help you avoid prob-lems later. 6.1.2   Style Sheets For technicalities in the composition, another important guide is a style sheet. For points of style beyond those specified by your department or graduate school, the discipline in which you are working probably has a style to which it generally adheres. Scientific Style and Format (Council of Science Editors, 2006), The ACS Style Guide (Coghill and Garson, 2006), and the AMA Manual of Style (Iverson et al., 2007) are convenient references for various disciplines on points of style such as abbreviations, punctuation, and bibliographical style. Other scientific groups, such as the publisher to whom you will submit manu-scripts and government agencies and associations, have specific style require-ments. Scientific Style and Format (Council of Science Editors, 2006) contains a list of style manuals for scientific disciplines. If you do not know which style to use, ask your advisor. Sometimes your advisor or committee will recom-mend that you choose a professional journal in your discipline and follow its style. Styles for publications differ with journal editors or publishers, but most provide “Instructions for Contributors” or other style sheets to follow. Becomefamiliar with the style of your professional societies and have a style sheet handy. For further information on style, see Chapter 8. 6.1.3  The Library The sooner you get acquainted with a library, the more time you will save yourself. The simplicity or complexity of your literature search will depend on your knowing what you want to find and how to find it quickly. Also, be quick to question the value and reliability of the sources you find. Some literature can be found and read through the Internet. Your library may have a librarian who specializes in your field. That person can help you navigate the manual and online indexes available and will be a valuable resource throughout your program. More information on the literature search and on evaluating sources is in Chapter 4. 6.1.4  Your Advisors Your major advisor is probably your most valuable resource. Take advantage of his or her expertise. Be independent, think for yourself, and find answers to questions with a graduate school catalog, a style manual, or other resources, but report to your advisor regularly too. Because departments and graduate divisions differ in their requirements for theses, I cannot provide the final word for what your thesis should be. Your advisor has many of the answers, but also consult the persons in the department who know answers regarding policies and procedures. This may be your advisor or it could be an administrative assistant or staff person. In addition, your other committee members can be valuable consultants as you proceed with your study. Each is on your com-mittee for a particular reason. Get acquainted with them early, visit with them periodically, and use their expertise. If possible, take a class with each one to learn more about them and their interests. 6.1.5   Other Professionals You may need to work with specialists in addition to your major advisor and the committee. For example, your thesis will most likely contain quantita-tive data, and a statistician may be available to consult even as you plan your experiment and collect the data as well as when you complete the analyses. Formulating the design for your experimentation and stabilizing your plans early in your research can pay big dividends in both time and research quality later. You may also have available a writing center or someone with expertise in writing, revising, and editing. These experts can prove valuable in getting the thesis put together well. Think for yourself, be independent, but do not hesitate to use all these people and sources of information to assist you with your work. 6.2  AVOIDING PROBLEMS Your thesis is the written record of your graduate research project and should contribute substantially to your professional reputation and your discipline. It will probably form the basis for a final graduate defense or oral exam by your committee. Building and maintaining your reputation with your peers, faculty, and other professionals in your discipline will depend on not only how good the final product is but also how you handle problems along the way. The pro-posal, your research, cooperation with others, and the thesis will illustrate your scientific acumen and professionalism. How well you integrate these individ-ual activities will determine, in large part, how successfully you complete your degree and what kind of recommendation you will get from your department when you apply for a position. Weeks, months, even years of delay can result from poor planning and execution of the graduate research project and thesis writing. You may want to read Getting What You Came For, particularly Chapters 17–19 (Peters, 1997), before you get too far into your program. Work closely with your major advi-sor but assume full responsibility for your program. Do not wait for the profes-sor to tell you to write a proposal, search the literature, and write a literature review. If these chores are not required by your department, you will be ahead to do them anyway. Work both cooperatively and independently, but do not get so independent that you step across the line of diplomacy and discretion. The department has policies, and you are probably using resources that belong to your department. The advisor may be supporting your research from funds des-ignated to accomplish specific goals, and your research must contribute to those goals. Consult with your advisor before taking drastic steps. As you become acquainted with departmental procedures and the personalities you work with, you will be able to determine how much independence you have. The following suggestions can help you avoid pitfalls common to graduate students.  6.2.1   Get Started Early The responsibility for getting the thesis finished is yours alone. From the day you begin a graduate program, planning for your thesis begins (see Appendix 6, Figure A6.1). Decide very early what area you want to work with so that your advisor, your course work, your exploration in the library, and your research in the laboratory or field can be chosen with the specific objectives of your the-sis in mind. If you realize as you get into your topic of research that it is not really the subject you would prefer to pursue, consider your options and objec-tives, but do so early in your program and be sure you make any changes in a professional manner. If your major advisor has agreed to support your project financially, it may be that the funds he or she is using come from a grant that requires the pursuit of a specific topic. If you have agreed to work on that project, it may be that the advisor can no longer support you if you change your thesis topic. Changing advisors, changing topics, or even changing majors is possible but not recommended, and once you have written a proposal that is accepted, remember that it is a contract and withdrawing from that contract affects your major advisor and your department as well as your own pursuit of the degree. Breaking any contract, whether or not it is a legal matter, is detri-mental to your reputation. Talk with your advisor and other professionals and make any change smoothly and professionally. 6.2.2   Maintain Professional Relationships with Your Advisors Recognize that advisors are humans with unique personalities. A single gradu-ate student is probably not the primary focus nor the only student they advise, but they should be actively involved with all their students including you. Most advisors are attentive to their graduate students, but do not be offended if your project does not take precedence over their many other activities. If your major advisor is sometimes too preoccupied to help you, take charge of your own destiny, with finesse and discretion of course. Work cooperatively but do some independent thinking too. That is part of being in graduate school. If you assume your own responsibility for your program, you should finish your degree on schedule regardless of how much or how little input the advi-sor contributes. Professors are abused in two ways: You ask too much or you ask too lit-tle. You waste time with questions you could answer by consulting a diction-ary, a college catalog, or a style manual. You can waste time for the professor with bits and pieces of your thesis that are too fragmentary or difficult to read, with too much casual talk, or with too many intrusions into busy schedules. However, graduate students also abuse their professors by avoiding them. A casual question or remark, a handy reference you find at the library, a per-sonal revelation—these things can be important to the advisor’s knowing you and your subject. The professor has an interest in your work and a responsibility to work with you. Maintain a constant, congenial, and professional relationship. Your work is important. Consultations on courses you should take, subjects of common interest, your research and your thesis—all are important for both of you, and advisors do not feel that such things are a waste of time. Discuss such issues as your time line, your responsibilities, and your position as author of any publications that come from your research. Certainly, the research for your thesis and the writing of it are points that bear repeated discussions. 6.2.3   Draw Up a Carefully Planned and Well-Written Proposal An attempt to pursue graduate research and produce a thesis without a written proposal is like taking a trip through unfamiliar territory without a road map. You may find your way and even be successful, but most likely you will waste time, have to double back over some roads, go down blind alleys, and even get lost.Working out hypotheses, objectives, justification, literature, and methods for the proposal will sharpen your perception of your subject. The written proposal pro-vides an early draft or outline of the thesis, and it will serve both you and your graduate committee in communicating and keeping on track. If the written pro-posal is not required, write a draft for yourself and take at least an outline of your plans to your professor. Be sure to include specific objectives and a hypothesis as well as some information from the literature and suggestions for specific meth-ods. These things show the advisor that you are really ready to begin research. Ask for advice and then suggest that you submit the entire proposal to your com-mittee and meet with them for their opinions. Your advisor will likely be pleased that you are assuming responsibility. Be ready to accept or at least discuss his or her modifications to your plan. 6.2.4   Maintain Accurate, Complete Data All data you collect should be considered important. Gather them carefully, write them legibly, analyze them thoroughly, respect their revelations, and then store all of them, not just the part you use. Read Macrina (2000) on keeping scientific records. Do not trust your memory. A short pencil can be more reli-able than a busy brain. Write down field plans. Write down chemical analyses. Write down techniques and amounts you use. In field observations, record the weather. Record full references from the library with page numbers and full names. Using et al. can get you in trouble. Your good memory cannot always fill in the blanks. In addition, for many of you, a camera can help record data. Have access to a quality camera and use it often. Pictures you take can be important in showing methods and results of your research and can often be used in the thesis and certainly in slide and poster presentations. For these formats, you will likely want color, but for publication you may still want black-and-white photographs. 6.2.5  Write the Thesis as Your Work Progresses It would be a formidable task to write the whole thesis at one time. But you can divide the work into logical portions (see Appendix 6, Figure A6.1). Both Peters (1997) and Bolker (1998) suggest that you write some every day. I agree. Before you begin your research or when you write the proposal, you should make a complete literature search and write a rough draft of the literature review. At this point, you can compile a first version of your references. When you set up your proposal and plans for research, you can also write the mate-rials and methods. As portions of your research are finished, you can draft the results and discussion section(s). All of these sections will require revi-sion, but the easiest time to write first drafts is when details are fresh in your mind. The introduction and conclusions can be the last sections you write.The introduction may be a modification of the introduction to the proposal. The purpose for the introduction is to direct the reader into the thesis; the conclu-sions need to focus the reader’s attention on your most important findings. You can best accomplish these purposes after you see where you have been. 6.2.6   Be Proud of the Final Copy Be certain that the content of your thesis is something you can be proud of by doing a meticulous job with your research and by having a thorough knowledge of what others have done and how your study complements or adds to the estab-lished literature. Write a clear, well-organized, and developed text. Make the appearance of the document attractive and professional. Choose details such as font and spacing carefully. Your name stands alone as the responsible author. 6.2.7  To Publish Is to Build Your Reputation The best time to publish is when your research and data are new in your mind. Sometimes, but rarely, a doctoral dissertation can be published as a book or monograph. You may want to register a copyright for your work. If your work is a doctoral dissertation, your graduate school may require publication of an abstract with Dissertation Services (UMI Dissertation Services, 300 North Zeeb Road, Ann Arbor, MI, USA 48106-1346). The graduate school office will prob-ably take care of submitting the abstract for publication. Whether or not you copyright or publish your entire thesis, you should con-sider publication of your research results as journal articles. If possible, have a journal manuscript or two ready to send or already en route to a publisher when you graduate. From your thesis, you can choose the most significant data and arrange them to comply with the format of a given journal, or your advi-sors may encourage you to include in your thesis the manuscripts ready in the style of the journal. If you postpone the effort to have your manuscripts ready for submission, you often never carry out the task simply because it becomes increasingly difficult as time passes. You will have new goals involving your career that do not allow time for revisiting old data. Without extension of your materials into an active journal, much of your valuable data can grow stag-nant in your thesis sitting on a library shelf. Work toward publication from the beginning of your program. 6.2.8   Last-Minute Jobs Can Delay GraduationAfter your thesis is written to your satisfaction, final chores will take more than a couple of weeks. They could take months if they are not accomplished in an efficient and timely manner. First, revisit the guidelines that you perused when you began this thesis project. In preparing for your final committee meeting or defense of your thesis, be sure to get copies to committee memberswell in advance to give them plenty of time to read and evaluate your written work. If possible, you will want to visit with each of them individually for spe-cific suggestions before the final meeting. New suggestions invariably come from individual committee members and their joint considerations. Allow time after their reviews and the defense to change entire sections and particular details. When you have polished your thesis by incorporating the suggestions from committee members, the procedure for most disciplines requires that you take to each of them your letter-perfect thesis along with three or more copies of a signature page for final approval. You may be lucky. You may get the signa-tures in 2 hours. However, 5 days later you may be still trying. One committee member is out of town collecting research specimens, another is at a meeting in London, and a third just happens to be out of the office every time you check. Still another committee member would like extended time to look over the revised thesis before signing it. That person is probably not being disagreeable nor harassing you. Advisors should thoroughly understand what they are sign-ing. Their reputations and that of the department, college, and graduate school, as well as your own, are at stake. Although almost any student wishes for quick approval of the final thesis, serious students know that their own degrees and reputations are far more respected if permissive is not the key word in the repu-tation of the department from which they graduate. The professor should check your thesis a final time and ask for further alterations in text, if needed, before signing the approval page. This careful scrutiny only adds to the quality of your final product. The last minute has now evolved into days or weeks, and you still are not finished. Proofread and double-check your graduate school instructions to be certain you have followed all guidelines. When you deliver copies to your department, the library, or the graduate office, your thesis can be rejected if you have not been careful enough with details. Along with the thesis, you may need copies of a copyright release that you have to sign to allow library person-nel to reproduce your work for research purposes. Because this signature must be yours, do not leave your thesis with a friend to hand in without signing the forms. Obtaining original signatures can take days and delay your graduation if you are pushing deadlines to their limits. With your thesis delivered to the designated offices, you are almost finished. You should offer a copy to your advisor and even to committee members who have special interest in your subject. You may want a bound hard copy for your-self. You will probably not want it in sight for some time, but someday you may even display it—at least on a bookshelf at your home or your office.

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Titles and Abstracts

2018-02-01  347

 Titles and abstracts are the parts of your paper that will be read most often, and they may be the most difficult sections to compose effectively. What Zinsser (1998) says about avoiding clutter and sticking to simplicity is particularly true for titles and abstracts. They should be written with simplicity, clarity, and as few words as possible. They serve (1) to disclose the basic information in the paper and (2) to help readers decide whether to read the entire paper. Key words from the title and abstract are used for indexes for literature searches. Informative abstracts along with their titles are often abstracted for separate publication, and it is essential that each be an entity that can stand alone. As you write them, keep the purpose and audience clearly in mind, and keep them uncluttered and concise.1.  TITLESThe title may be the most notable phrase you write. The title is the first impression you make on your audience. It should attract attention, but most important, it should be informative. Many people will read it, but few will read the rest of your paper. It should use the following:1.The most precise words possible2.Words that indicate the main point of the paper3.Words that lend themselves to indexing the subject.One technique for creating a title is to write the objectives first and then write the rough title, which is sometimes called the working title. Go on to write the entire paper, and then rewrite the title. Write and revise the abstract, and then check the title again. It may need another revision.Common problems with titles are in their length and in the selection and arrangement of words. Be sure your title will make sense to someone not familiar with your subject. Use words that other readers might consult to find information such as your paper contains and use them in a sequence that is not ambiguous or misleading. Study your title for unnecessary words and put the most important ones first. Avoid abbreviations, trade names, and jargon. Provide adequate information but keep your title relatively short. Eight to twelve words is a good range to target. Scientific titles should not be news-paper headlines. Scientific readers are not looking for a journalistic sensation story; they want information. A full sentence with an active verb is usually not a good title. Just be informative and as specific as possible.The journal may also request a running title, or running head. This is sim-ply an abbreviated form of the title that appears on journal pages beyond the first page of an article. For more suggestions about titles, see Day and Gastel (2006). Hofmann (2010) has some examples of good and bad titles. Also, take a look at the versions of a title in Appendix 8. Style sheets of journals will give you details on what is expected in titles for their articles.2.  ABSTRACTSAbstracts are of foremost importance to the research paper or proposal and are also used as a single entity for abstracting services or conferences. The word abstract is used loosely to refer to almost any brief account of a longer paper. The term is often applied to abbreviated forms or summaries of reports, pro-posals, reviews, posters, and presentations as well as journal articles. Content summaries such as descriptive summaries or executive summaries of proposals are sometimes referred to as abstracts, and conference proceedings sometimes publish extended abstracts.The descriptive abstract, or indicative abstract, describes the contents of a paper but does not give a precise condensation of the information contained therein. Its contents would be relatively worthless if it were not accompanied by the report. It is the best form for some reports and reviews. Like a table of contents, it is helpful for a reader in deciding whether to read the entire paper. But one must read the entire paper for substance. Descriptive abstracts con-tain too little information to substitute for the informative abstract that most refereed journal articles require. They can be helpful summaries of reviews or reports and for papers presented at meetings, especially if research to be reported is not yet complete.Conference proceedings may also publish extended abstracts, which are more lengthy than those for journal articles. They are still summaries of research studies but can contain more details of the methods or include more data (sometimes even a table or figure) than can an informative abstract of a journal article. The executive summary for a proposal is also longer than the abstract for a journal article and serves a different role for the audience.It concentrates on the need, the feasibility, and the benefits of a proposed study. For further comment on the executive summary, see Chapter 5.Do not let all this fuss over definitions confuse you. Just know that these strange breeds exist, and then recognize that for journal publications you need the informative abstract. Informative abstracts used with scientific journal articles are a more structured form than a loose definition permits. The organi-zation follows that of the article, and the length is restricted. Like the report, this abstract must include the following:1.The research objectives and rationale for conducting the investigation2.The basic methods used3.The results and significant conclusion that can be drawn.Notice that the two parts generally included in the full paper that are omit-ted from the informative abstract are the literature review and the discussion. This abstract should contain no reference to the literature. A concluding state-ment may give an interpretation or conclusion to the results, but any lengthy discussion or speculation is out of place. Although some journals will require fewer words and some will allow more, many style sheets specify that the abstract should not exceed 200–250 words or 3–5% of the length of the paper and that the form should be one paragraph. This concise summary can be pub-lished alone or disseminated electronically as a complete document. Some societies publish collections of abstracts as in Biological Abstracts. Study the sample abstracts in Appendix 9. McMillan (2001) also presents and discusses some examples of abstracts.The structured abstract as described by the AMA Manual of Style (Iverson et al., 2007) is a form of informative abstract with side headings of the several parts required in medical reports. Other style guides will give infor-mation on acceptable form and content for abstracts. Silyn-Roberts (2000) has a good chapter including checklists on the various kinds of abstracts. Study the journal to which you will submit a manuscript to obtain specific instructions and to read examples of published abstracts. You will find a few differences between journals, such as length allowed, but any informative abstract must do the following:1.Show readers quickly whether the full report is valuable for their further study2.Be extracted abstracted) from the full report for separate publication or electronic distribution3.Furnish terminology to help in literature searches by individuals or by lit-erature retrieval specialists for indexes and electronic databases.To serve these purposes, the informative abstract must be a short, concise, but completely self-explanatory report on a scientific investigation.Although brief and concise, along with the essentials (i.e., research objec-tives, basic methods, and results), the informative abstract should maintainclarity and avoid a choppy style that does not flow smoothly. Emphasize the main points and avoid long lists of information. In presenting the main points, be as specific as possible. For example, say “20 and 40 kg ha1  of nitrogen” and not just “two rates of nitrogen.” Keep the tone strictly objective. Provide any scientific information, such as scientific names for species, that is impor-tant for a complete understanding of your subject. Avoid jargon, brand names, and abbreviations that are not immediately evident to the scientific commu-nity. Use no references to the literature or to any other material that would require a footnote or pursuit of external information.When you think about it, all these requirements for the informative abstract simply emphasize its purpose: to be a concise, complete report of your work that can stand alone without further explanation. In addition to the references listed here, study titles and abstracts in the journals in your discipline and any instructions your publisher provides.   

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Endnote软件在医学文献管理和论文写作中的应用

2018-02-01  523

医学科学研究中,每一项重要理论的提出、每一个重大发现的问世,无不是建立在对前人科研成果总结归纳和借鉴的基础上的。一名合格的医学科研工作者,必须要对自己本专业领域的研究现状充分地了解和掌握,这样才能保证对科研背景资料具有充分的分析能力和对科学问题的敏锐洞察力。这就要求对科研论文的大量阅读和有效分析管理,阅读分析的效率如何直接关系到科研成果的输出效率。在知识大爆炸的数字化信息时代,面对飞速增加的科学文献数据,如何更加高效地查询管理和应用科学文献,是广大医学科学工作者共同面临的重要问题。此外,在撰写医学科学论文的过程中,对参考文献的查询、插入、排版、格式修改、顺序调整等工作费时费力、极易出错,也是降低科研成果输出效率的重要方面。如能更好解决这一问题,必将极大提高科研效率,提升科研积极性。正因如此,参考文献管理软件应运而生。参考文献管理软件又叫书目管理软件[1],能够协助科研工作者方便地查找需要的文献、存储生成个人数字图书馆、在word中插入并自动生成符合特定杂志格式要求的文献,此外还可轻松地完成参考文献的修改及参考文献格式的变更,可嵌入文字处理软件内使用,还可通过在线数据库直接下载文献题录并进行统计分析[2]。本文以目前应用最广泛的EndNote软件为例,探讨该软件在医学文献管理和论文写作中的应用。 1 EndNote软件简介 EndNote是由美国Thomson公司开发,是现阶段全球最受欢迎的文献管理软件之一[3],目前最新版本为EndNoteX7。EndNote可完成对网络中不同数据库来源的文献信息资料的下载、分类、建库、生成和插入参考文献条目,以期方便地实现对文献信息的管理和使用。其主要功能包括[4]:建立本地文献数据库:使用者可通过将本地计算机内存储的文摘数据库或将在网络数据库(Pubmed、WebofScience、LibraryofCongress等)检索结果保存后导入、网络数据库检索后结果直接输出、人工手动编辑等方法,建立本地个人个性化数字图书馆,达到文献浏览、管理的简单化和人性化。自动生成参考文献条目:该软件安装后可嵌入Word内置模块,在用 Word撰写、修改论文时,在文中特定位置插入需要的参考文献,同时会在文末自动生成相应的符合不同杂志要求的参考文献条目,更重要的是,可以轻松实现对参考文献的调整修改(增加、删除、变更顺序),而不影响其他参考文献的格式和顺序[5]。参考文献相关附件管理:这些附件可以链接方式提供,种类可以是独立文件夹、文件、笔记、题录、网络链接地址,通过将EndNote存储的数据库内的文献与本地文献全文、图片、声音等建立链接,有助于形成以文献信息为基础的个性化知识网络。排序、查重和库内检索:使用者可根据不同排序策略(作者、出版时间、发表期刊、题目等)对得到的文献信息进行归纳排序、去除重复文献信息,同时支持复合检索功能,方便使用者对现有文献的精确查找和管理。 2 EndNote的基本使用方法 建立个人数据库:首先运行 EndNote程序,选择File-New,创建一个新的 EndNote数据库,自定义文件名,点击保存,将文件存储于选定的文件夹,此时系统可自动生成扩展名为.enl的文件,即EndNote个人参考文献数据库。根据个人需要选择不同的建库方式:EndNote建立数据库的方式有4种[6]即直接联网检索、格式转换、网站输出和手动输入。不同的建库方式其操作步骤及优缺点各不相同,比如直接联网检索方便快捷、内容涵盖量大,可将文献直接导入,无须下载文本,并且可将多条文献数据同时批量导人。但对因filter的限制,目前对中文文献的查找和生成效果不佳;格式转换操作较繁琐,容易出错;网站输出目前诸如 Google学术搜索等知名学术网站均可提供此类服务,较为方便,但其参考文献格式较为单一,输出后还需EndNote二次转换,较为繁琐;手动输入方法中英文均适用,可满足部分EndNote内置数据库查询不到的特殊文献,尤其中文文献的要求,但需要输入的内容较多,相对而言,比较费时,容易出现输入错误,一般不提倡使用。现在网络上也有大量较为详尽的相关操作方法和注意事项可供广大使用者参考。数据库的应用:这里主要介绍EndNote软件在生成参考文献条目中的应用。EndNote安装完成后,会在 Word等文字处理软件的工具栏中自动生成一个EndNote工具条选项,当撰写论文时,即可通过点击工具条中 GotoEndNote启动EndNote,通过上述方法建立参考文献数据库后,将光标置于文中需要插入参考文献的位置。选择目的杂志格式确定参考文献输出格式,若库中没有目的杂志,则可前往 EndNote参考 文 献 格 式 下 载 官 方 网 站 http://EndNote.corn/downloads/style(该网站定期发布最新过滤器供用户下载使用)下载并存储于 EndNote安装文件夹Style子文件夹中,此时即可在Style下拉菜单中选定目标参考文献格式,选择需要插入的参考文献条目,点击InsertCitation,即可在光标所在处插入引用标号,同时在文末自动生成符合杂志要求的参考文献条目。若要改变参考文献格式使其符合另一杂志需要,则需在Style下拉菜单选定杂志名称,点击 FormatBibliogra-phy,即可完成参考文献格式的修改。此外,在选定数据库中某一参考文献后,点击 OpenLink,即可转到此文献在Pubmed上的搜索页面,得到更加完整的文献相关信息及全文链接,从而方便快捷地实现了文献相关的网络资源的连接和共享。 3 EndNote较传统文献编辑的优势 插入添加功能:用户在编辑写作过程中可在 word界面EndNote快捷工具栏中选InsertCitation,或在word界面 EndNote快捷工具栏点击 GotoEndNote切换到EndNote数据库选择特定文献再插入,此时软件会自动根据文献在文章中出现的先后顺序编号,同时在文末自动生成参考文献列表,避免参考文献在成稿后将原有标号重新统一编辑排序。编辑功能:针对广大科研工作者在科研论文因各种原因更换杂志投稿后所面对的参考文献格式修改问题,EndNote内置的参考文献格式修改功能很好地发挥了其人性化的特点。使用者再也不用在每次修改后都对每条参考文献条目逐一修改格式后重新输入,而只需要在 Word等文字处理软件中的 EndNote快速工具栏中Style下拉菜单选择目的期刊,点击 UpdateCitationandBibliography,或通过在 EndNote软件中点击FormatBibliography,即可迅速完成对整篇文章参考文献格式的统一修改;部分中文期刊因filter的限制可能无法同步修改,此时可根据目的期刊参考文献格式要求手动修改模板使用。去重功能:EndNote软件可自动识别插入的相同参考文献,并生成相同文献标号,这就很好地避免了论文对同一篇参考文献多次引用时较易出现的参考文献重复列出,极大地减少了作者的工作量。库内检索功能:使用者可通过EndNote采用诸如作者、出版时间、期刊名称、卷期、题目等信息的任意组合搭配方式,快速而精确地从软件内置的网络数据库中搜索到符合要求的参考文献,大大减少了查找文献的难度,并且文献信息可按照出版时间、作者、期刊名称、题目等不同文献关键字段进行排序,使得库内文献的查找更加方便快捷。删除或增加功能:此项功能主要针对在文章中增加或删除一篇或数篇参考文献的情况,此时文献标号将被自动重新调整后排序,而不会引起文中其他参考文献标号的错乱,同时在文末的参考文献清单中也会即时实现相应条目的增减和标号的重排。避免因个别地方的修改而“大动干戈”。此外,EndNote软件还具有题录信息的导出与交换、笔记评录、统计分析等更加高级的功能,若能熟练掌握,可更加灵活和高效地实现参考文献的管理和分析。 4 EndNote软件功能存在的不足 与其他的参考文献管理软件缺乏很好的兼容性。不同软件间为了维护知识产权,保护自身利益,会运用技术使各自的参考文献库具有自身特点而不能被其他同类软件利用。这就造成用户在同时运用几个参考文献管理软件时,几个不同参考文献库间资源无法实现共享,在一定程度上将用户“绑架”在了某一款软件上,也不利于用户对个人文档信息的整合和全面利用。因此,制成 “统一化、用户友好化”参考文献库就成为各参考文献管理软件所共同面对且亟待解决的问题。用户无法在互联网和个人计算机之间自由转移和同步自己的参考文献库及其他个人数据。这种情况对于工作学习环境经常发生变化的学者和商务人士尤其多见。若能很好解决,则可大大方便用户科研学习工作的延续和对个人数据库的管理维护。插件与文字处理软件兼容性不佳。目前软件所提供的字处理软件插件几乎都是针对 MicrosoftWord的,对Swriter、WPS等软件均存在不同程度的兼容性问题。易用性有待提高。比如 EndNote软件的中文参考文献搜索和条目生成功能,目前EndNote软件尚不提供维普或CNKI中文全文数据库链接,无法通过软件直接搜索到中文参考文献,现阶段中文参考文献只能通过手动编辑的方法生成,错误率高、编辑条目繁琐、对使用者要求较高,今后应着重改善此方面的功能,使其更加适应广大中国用户的要求。综上所述,尽管 EndNote软件还有一些不足,但与传统文献编辑相比,具有高效、准确和便捷的优势,可极大程度地方便医学科研工作者对所需参考文献的查找、归类、整理、分析,方便阅读和记录;同时在科研论文写作中,使得参考文献条目的插入、替换、修改、增加和删除更加简便,降低错误率,节约大量时间精力用于论文主体部分的把握,从而提高了论文写作效率,提升了论文质量。因此,熟练掌握此软件的使用方法,对于医学科研工作的开展具有重要意义。 

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NoteExpress在撰写文章综述时的技巧解析

2018-02-01  494

NoteExpress 出现背景及简介高校师生及其他人员在工作和学习过程中往往需要撰写文章的综述,文献管理软件对于使用word 撰写综述十分有用。国外知名的文献管理软件有EndNote、Refworks 等等; 国内以NoteExpres( NE) 为代表。NoteExpress 的优越性在于可以很好的兼容中英文,支持常见的中英文数据库如CNKI、万方、维普、ProQuest 以及Wiley,等等。目前关于NoteExpress的文章多集中在分析几种常见文献管理软件的优劣,介绍NE 的功能使用,将NE 应用到具体案例中,以及对NoteExpress 的评析及展望。本文将以撰写“高校新图书馆建设中的信息技术应用研究”为例,探究其在撰写文章综述时的技巧。 NoteExpress 使用及其在撰写文献综述时的技巧NE可以嵌入到Word 中使用。下载NE 软件并安装,打开或者重启word 就会发现word 工具栏上多了NE 工具条。如果没有该插件,可以点击NE 菜单“工具”下面的“选项”,在扩展中利用“安装”和“卸载”两个按钮修正。首先需要收集相关资料。文献、书籍等条目在NE 中称为题录,NE 以题录为核心进行管理。在NE 中建立“图书馆信息技术”数据库,并添加自己需要的题录。NE 提供了四种导入题录的方式: ( 1) 在线检索导入或内嵌浏览器检索导入; ( 2) 过滤器导入; ( 3) 手工录入,多用于完善个别题录;( 4) 全文导入,针对已经下载了大量全文的用户。构建好数据库之后,使用NE对题录进行管理,如查找重复题录、为题录添加附件、全文下载、题录排序等等。下面重点阐述NE 如何为撰写文章综述服务。 统计题录信息撰写NoteExpress 综述,需要对以往的研究做一个系统的归纳总结。NE 的“文件夹信息统计”功能可以系统地为我们提供统计数据。首先选中要统计的题录所在文件夹,右击选择“文件夹信息统计”,选定某字段点击“统计”便会出现所需统计数据,双击某条目可以查看其中的题录。NE 中题录列表 头字段及其显示顺序可以自定义。构建数据库过程中不可避免地会造成题录重复,这些重复题录不仅会增加我们的阅读量、浪费数据库空间,还会导致统计结果不准确,为此NE提供查找重复题录功能。点击NE 菜单项“检索”—“查找重复题录”,设置待查重文件夹、查重依据的字段等等。 标签及优先级撰写综述需要阅读大量的文献,NE 提供多种方式方便用户管理这些文献。除了支持树状结构文件夹管理题录之外,NE 还支持单独为题录设置星标与优先级。有3 种方式可供选择: ( 1) 设置星标; ( 2) 设置优先级;( 3) 设置标签,NE 左下角“标签云”处可以看到已定义的“标签”,点击某一标签可以看到该标签中的题录。两者结合起来使我们可以更加灵活地管理题录。标签是题录的一个字段,因此可以像其他字段一样显示在题录处,可以通过“自定义表头”功能实现。 全文与题录相关联题录仅仅为我们提供了作者、期刊、摘要等基本信息,多数情况下还需要进一步阅读全文。在NE 中,全文是以“附件”形式关联到题录。前面介绍的4 种题录导入方式,只有“全文导入”是题录和全文同时添加,其它3种方式则需要通过“添加附件”或者“下载全文”的方式为题录添加全文。 笔记功能有了全文数据库,阅读过程中可以使用NE 自带的笔记随时记录心得、思路和灵感等。NE 笔记支持文字、图片、公式等,它可以关联到题录,加强了思路与文献的关联性,在撰写文章时可插入到word 中。 快捷插入引文、引文管理撰写文章综述往往需要引用大量的引文,插入引文正是NE 的核心功能。NE 为引文管理提供一系列操作,如编辑引文、删除引文、引文快速定位等。在撰写综述过程中,有时会遇到需要调整引文顺序,手工一篇篇修改既耗时又十分容易出错。使用NE 管理word 引文,可以直接在word 中调整引文顺序角标,文末参考文献会自动随之调整; 同理,删除某引文时、或向文章中间插入引文时,引文会自动调整,文末参考文献也会相应调整。这项功能为撰写综述者提供了很大的便利。 引文格式化文章写好后,确定要投稿的期刊,接下来就要按照期刊要求修改格式。点击word 中NE 工具栏“格式化”按钮,在弹出的“格式化对话框”中点击“选择输出样式”下拉菜单并选择所需的期刊格式,若没有所需样式,可以点击“浏览”按钮进行选择,“引文色彩”可以选择醒目的颜色方便引文管理,之后点击“确定”,此时文末引文已经是新格式了。文章投出之前,需要“清除域代码”,点击word 中NE 工具栏“去除格式化”按钮———“清除域代码”———“确定”即可。但要注意做好备份,以备日后修改之用。 方便迁移数据库比如,想在另一台电脑打开自己的个人数据库,此时只需把原来创建的数据库文件拷贝出来,注意拷贝的时候要把个人数据库***. nel 文件和附件文件夹***. Attachements 一同拷贝,该文件存放的是对应题录的附件。附件文件夹的位置可在NE 菜单栏“工具”———“选项”———“附件”中查看。有用户反映向NE 数据库添加附件时,文献被移动了且不知去向。其实,最开始建立数据库时NE 就提供设置“当向该数据库添加附件时”采取哪种方式处理该附件:“复制文件到附件文件夹”“移动文件到附件文件夹”或者“不执行文件复制或移动”。当选择第二项时就会出现文件从原存放位置移动到附件文件夹的情况。此设置后期可以通过NE 菜单栏“工具”———“选项”———“附件”中修改或查看。注意当同时管理几个数据库时,每个数据库是单独设置此选项的。 总结综上,使用NE 在撰写文献综述或综述性文章时有很多技巧,善加利用可以使我们的工作或学习更加高效。虽然NE 也有需要改进的地方,如“表头自定义”时“被引用次数”无法实现自动更新; 导入已有文件时,题录自动更新有时不准确,等等。但是,NE 仍不失为我们文献管理和文章撰写的好助手。

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Prevalence of Haemophilus influenzae type b infection in Chinese children: a systematic review and meta-analysis

2018-02-01  400

AbstractBackground Haemophilus influenzae type b is an important cause of invasive bacterial disease in children worldwide. The establishment of epidemiological estimates is an essential first step towards the introduction of H influenzae type b vaccine into the Chinese national immunisation programme. We therefore undertook a systematic review and meta-analysis to estimate the prevalence of H influenzae type b in Chinese children. Methods We systematically searched PubMed, Web of Science, CNKI, Wanfang, and Ovid databases for studies published up to Dec 31, 2016, that reported the prevalence of H influenzae type b among children in mainland China. We used random-effects meta-analysis to obtain the pooled prevalence of H influenzae type b in healthy children and in those with acute lower respiratory tract infection or bacterial meningitis. Findings 27 studies met prespecified inclusion criteria, and these included 15 783 children in 14 provinces. The pooled prevalence of H influenzae type b in healthy children, children with acute lower respiratory tract infection, and bacterial meningitis was 5·87% (95% CI 3·42–8·33), 4·06% (3·29–4·83), and 27·32% (0·41–54·24), respectively. Meta-regression showed that the prevalence of H influenzae type b in healthy children remained stable after the introduction of H influenzae type b vaccine in 1997 (p=0·725), whereas the proportion of children with acute lower respiratory tract infection due to H influenzae type b showed a decreasing trend (P<0·0001) and was higher in northern China than in the south (p<0·0001). Significant heterogeneity was noted across and within regions (P<0·0001). Differences in sex, age groups, and study sample size did not explain the heterogeneity. Interpretation H influenzae type b is a common pathogen in healthy children and an important cause of lower respiratory tract infection and bacterial meningitis in China. Introduction of H influenzae type b vaccine into the Chinese national immunisation programme could reduce the burden of H influenzae type b disease in China.