美国国家综合癌症网络临床实践指南:胃癌(2020V2)更新要点和解读

2020年5 月,美国国家综合癌症网络(NCCN )发布了《NCCN临床实践指南:胃癌2020.V2》(以下简称指南)[1].相比于NCCN胃癌临床指南2019.V4 版和2020.V1 版,新版指南对胃癌诊断评估、系统治疗(内镜、手术、放化疗、靶向/免疫治疗等)、遗传风险评估等作出全面更新.更新内容及当前热点包含以下...     

2021.V1版NCCN临床实践指南：结肠癌/直肠癌更新解读(外科部分)

正2020年12月22日,美国国立综合癌症网络(National Comprehensive Cancer Network, NCCN)在线发表了《2021.V1版NCCN临床实践指南:结肠癌/直肠癌》(以下简称新版《指南》),分别对《2020.V4版NCCN临床实践指南:结肠癌》和《2020.V6版NCCN临床实践指南:直肠癌》(以下简称旧版《指南》)作了更新。因每年的V1版为主要更新,故新版《指南》一经发布,便引起了学者们的广泛关注。     

NCCN结直肠癌临床实践指南2011年更新解读

美国国家综合癌症网络（National Comprehensive Cancer Network,NCCN）于2006年在孙燕院士倡导下引入中国,并每年进行内容更新.尽管与西方国家在人种特点、医疗体制等方面存在差异,但是,NCCN指南仍然在我国临床肿瘤诊治过程中受到极大的关注.包括2010年底首次由卫生部公布的我国《结直肠癌诊疗规范（2010年版）》也吸收了NCCN指南部分内容作为重要的参考和临床推荐[1].     

直肠癌新辅助治疗疗效评价现状与思考

2009年3月28日，第二届美国国家癌症综合网（National Comprehensive Cancer Network，NCCN）亚洲学术会议在北京召开，针对2009版NCCN直肠癌临床实践指南的重点内容进行解读和讨论。同年6月，第45届美国临床肿瘤学会（American society of clinical oncology，ASCO）年会将“个体化癌症医疗”作为本次会议的主题，提出21世纪肿瘤诊治新理念。     

2021年V1版《NCCN非小细胞肺癌临床诊治指南》更新解读

美国国家综合癌症网络(National Comprehensive Cancer Network,NCCN)根据新的临床证据,更新发布的《NCCN非小细胞肺癌临床诊治指南》已成为全球临床医师遵循和认可的临床诊治参考.2020年11月25日,最新的2021年V1版《NCCN非小细胞肺癌临床诊治指南》(下文简称为《指南》)...     

2022年V1版《NCCN非小细胞肺癌临床实践指南》更新解读

目前美国国立综合癌症网络(National Comprehensive Cancer Network,NCCN)已更新发布2022年V1版《NCCN非小细胞肺癌临床实践指南》(以下简称为《指南》)的最新内容。该指南以高质量的临床证据和最新的研究进展为基础制定非小细胞肺癌诊治标准,受到了全球临床医师的广泛认可和肯定。相比于2021年V7版《指南》有了较多的更新、修订,主要集中在靶向治疗和分子学检测方面。本文将对新版《指南》更新内容进行逐一解读。     

2016年NCCN胰腺癌临床实践指南（V1版）更新内容解读

胰腺癌的发病率逐年升高,预后极差,以循证医学为基础的多学科联合诊治是延长胰腺癌病人生存的最佳选择。美国国家综合癌症网络（National Comprehensive Cancer Network,NCCN）出版的胰腺癌临床实践指南为指导胰腺癌诊治的重要参考。2016年第一版NCCN胰腺癌指南主要在可能可切除胰腺癌的治疗策略、胰腺癌的影像学评估及治疗后监测等方面进行了更新。     

2022年V1版《NCCN小细胞肺癌临床实践指南》更新解读北大核心CSCD

由美国国家综合癌症网络(National Comprehensive Cancer Network,NCCN)牵头制定的2022年V1最新版《NCCN小细胞肺癌临床实践指南》(以下简称为《指南》)刚发布。该指南以高质量的循证医学证据为基础,为全球临床医师提供临床诊治参考,受到了广泛认可和肯定。相比于2021年V3版,《指南》有了较多重要信息的更新修订,主要集中于放疗和全身治疗进展。本文将对该新版《指南》更新内容进行解读。     

腹部手术患者静脉血栓栓塞症的预防策略

静脉血栓栓塞症(VTE)是外科手术后常见的并发症,在一定的程度上影响着病人的预后,外科手术后VTE的预防也因此越来越受到重视.但目前国内针对术后VTE预防尚缺乏指南性建议.本文就目前国内外VTE发病情况及预防策略进行了综述.     

NCCN结直肠癌临床实践指南2011年更新解读

美国国家综合癌症网络(National Comprehensive Cancer Network,NCCN)于2006年在孙燕院士倡导下引入中国,并每年进行内容更新.尽管与西方国家在人种特点、医疗体制等方面存在差异,但是,NCCN指南仍然在我国临床肿瘤诊治过程中受到极大的关注.包括2010年底首次由卫生部公布的我国<结直肠癌诊疗规范(2010年版)>也吸收了NCCN指南部分内容作为重要的参考和临床推荐[1].     

D-二聚体联合凝血酶时间检查对腹膜癌患者下肢深静脉血栓排除的诊断价值

目的:探讨D-二聚体(D-D)联合凝血酶时间(TT)检查对腹膜癌患者排除下肢深静脉血栓(DVT)的诊断价值。方法:以2015年5月—2017年5月收治的241例腹膜癌患者为研究对象,检查患者术前凝血及纤溶指标,用Wells风险模型对患者进行DVT可能性评分,对所有患者行双下肢静脉超声确诊是否存在DVT,并观察围手术期症状性静脉血栓栓塞(VTE)事件的发生情况。结果:241例患者中经下肢静脉超声确诊DVT共21例(8.7%),术后随访3个月均未出现症状性VTE事件。DVT患者与非DVT患者比较,TT明显缩短,纤维蛋白(原)降解产物与DD明显升高(均P0.05)。ROC曲线确定腹膜癌患者中TT诊断DVT的最佳临界值为13.55 s,联合D-D诊断下肢DVT的阴性预测值为100%,漏诊率为0。无论Wells评分低度或高度可能,联合试验的阴性预测值均为100%。结论:腹膜癌患者就诊时有一定的DVT的发生率,D-D联合TT检测对腹膜癌患者排除DVT诊断有很强的阴性预测价值,且不依赖于Wells评分,联合试验阴性者(D-D243 ng/m L DDU且TT13.55 s)可不接受下肢血管超声检查而安全排除下肢DVT。     

Prophylaxis of venous thromboembolism in general surgery: guidelines differ and we still need local policies

INTRODUCTION

Venous thromboembolism (VTE) prophylaxis has become a major issue for surgeons both in the UK and worldwide. Sev-eral different sources of guidance on VTE prophylaxis are available but these differ in design and detail.

METHODS

Two similar audits were performed, one year apart, on the VTE prophylaxis prescribed for all general surgical inpatients during a single week (90 patients and 101 patients). Classification of patients into different risk groups and compliance in prescribing prophylaxis were examined using different international, national and local guidelines.

RESULTS

There were significant differences between the numbers of patients in high, moderate and low-risk groups according to the different guidelines. When groups were combined to indicate simply ‘at risk’ or ‘not at risk’ (in the manner of one of the guidelines), then differences were not significant. Our compliance improved from the first audit to the second. Patients at high risk received VTE prophylaxis according to guidance more consistently than those at low risk.

CONCLUSIONS

Differences in guidance on VTE prophylaxis can affect compliance significantly when auditing practice, depending on the choice of ‘gold standard’. National guidance does not remove the need for clear and detailed local policies. Making decisions about policies for lower-risk patients can be more difficult than for those at high risk.     

极度肥胖静脉血栓栓塞预防围手术期管理流程

静脉血栓栓塞（VTE）是减重代谢外科术后常见的并发症之一,极度肥胖患者具有较高的VTE发生风险。笔者就国内外相关指南、文献进行梳理分析,同时结合笔者中心的临床经验,整理并总结极度肥胖患者围手术期VTE预防管理流程,以期为VTE的防治提供参考。     

Venous Thromboembolism in Lower Extremity Arthroscopy

Venous thromboembolism (VTE) is a relatively rare complication of arthroscopic surgery of the lower extremity, but it does have the potential to result in significant morbidity and possible mortality. VTE has been reported to occur with knee arthroscopy, and guidelines for VTE prophylaxis before and after knee arthroscopy have been proposed. There are much fewer data regarding the incidence of VTE occurring after arthroscopy of the ankle and the hip. This article reviews the literature on the incidence, treatment, and prevention of VTE in association with arthroscopy of the lower extremity.     

A critical appraisal of clinical practice guidelines for management of four common complications after spinal cord injury

BACKGROUND CONTEXTComplications such as pressure sores, pulmonary infection, urinary tract infection (UTI), and venous thromboembolism (VTE) are common after spinal cord injury (SCI). These have serious consequences for patients’ physical, social, and vocational well-being. Several authoritative organizations have developed guidelines for managing these complications after SCI.PURPOSEWe aim to systematically review and appraise guidelines on the management of four common complications (pressure sores, pulmonary infection, UTI, and VTE) after SCI as well as to summarize relevant recommendations and assess the quality of their supporting evidence.DESIGNSystematic review.METHODSWe searched Medline, Embase, Cochrane, and Web of Science, as well as guideline-specific databases (eg, National Guideline Clearinghouse) and Google Scholar, from January 2000 to January 2022. We included the most updated guidelines developed by specific authoritative organizations. We evaluated the included guidelines using the Appraisal of Guidelines for Research and Evaluation 2nd edition instrument, which measures six domains (eg, applicability). Recommendations extracted from guidelines were categorized as for, against, or neither for nor against. An evidence assessment was adopted to classify the quality of supporting evidence as poor, fair, or good.RESULTSEleven guidelines from 2005 to 2020 were included, all of which, among the six domains, scored lowest in the domain of applicability. For pressure sores, guidelines recommended for skin inspection, repositioning, and the use of pressure reduction equipment as preventive measures and dressings, debridement, and surgery as treatment measures. For pulmonary infection, guidelines recommended for physical (eg, the use of an insufflation–exsufflation device) and pharmacological measures (eg, the use of bronchodilators). For UTI, guidelines recommended for antibiotics as a treatment measure but recommended against cranberries, methenamine salts, and acidification or alkalinization agents as preventive measures. For VTE prophylaxis, five guidelines recommended for low molecular weight heparin (LMWH). Three guidelines recommended against unfractionated heparin, whereas one guideline recommended for it. Most of the supporting evidence was of poor quality (130/139), and the rest was of fair quality (9/139).CONCLUSIONSFor pressure sores, pulmonary infection, and UTI, evidence of poor to fair quality indicated consistent recommendations for prevention and treatment measures. For VTE, LMWH was consistently recommended, whereas recommendations on the use of unfractionated heparin were controversial.     

从2020年国内外主要指南更新变化解读胃肠间质瘤精准诊治

酪氨酸激酶受体抑制剂在GIST中取得成功是精准医学时代分子靶向药物治疗的里程碑.2020年,国内外各学术组织围绕GIST的诊疗实践相继发布或更新了各种诊疗指南与专家共识.其中在指南层面,中国临床肿瘤学会(CSCO)发布我国首部GIST诊疗指南《胃肠间质瘤诊疗指南2020》,美国国家综合癌症网络也对NCCN指南GIST部...     

《欧洲血管外科学会（ESVS）2021年静脉血栓管理临床实践指南》临床热点解读

欧洲血管外科学会（ESVS）于2021年在《European Journal of Vascular and Endovascular Surgery》发表了该协会首个静脉血栓诊疗领域的指南：《欧洲血管外科学会（ESVS）2021年静脉血栓管理临床实践指南》,该指南包括了下肢深静脉血栓形成（DVT）、上肢DVT、浅静脉血栓形成（SVT）以及特殊部位血栓形成等方面,共给予了72条推荐意见;同时,除了关于治疗方法的推荐,还包括了健康经济学以及特殊患者人群的相关问题。该指南中的建议是通过对目前可以得到的研究证据进行分析及评估制定的,会对临床实践有较大的借鉴意义,但是,随着技术、证据以及知识的发展,指南可能需要不断更新。笔者团队根据指南更新的循证医学证据,结合临床中的热点问题,对指南给出的推荐意见做重点解读,以期更好地理解指南原则及实用建议。     

Efficacy of surveillance ultrasound for venous thromboembolism diagnosis in critically ill children after trauma

Introduction

Venous thromboembolism (VTE) is increasingly prevalent in injured children admitted to the intensive care unit (ICU). Few data exist to support VTE pharmacologic prophylaxis or ultrasound (US) surveillance in children with high bleeding risk. After implementation of screening US guidelines, we sought to describe our experience, hypothesizing that screening US of children at highest risk for VTE results in earlier detection and management.

Institutional validation of breast cancer treatment guidelines

Several groups have developed clinical guidelines for the management of breast cancer, yet little data exist regarding their validation. Therefore, we examined the effect of published National Comprehensive Cancer Network (NCCN) guidelines for invasive breast cancer on survival, quality of life (QOL), and hospital cost. From 260 consecutive breast cancer patients, 129 patients were identified for analysis: 93 patients (72%) were treated according to the guidelines (NCCN+), while the treatment of 36 patients (28%), with a similar stage distribution, deviated from the guidelines (NCCN-). Patients were excluded from analysis with a diagnosis of carcinoma in situ, inflammatory cancer, stage IV disease, and comorbid conditions that affected treatment. The 5-year survival was 87.6% for the NCCN+ patients versus 83.3% for NCCN- patients (P = 0.319 by Kaplan-Meier). Twelve QOL parameters were evaluated using a Likert-type scale (1 = severe and 5 = none). NCCN+ patients had a cumulative QOL score of 4.18 +/- 0.08 versus 4.24 +/- 0.14 for NCCN- patients (P = 0.745). Treatment-related costs were $20,300 +/- 1800 for NCCN+ patients versus $59,700 +/- 25,200 for NCCN- patients (P = 0.016 by t test). Although deviation from NCCN breast cancer guidelines had no effect on perceived quality of life or survival, there was a significant decrease in cost in the NCCN+ group. These findings suggest that adherence to NCCN guidelines can significantly reduce the cost of breast cancer care without adversely affecting either survival or quality of life.