第一届中青年医师真空辅助乳腺微创旋切手术视频大赛

正乳腺微创与功能治疗的理念和实践正在逐步改变着乳腺外科临床治疗的面貌,真空辅助乳腺微创旋切(vacuum-assisted breast biopsy,VABB)是乳腺良性肿瘤切除及恶性肿瘤活组织检查的重要手术方式。为更好地交流乳腺微创和功能治疗的发展现状,探索崭新的学术交流模式,展示中青年乳腺外科医师,尤其是基层医疗单位医师的诊疗水平,分享VABB的操作流程及技巧,促进VABB手术操作的规范化,2019年第一届中青年医师VABB手术视频大赛即将拉开序幕!     

甲状腺疾病日间手术应用效果临床初探

目的：探讨甲状腺日间手术的临床应用效果及优点,为进一步推广日间手术提供依据。方法：回顾性分析四川大学华西医院2018年6月至12月日间手术中心收治的62例甲状腺疾病患者(包括分化型甲状腺癌18例、甲状腺良性肿块44例)作为研究组,并以同时期普通病房住院治疗的124例甲状腺疾病患者(包括分化型甲状腺癌40例、甲状腺良性肿块84例)作为对照组,两组患者均由同一主刀医生及其团队完成,对两组患者的手术情况、平均住院天数、人均住院费用、再入院率、并发症等方面进行比较。结果：手术时间和术中出血量在研究组和对照组之间差异无统计学意义(P>0.05),研究组术中引流的比例均低于对照组(P<0.05),研究组患者切除范围高于对照组(均P<0.05)。研究组患者的住院时间和住院费用均较对照组有明显降低(均P<0.05)。结论：甲状腺手术实行日间手术治疗模式是安全可行的,且日间手术能够有效的降低住院天数和住院费用,简化诊疗流程,提高公共医疗资源的利用效率,值得进一步推广应用。     

第一届中青年医师真空辅助乳腺微创旋切手术视频大赛

正乳腺微创与功能治疗的理念和实践正在逐步改变着乳腺外科临床治疗的面貌,真空辅助乳腺微创旋切(vacuum-assisted breast biopsy,VABB)是乳腺良性肿瘤切除及恶性肿瘤活组织检查的重要手术方式。为更好地交流乳腺微创和功能治疗的发展现状,探索崭新的学术交流模式,展示中青年乳腺外科医师,尤其是基层医疗单位医师的诊疗水平,分享VABB的操作流程及技巧,促进VABB手术操作的规范化,2019年第一届中青年医师VABB手术视频大赛即将拉开序幕!     

乳腺外科最后堡垒

目前乳腺外科发展趋势不单注重规范化治疗,更关注个性、微创、精准以及保护患者身心健康。微创和功能治疗是最后的堡垒。改良根治术开创了"乳腺微创"的临床实践新纪元,乳腺癌腋窝淋巴结亦进入了"微创功能性清扫"时代。乳腔镜技术在诸多方面己经和正在改变着传统乳腺外科的治疗方法和理念,是应用外科新理论和技术解决现有临床问题、在治疗疾病的同时探索患者生理和心理康复方法的典型手术范例,成为乳腺外科"微创与功能"的最佳体现。目前,手术微创化、保留功能性等各种个体化、人性化的治疗方式逐渐成为趋势。践行乳腺外科的"加减法","微创与功能"这一乳腺外科最后堡垒终将融合汇聚成共同体。     

互联网+乳腺日间手术的实践和思考

常规日间手术存在患者就医手续繁琐、工作计划性不强、医疗文书重复书写、术前告知耗时长、术后病情观察信息不畅和术后管理缺乏等问题。日间手术引入互联网+技术后,可以极大减少大量重复性计算机录入工作,患者能快速了解和掌握就医程序和路径,实现乳腺日间手术前一站式服务,使临床效率和效益最大化。它能增强术前医患互动,使术前谈话更高效,并能科学进行患者的术后管理。互联网+技术用于乳腺日间手术,方便了患者,改变了患者的就医体验;增加了患者对疾病诊疗的参与度;建立了新型的医患关系,增加了医患之间的理解和信任。互联网+乳腺日间手术是医疗服务的供给侧改革,实现了数字化医疗与网络的跨界融合,使医疗活动更加精准、便捷和高效,推动了现代医疗模式的改革和发展。     

腔镜技术在乳腺外科中的应用进展

腔镜技术已经被广泛应用于外科领域,在乳腺外科中的应用也不断深入,尤其是近年来腔镜微创的理念被更多人所重视,腔镜技术的变革也越来越多。对既往建腔方法、手术方式存在问题的思考催生了一些新观点、新术式和新技巧。笔者针对近10年来腔镜技术在乳腺外科应用的发展和变革进行综述,一方面总结了乳腺外科建腔方法的思路变革,从经典的3孔充气法到隐蔽的单切口设计,更体现"无痕化"的人文关怀理念;另一方面阐述了腔镜技术在乳腺癌保留乳房手术、保留乳头、乳晕的皮下全乳切除术、乳房重建修复整形术、腋窝淋巴结处理以及乳腺良性疾病等手术中的应用进展,探索优化手术操作流程、规范学习曲线对腔镜技术推广的意义。随着微创理念的推广,乳腺腔镜技术将会成为一部分合适患者的优选方案。     

互联网＋乳腺日间手术的理论设计和关键技术研究

互联网＋临床实践是新型医疗资源管理方式和卫生服务业态。在互联网＋乳腺日间手术项目中,笔者对其理论设计及关键技术进行了系统研究。其中,理论设计包括多学科合作为基础的顶层系统设计、以问题为导向的新型工作模式设计、以患者参与为重点的人性化设计和以医疗规章制度及医学伦理原则为指导的论证设计。为了实现理论设计,形成和完善了7项关键技术,包括：统一语言环境技术、网络整合和拼接技术、病历自动生成技术、针对患者的一站式服务技术、实现患者主动参与的关键技术和网络安全及患者隐私保护技术。通过学科专项问题调研、应用定义、问题分析、服务定位、设计规划、临床体验、修改完善等线路框架的逐步推进,最终实现互联网＋乳腺日间手术临床应用。该模式省时快捷、应用方便、经济高效,患者参与度显著提高和安全性良好,具有明显的示范效应。     

腔镜在乳腺外科的临床应用

目的 探讨腔镜在乳腺外科的临床应用及存在的问题.方法 对45例乳腺癌患者行腋窝脂肪抽吸后,采用腔镜施行腋窝淋巴结清扫,并对3例乳腺多发性纤维腺瘤和3例男性乳房发育症患者行腔镜下乳腺肿物切除术或皮下乳房切除术.结果 全部患者均顺利完成手术,手术历时50～180 min.除1例术后有切口内出血外,其余患者术后恢复顺利.结论 腔镜在乳腺外科的应用具有传统手术无法达到的微创优势和美容效果,提高了患者的生活质量,是对传统手术方法的挑战.     

重视临床基本问题，推动乳腺外科学科发展

中华医学会外科学分会乳腺外科学组(CSBrS)成立3年以来,共针对10项乳腺外科临床基本问题撰写了共识意见。其中,强调乳腺病灶空芯针穿刺活检和前哨淋巴结活检的临床价值;推广中心静脉输液港的临床应用范围;重申并规范真空辅助旋切和乳腺标记物植入技术的临床适应证;以及中国妊娠相关性乳腺癌的诊治策略等内容获得临床医生的广泛认同。2019年,CSBrS共完成10项中国乳腺外科领域的多中心真实世界研究。2020年,已经启动包括：《疫情期间乳腺外科临床工作多中心研究》和《多基因检测和BRCA基因检测中国现状》等15项研究课题。作为中国乳腺外科领域的专业学术团体,CSBrS始终关注乳腺外科临床基本问题,并以加强多学科合作,搭建适宜国情的学术研究平台为己任,努力为推动中国乳腺外科临床规范化进程做出贡献。     

中国恶性肿瘤日间诊疗专家共识(2022版)

为深入贯彻落实国务院办公厅关于推进分级诊疗制度建设的指导意见(国办发〔2015〕70号), 以日间诊疗服务为切入点, 推进实现急慢病分治, 提高医疗资源使用率和医疗服务效率, 节约医保统筹基金, 减轻患者经济负担, 提高患者生活质量, 从而让更多患者得到急需的治疗。基于中国恶性肿瘤日间诊疗开展现状及在管理模式、制度、流程、安全管理、信息化建设等方面存在的问题, 多学科专家综合国内外文献, 结合临床实践, 经过多次反复讨论修改, 最终形成中国恶性肿瘤日间诊疗专家共识(2022版), 旨在为临床肿瘤医师提供更好的日间诊疗指导, 以推动我国肿瘤日间诊疗工作进一步发展, 提高社会医疗资源的有效利用率, 更好地服务患者、医院及社会。     

Curiethérapie en France : état des lieux et perspectives économiques après l’arrêt de la commercialisation des fils d’iridium

In 2013, about 6000 patients were treated with brachytherapy, the number diminishing by 2.6% per year since 2008. Prostate, breast and gynecological cancers are the most common types of cancers. Since 2008, the number of brachytherapy facilities has decreased by 18%. In medicoeconomic terms, brachytherapy faces many problems: the coding system is outdated; brachytherapy treatments cost as much as internal radiation; fees do not cover costs; since iridium wire has disappeared from the market, the technique will be transferred to more expensive high-speed or pulse dose rates. The French financing grid based on the national study of costs lags behind changes in such treatments and in the best of cases, hospitals resorting to alternatives such as in-hospital brachytherapy are funded at 46% of their additional costs. Brachytherapy is a reference technique. With intense pressure on hospital pricing, financing brachytherapy facilities will become even more problematic as a consequence of the disappearance of iridium 192 wires. The case of brachytherapy illustrates the limits of the French financing system and raises serious doubts as to its responsiveness.     

111例白血病医院感染的微生物学分析

对１１１例白血病患者不同部位的细菌培养阳性结果进行分析，其中Ｇ－杆菌占５４．８％，Ｇ＋球菌占２７％，Ｇ＋杆球占３．６％，真菌占１４．６％。感染的病原菌前四位为绿脓杆菌、金黄色葡萄球菌、白色念珠菌、大肠杆菌。感染的临床分类依次是咽部感染、呼吸道感染、败血症及皮肤化脓性感染。感染的性别之间及淋、粒系白血病之间无显著差异。同时对Ｌ型感染、混合感染、特殊菌感染及同一患者多细菌多部位感染进行了分析     

Impact of a Clinical Pathway on Hospital Costs,Length of Stay and Early Outcomes after Hepatectomy for Hepatocellular Carcinoma

Background: A clinical pathway (CP) can standardize and improve perioperative care for a number of interventions. In hepatic surgery, however, pertinent evidence is very limited. This study was conducted to implement a CP for hepatocellular carcinoma (HCC) patients undergoing hepatectomy, and to  evaluate its effects on hospital costs, length of hospital stay (LOHS) and early clinical outcomes. Materials and Methods: Medical records for HCC patients undergoing hepatectomy were retrospectively reviewed before implementation of a CP(the non-CP group) from March 2012 to August 2012. This information was compared with the data collected prospectively from patients after implementation of the CP (the CP group) between September 2012 and April 2013. Hospital costs, LOHS and early clinical outcomes were evaluated and compared between groups. Results: There were no significant differences in terms of patient clinical characteristics between the two groups. For clinical outcome measures, no significant differences were found in postoperative complications, mortality andreadmission rate. The hospital costs were significantly reduced from 24,844 RMB in the non-CP group to 19,761 RMB in the CP group (p<0.01). In addition, patients of the CP group also had shorter LOHS compared with the non-CP group (8.3 versus 12.3 days, p<0.001). Conclusions: The CP proved to be an effective approach to minimize hospital costs and LOHS with hepatectomy for HCC without compromising patient care.     

Temporal Trends and Outcomes Among Patients Admitted for Immune-Related Adverse Events: A Single-Center Retrospective Cohort Study from 2011 to 2018

BackgroundThe aim of this study was to characterize severe immune‐related adverse events (irAEs) seen among hospitalized patients and to examine risk factors for irAE admissions and clinically relevant outcomes, including length of stay, immune checkpoint inhibitor (ICI) discontinuation, readmission, and death.MethodsPatients who received ICI therapy (ipilimumab, pembrolizumab, nivolumab, atezolizumab, durvalumab, avelumab, or any ICI combination) at Massachusetts General Hospital (MGH) and were hospitalized at MGH following ICI initiation between January 1, 2011, and October 24, 2018, were identified using pharmacy and hospital admission databases. Medical records of all irAE admissions were reviewed, and specialist review with defined criteria was performed. Demographic data, relevant clinical history (malignancy type and most recent ICI regimen), and key admission characteristics, including dates of admission and discharge, immunosuppressive management, ICI discontinuation, readmission, and death, were collected.ResultsIn total, 450 admissions were classified as irAE admissions and represent the study''s cohort. Alongside the increasing use of ICIs at our institution, the number of patients admitted to MGH for irAEs has gradually increased every year from 9 in 2011 to 92 in 2018. The hospitalization rate per ICI recipient has declined over that same time period (25.0% in 2011 to 8.5% in 2018). The most common toxicities leading to hospitalization in our cohort were gastrointestinal (30.7%; n = 138), pulmonary (15.8%; n = 71), hepatic (14.2%; n = 64), endocrine (12.2%; n = 55), neurologic (8.4%; n = 38), cardiac (6.7%; n = 30), and dermatologic (4.4%; n = 20). Multivariable logistic regression revealed statistically significant increases in irAE admission risk for CTLA‐4 monotherapy recipients (odds ratio [OR], 2.02; p < .001) and CTLA‐4 plus PD‐1 combination therapy recipients (OR, 1.88; p < .001), relative to PD‐1/PD‐L1 monotherapy recipients, and patients with multiple toxicity had a 5‐fold increase in inpatient mortality.ConclusionThis study illustrates that cancer centers must be prepared to manage a wide variety of irAE types and that CTLA‐4 and combination ICI regimens are more likely to cause irAE admissions, and earlier. In addition, admissions for patients with multi‐organ involvement is common and those patients are at highest risk of inpatient mortality.Implications for Practice The number of patients admitted to Massachusetts General Hospital for immune‐related adverse events (irAEs) has gradually increased every year and the most common admissions are for gastrointestinal (30.7%), pulmonary (15/8%), and hepatic (14.2%) events. Readmission rates are high (29% at 30 days, 49% at 180 days) and 64.2% have to permanently discontinue immune checkpoint inhibitor therapy. Importantly, multiple concurrent toxicities were seen in 21.6% (97/450) of irAE admissions and these patients have a fivefold increased risk of inpatient death.     

Effect of hospital characteristics on outcome of patients with gastric cancer: A population based study in North-East Netherlands

Background

Surgical resection is an important factor in the curative treatment of gastric cancer. However a variety of aspects of surgical treatment that potentially influence outcome are still not well defined. This study aims to assess the influence of hospital type, referral pattern and proximal or distal location of the tumour on the ultimate survival.

Methods

From January 1994 to January 2007, a total of 5245 patients were diagnosed with gastric adenocarcinoma in the region of the Comprehensive Cancer Centre North-East Netherlands. Hospitals in this region were categorized into three types: teaching university (TU), teaching non-university (TNU), and non-teaching hospitals (NT). The influence of hospital type, referral for surgery and location of the tumour on the relative survival of operated patients was studied.

Results

Of the 5245 patients, 2334 patients underwent surgery. For operated patients, the 5-year relative survival was 42.5% for the TU versus 34.0% and 35.5% for respectively TNU and NT hospitals (p = 0.064), with no difference (p = 0.38) in relative survival (25.6–31.9%) in the proximal tumours. A significant difference was found between the hospitals in the 5-year relative survival in the distal tumours; 59.7% in the TU versus 36.4% in the TNU and 36% in the NT (p = 0.03 univariate), however this was not confirmed in the multivariate analysis (p = 0.184). High referral centres did not perform better as far as survival is concerned than low referral hospitals.In conclusion the hospital type in our region did not significantly influence outcome of surgery for gastric cancer.     

出院护理计划服务在行肠造口术的结直肠癌患者中的应用效果

目的：探讨出院护理计划服务在行肠造口术的结直肠癌患者中的应用效果。方法选取本院接受肠造口术的结直肠癌患者98例,随机分为试验组和对照组,每组49例。两组患者均行常规健康教育,试验组在此基础上接受出院护理计划服务。采用焦虑自评量表（self－rating anxiety scale, SAS）和抑郁自评量表（self－rating depression scale,SDS）对患者情绪状态评估,肠造口患者健康知识知晓度调查表调查患者常用健康知识的知晓程度,同时统计患者自我护理情况。结果出院时,试验组与对照组患者 SAS 评分（43．5±4．2 vs．42．5±6．3,t＝0．985,P＞0．05）和 SDS 评分（41．5±3．6 vs．41．3±4．1,t＝1．047,P＞0．05）比较无统计学差异。出院3个月后,试验组SAS（44．5±3．5 vs．52．5±4．5,t＝2．382, P＜0．05）和SDS（42．5±3．5 vs．50．5±4．2,t＝2．411,P＜0．05）评分显著低于对照组。在入院和出院时,试验组和对照组患者健康知识知晓得分比较无统计学差异[入院时（5．5±2．8 vs．．5．8±1．5,t＝0．639,P＞0．05）;出院时（12．6±3．6 vs．12．5±3．3,t＝5．325,P＞0．05）],出院 3个月后,试验组患者健康知识知晓得分显著高于对照组（13．7±3．8 vs．8．5±2．5,t＝9．342,P＜0．01）。出院 3个月后,试验组患者生活自理能力和造口自理能力明显优于对照组[100％（49／49） vs．95．9％（47／49）,P＜0．05;97．9％（48／49） vs．89．8％（44／49）,P＜0．05],试验组的造口并发症发生率明显低于对照组（81．6％ vs．63．3％,P＜0．05）。结论出院护理计划服务用于结直肠造口患者,可显著改善患者的焦虑和抑郁情绪,使患者维持较高的健康知识水平并提高其自我护理能力。     

Use of smoke-less tobacco amongst the staff of tertiary care hospitals in the largest city of Pakistan

Background: Use of smoke-less tobacco (SLT) is very common in South and South-East Asian countries. It issignificantly associated with various types of cancers. The objectives of this study were to assess the proportionof hospital staff that use SLT, and to identify the factors associated with its use and their practices. Methods: Ina cross-sectional study, 560 staff of two tertiary care hospitals were interviewed in the year 2009. Nurses, wardboys and technicians were counted as a paramedic staff while drivers, peons, security guards and housekeepingstaff were labeled as non-paramedic staff. SLT use was considered as usage of any of the following: betel quid(paan) with or without tobacco, betel nuts with or without tobacco (gutkha) and snuff (naswar). Results: Abouthalf (48.6%) of the hospital staff were using at least one type of SLT. Factors found to be statistically significantwith SLT were being a male (OR=2.5; 95% CI=1.8-3.7); having no/fewer years of education (OR=1.7; 95%CI=1.2-2.4) and working as non-paramedic staff (OR=2.6; 95% CI=1.8-3.8). Majority of SLT users were usingit on regular basis, for > 5 years and keeping the tobacco products in the oral cavity for >30 minutes. About halfof the users started due to peer pressure and had tried to quit this habit but failed. Conclusion: In this study,about half of the study participants were using SLT in different forms. We suggest educational and behavioralinterventions for control of SLT usage.     

Gastric carcinoma survival at the pennsylvania hospital — 1964 to 1974

Despite major improvements in diagnosis, anesthesia, surgical techniques, and postoperative care, the survival rate for adenocarcinoma of the stomach remains a dismal one. In our series of 109 patients, almost all patients seen were diagnosed too late to effect any kind of surgical care. In the period from January 1964, to December 1974, 122 patients were admitted to Pennsylvania Hospital with a diagnosis of gastric adenocarcinoma. Of the 109 patients followed to their death, only seven survived 5 years; the longest survival was 80 months. Among the 33 patients not resected, median survival was only one month. Of the 74 patients who had surgical resections survival ranged from a median of 5.5 months for those who had total gastrectomy to a median of 8 months for those receiving subtotal gastrectomy.     

Antibiotic consumption in Turkish hospitals; a multi-centre point prevalence study

This multi-centre study aimed to determine the antibiotic consumption in Turkish hospitals by point prevalence. Antibiotic consumption of 14 centres was determined using the DDD method. Among hospitalized patients, 44.8% were using antibiotics and the total antibiotic consumption was 674.5 DDD/1000 patient-days (DPD). 189.6 (28%) DPD of the antibiotic consumption was restricted while 484.9 (72%) DPD was unrestricted. Carbapenems (24%) and beta lactam/beta lactamase inhibitors (ampicillin-sulbactam or amoxicillin-clavulanate; 22%) were the most commonly used restricted and unrestricted antibiotics. Antibiotics were most commonly used in intensive care units (1307.7 DPD). Almost half of the hospitalized patients in our hospitals were using at least one antibiotic. Moreover, among these antibiotics, the most commonly used ones were carbapenems, quinolones and cephalosporins, which are known to cause collateral damage. We think that antibiotic resistance, which is seen at considerably high rates in our hospitals, is associated with this level of consumption.