Objective:Under the premise of the policy of everybody has medical insurance,it discussed the integration plan of the basic medical insurance system for urban and rural residents in Tibet about the problems and the countermeasures.Methods:Descriptive and contrastive methods were used to analyze the status of urban and rural medical system operation in Tibet.Results:The problem of unbalanced development of urban and rural medical and health services in Tibet and the management of post-merger were put forward.Conclusion:It was necessary to put forward policy recommendations from the aspects of horizontal co-ordination,multi-sectoral collaborative management,unified medical insurance information management system,hierarchical diagnosis and treatment mechanism,perfect Tibetan medicine reimbursement catalog,one system and multiple files and vertical co-ordination,and gradually realize the urban and rural medical insurance in Tibet System integration.

Objective To study protective and therapeutic measures to improve perioperative safety in extremely elderly patients with biliary diseases.Methods A retrospective case-control study was conducted.The clinical data of elderly patients with biliary diseases treated at the Department of General Surgery,Beijing Electric Power Hospital,from July 2013 to December 2018,were collected.According to age,the patients were divided into the high age (HA) group (≥80.0 years) and the middle-low age (MLA) group (60.0～79.0 years).The related indexes of perioperative safety such as preoperative coexisting diseases,functions of liver,kidney,heart and lung,surgical procedures,intraoperative blood loss,operation time,postoperative hospital stay and postoperative hospital stay were analyzed and compared between the two groups.Results Of the 372 included patients,there were 168 males and 204 females,aged 60.0 to 96.0 (72.0 ± 8.6) years.There were 69 elderly patients (37 males and 32 females) aged 80.0 to 96.0 (84.4 ±3.8) years in the HA group.There were 303 patients in the middle and lower age group (131 men and 172 women),aged 60.0 to 79.0(68.4 ±5.8) years (MLA group).(1) Preoperative coexisting diseases were significantly increased in the HA compared with the MLA group (all P ＜ 0.05),including the proportion of coexisting coronary heart disease [34.8％ (24/69) vs.18.5％ (56/303)],hypertension [68.1％ (47/69)vs.46.9％ (142/303)],chronic bronchitis with emphysema [17.4％ (12/69) vs.3.6％ (11/303)],hypoproteinemia [39.1％ (27/69) vs.26.7％ (81/303)],and anemia [42.0％ (29/69) vs.11.9％ (36/303)].(2) Laboratory examinations:the functions of liver,kidney,heart,lung and blood coagulation were significantly worse in the HA compared with the MLA group (P ＜ 0.05).(3) Surgical procedures:the proportion of open cholecystectomy with transcystic common bile duct exploration (OC + OTCBDE) was higher [17.4％ (12/69) vs.6.9％ (21/303)],while laparoscopic cholecystectomy (LC) was lower [43.5％ (30/69) vs.62.7％ (190/303)],in the HA compared with the MLA group (P ＜0.05,totally).(4) Operative effects:the intraoperative blood loss [30.0 (20.0,75.0) ml vs.20.0 (10.0,30.0) ml],operation time [90.0(72.5,137.5) min vs.77.0(55.0,115.0) min],postoperative hospital stay [10.0(6.0,18.0) d vs.7.0(4.0,11.0) d],and length of hospitalization [17.0(11.5,23.0) d vs.13.0(9.0,19.0) d] were significantly increased or prolonged in the HA compared with the MLA group (all P ＜0.05).(5) Postoperative complications:the incidence of postoperative complications was significantly higher [30.4％ (21/69) vs.12.2％ (37/303)] in the HA compared with the MLA group (P ＜ 0.05).(6) Therapeutic outcomes:there was a cure rate of 95.7％ (66/69) in the HA group,and 97.7％ (296/303)in the MLA group.No significant difference in the therapeutic effects was found between the two groups (P ＞ 0.05).Conclusions Operation in extremely elderly patients with biliary diseases is safe and feasible.The key is to take measures such as actively treating preoperative coexisting diseases,strictly mastering operative indications,reasonably selecting surgical procedures,accurately carrying out precise operation,strictly monitoring and dealing with intraoperative emergency,timely preventing and treating postoperative complications,and especially focusing on maintaining cardiopulmonary function during the perioperative period.

Cholelithiasis is a kind of common and multiple diseases.In recent years,traditional laparotomy has been challenged by a minimally invasive surgery.Through literature review,the therapeutic method,effect,and complications of minimally invasive treatment of intrahepatic and extrahepatic bile duct stones by combining our practical experience were summarized as follows.(1) For intrahepatic bile duct stones,the operation may be selected by laparoscopic liver resection,laparoscopic common bile duct exploration (LCBDE),or percutaneous transhepatic cholangioscopy.(2) For concomitant gallstones and common bile duct stones,the surgical approach can be selected as follows:laparoscopic cholecystectomy (LC) combined with endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilatation,LC plus laparoscopic transcystic common bile duct exploration,LC plus LCBDE,and T-tube drainage or primary suture.(3) For concomitant intrahepatic and extrahepatic bile duct stones,laparoscopic liver resection,choledochoscopy through the hepatic duct orifice on the hepatectomy cross section,LCBDE,EST,and percutaneous transhepatic cholangioscopic lithotripsy could be used.According to the abovementioned principle,the minimally invasive treatment approach combined with the surgical technique and equipment condition will be significant in improving the therapeutic effect and avoiding the postoperative complications or hidden dangers of intrahepatic and extrahepatic bile duct stones.

Objective:The purpose of this study was to explore the critical values of monitored indexes of perioperative major adverse cardiac events(MACE), so as to take effective prevention and treatment measures in time to maintain the stability of perioperative cardiac function to further improve the perioperative safety of elderly patients with biliary diseases.Methods:The clinical data of 246 elderly patients with biliary diseases in our hospital from May 2016 to February 2022 were collected.According to whether MACE occurred during the perioperative period, they were divided into the MACE group and the non-MACE group.The differences of clinical data, the monitoring indexes of postoperative cardiac function, and the coagulation function between the two groups were compared and analyzed.Logistic regression was used to analyze the independent risk factors of perioperative MACE, the cut-off value of the receiver operating characteristic(ROC)curve was calculated, and the Logistic multivariate prediction model was established.Results:In the MACE compared with the non-MACE group, age, postoperative complications and mortality, postoperative hospital stay, and the levels of postoperative high sensitivity troponin-I(Hs-TnI), creatine kinase isoenzyme(CK-MB), myoglobin(MYO), B-type natriuretic peptide(BNP), and D-dimer(D-D)were significantly increased(all P<0.05). Multivariate Logistic regression showed that postoperative BNP and D-D were two independent risk factors for perioperative MACE, and their cut-off values in the ROC curve were 382.65 pg/mL and 0.975mg/L respectively.The Logistic multivariate prediction model established by the Logistic regression equation was P= ex/(1+ ex), X=-5.710+ 0.003X 1+ 0.811X 2, where X 1 was the postoperative BNP level and X 2 was the postoperative D-D level.The accuracy, specificity and sensitivity of this prediction model for predicting perioperative MACE were 96.3%(237/246), 100.0%(235/235), and 18.2%(2/11). Conclusions:The Logistic multivariate prediction model established in this study can effectively predict the occurrence of perioperative MACE in elderly patients.Postoperative BNP and D-D were two independent risk factors for perioperative MACE.The cut-off values of BNP and D-D in the ROC curve could be used as critical values for monitoring perioperative MACE.Therefore, it is of great clinical significance to take effective prevention and treatment measures in time to maintain the stability of perioperative cardiac function, and further improve the perioperative safety of elderly patients with biliary diseases.