头颈部恶性肿瘤诊断治疗指南

恶性肿瘤是威胁人类生存的第一杀手,就头颈肿瘤来说虽然发病率在我国并不高,但由于我国人口众多,发病率的绝对数字也是不可忽视的。当今提倡晚期头颈肿瘤的综合序列治疗,患者的生存率及生存质量已有很大的提高,由于我国的地域差异和医学发展水平的不平衡,对于头颈肿瘤的治疗难以形成统一的治疗标准,目前国内也缺少头颈肿瘤的诊断治疗指南,客观存在着肿瘤的诊断治疗欠规范,延误诊治、过度治疗、治疗不够等现状,这不仅导致医疗资源的浪费和国家及个人的经济负担加重,而且由此导致的医患纠纷时有发生。鉴于此,本期刊出由上海交通大学医学院附属第九人民医院·口腔医学院郭伟等医师编译的2005年美国国立癌症综合信息网(National Comprehensive Cancer Network,NCCN)公布的由NCCN头颈肿瘤专家组31位专家撰写的关于头颈部恶性肿瘤诊断治疗指南的有关内容,旨在结合我国实际情况供专业人员参考。     

Management of chronic viral hepatitis in HIV-infected patients: Spanish Consensus Conference. October 2000

Co-infection by human immunodeficiency virus and hepatitis B and C viruses is quite common because they share similar routes of transmission. The introduction of highly active antiretroviral therapy has significantly improved the life expectancy of HIV-infected patients in the last few years. However, chronic viral hepatitis represents an emerging cause of morbidity and mortality in this population, either as a result of end-stage liver disease or as a consequence of hepatotoxicity induced by antiretroviral drugs. The main goal of the Consensus Conference was to establish specific recommendations for the management of chronic viral hepatitis B and C in HIV-infected patients. The role of orthotopic liver transplantation for co-infected individuals with end-stage liver disease was also assessed.     

Statement on breast feeding,fertility and contraception

An important part of the human reproductive process, breastfeeding also plays a key role in infant nutrition while protecting the infant from exposure to infection. Breastfeeding also plays a major role in the natural regulation of fertility, but breastfeeding patterns are changing along with urbanization and lifestyle changes. These changes are tending towards a shortening of the duration of breastfeeding, a reduction in the daily frequency of breastfeeding episodes, and an earlier introduction of food supplements. Consequently, the risk of pregnancy during lactation has increased. The literature suggests considerable variability in the length of breastfeeding and postpartum amenorrhea and in the duration of lactational infertility among different populations. Both the return of ovarian activity and fertility depends on the time elapsed since delivery. Variables that play a primary role in the length of amenorrhea and infertility include: the duration of breastfeeding the frequency and duration of suckling; the administration of supplements to the infant; the mother's nutritional status; and geographic, social, and cultural factors. Knowledge of local breastfeeding practices and the associated risks of pregnancy should be a prerequisite for those counseling nursing women. All women should be advised and encouraged to breastfeed fully, as far as is practicable. Women also need to be informed that it is difficult to predict exactly the duration of lactational infertility for each woman. The timing of the introduction of contraception depends on the risk factors and some programmatic aspects, such as the possibility that the woman may not return after delivery or after the 1st postpartum visit as well as the type of contraceptive chosen. Current information on the influence of contraceptive methods -- IUDs, oral contraceptives, injectable contraceptives, norplant, barrier methods, periodic abstinence, and sterilization -- upon breastfeeding are summarized.     

IPPF statement on infertility

The policy statement on infertility issued by the International Medical Advisory Panel of the International Planned Parenthood Federation (IPPF) and adopted by the Central Council of the IPPF in November, 1984, is provided. The IPPF recognizes that subinfertility and infertility is a part of family planning and provides suggestions for how Family Planning Associations (FPAs) can provide supportive assistance in this area of concern. Depending on the facilities and resources available at specific clinics, FPS can provide preventive, counseling, diagnostic, treatment, and referral services. FPAs can play a major role in prevention. Many conditions which cause infertility are preventable, and these include sexually transmitted diseases, infections stemming from abortion and childbirth, and possibly tuberculosis. IUDs increase the risk of pelvic inflammatory disease and may increase the risk of infertility; however, a direct relationship between IUDs and infertility has not been established. Injectable contraceptives may delay the return of fertility but do not lead to permanent infertility. Barrier methods protect againsr sexually transmitted diseases, and oral contraceptives may provide protection from pelvic inflammatory disease. FPAs should be familiar with the major causes of infertility in their region and adopt an advocacy role by promoting community programs to control sexually transmitted diseases which may play a role in infertility, to improve obstetric care, to increase access to reproductive health services, and to provide reproductive educational services for adolescents. FPAs can work in cooporation with other agencies concerned with infertility prevention and management. FPAs can play a direct role by educating their clients about infertility prevention. Most FPAs do have have the facilities and personnel to provide diagnostic and treatment services, but they can provide referral services. They should establish a link with centers which are fully equipped to provide diagnostic and treatment services. FPAs, with appropriately trained personnel, may offer screening services such as taking sexual histories and providing instruction in the timing of sexual intercourse. Clinics, with appropriate laboratory facilities, may offer endometrial biopsy, postcoital testing, and semen analysis.     

IMAP statement on Norplant subdermal contraceptive implant system

The Norplant implant system consists of 6 silastic capsules which deliver levonorgestrel to protect against pregnancy over 5 years. Clinical trials were conducted in 46 countries. The 5-year cumulative pregnancy rate is 3.9%. Norplant's efficacy falls as weight increases. Its failure rate is lower than that of combined oral contraceptives and most IUDs. Counseling is linked to acceptability. Medical personnel should be trained in counseling potential Norplant acceptors. They must undergo formal training in insertion and removal of Norplant. The first year and fifth year continuation rates are 75-90% and 25-78%, respectively. Bleeding irregularities are the main reason for discontinuation and the most commonly reported side effects. Levonorgestrel changes the cervical mucus and suppresses ovulation and the endometrium. Toxicological and teratological data on levonorgestrel and silastic show that Norplant is safe. It appears that Norplant does not cause any major pathological changes in the endometrium, liver, kidney, and adrenal and thyroid glands. Levonorgestrel in Norplant is linked to a slight increase in serum glucose levels which are not of significant consequence. Its effects on lipids and lipoproteins are not clear. Fertility returns to Norplant users shortly after removal. The return to fertility pattern basically matches that of other methods. Contraindications of Norplant use are confirmed or suspected pregnancy, previous ectopic pregnancy, breast cancer, cancer of the genital tract, cerebrovascular or coronary artery disease, acute liver disease, and undiagnosed abnormal genital bleeding. Norplant should be inserted subdermally in the upper arm during the first 7 days after menstruation begins. The capsules must be removed after 5 years if pregnancy is to be avoided. Before family planning programs provide Norplant, managers should make sure the staff is adequately prepared. Health personnel, counselors, potential users, and the public need informational materials on Norplant.     

IMAP statement on contraceptive counselling

Decisions regarding sexual and reproductive behavior involve biomedical, cultural, socioeconomic, and ethical considerations, and have a major impact upon personal and family life over both the long and short terms. Family planning service providers should therefore help their clients assess such issues, especially when permanent or long-term decisions are of issue. Contraceptive counselling is a two-way process of communication characterized by an exchange of information and views, discussion, and deliberation. Research demonstrates that contraceptive use improves when service delivery personnel listen and respond to clients' worries and concerns. Considerations should be given to the following issues when counseling clients on the use of contraception: the technical competence of the counselor and the quality of interaction with clients; tailoring counseling to meet clients' characteristics and needs, with priority given to discussing any issues the clients choose; encouraging useful discussion without overwhelming the client with information; gaining clients' confidence to help them voice personal concerns, yet not infringing upon their privacy; providing counseling in privacy; avoiding misunderstandings and the omission of important information or instructions; and not expecting clients to learn everything in one counseling session. Counseling should instead be supplemented by other means of education and information such as group sessions, posters, leaflets, and videos. Training in counseling, and counseling in special situations such with adolescents, perimenopausal women, postpartum and post abortion women, and women with medical disorders are discussed. A supplement to the statement focuses upon the social and health problems which arise when family planning services and sex education for adolescents are limited or absent.     

The Dalkon Shield IUD

The Dalkon Shield IUD was introduced to the list of contraceptives being distributed to developing countries by IPPF (International Planned Parenthood Federation) in 1973. By 1974, doubts had arisen about the safety of the Dalkon Shield and several cases of maternal mortality and sepsis in Dalkon Shield users had been reported. In 1974, IPPF stopped supplying Dalkon Shields to its affiliates. During the 1973-74 period of distribution, IPPF had distributed approximately 300,000 of the Shields in 41 countries. Almost 1/2 that amount had already been inserted. The position of IPPF's IMAP (International Medical Advisory Panel) on any relationship existing between use of IUDs and pelvic inflammatory disease is as follows as of 1980: 1) infection with actinomycosis makes up only a small component of all the incidents of pelvic inflammatory disease connected with IUDs; 2) the occurrence of pelvic inflammatory disease is not related to the length of use of an IUD; 3) data do not now support the recommendation that inert devices free from major side effects should be removed; and 4) any woman still wearing a Dalkon Shield should have it removed.     

Fatal shoulder dystocia: a review of 56 cases reported to the Confidential Enquiry into Stillbirths and Deaths in Infancy

Objective To use information collected by the Confidential Enquiry into Stillbirths and Deaths in Infancy to help obstetric, midwifery and paediatric practice in the management of shoulder dystocia.
Design Review of casenotes by a multidisciplinary focus group.
Sample All 56 cases reported to the Confidential Enquiry into Stillbirths and Deaths in Infancy from England, Wales and Northern Ireland in 1994 and 1995, where stillbirth or neonatal death was attributed to shoulder dystocia.
Main outcome measures Case notes were reviewed with respect to a range of perinatal variables. Comparisons were made with normative data from other studies when appropriate.
Results Maternal obesity and big babies were over-represented in pregnancies complicated by fatal shoulder dystocia. Fetal compromise was recorded in 26% of labours. The median time interval between delivery of the head and the rest of the body was only five minutes. The lead professional at the time the head was delivered was a midwife in 65% of cases. Middle grade or senior obstetric staff were supervising 47% of cases by the time the body was delivered.
Conclusions Antenatal prediction of shoulder dystocia is imprecise, and the majority of deliveries are attended by midwives. A relatively brief delay in delivery of the shoulders may be associated with a fatal outcome.