Objective:To evaluate the impact of laparotomy pancreatoduodenectomy (OPD), laparoscopic pancreatoduodenectomy (LPD) and Da Vinci robot assisted pancreatoduodenectomy (RPD) on the risk of pancreatic fistula in postoperative patients.Methods:The key words were laparoscopic, pancreaticoduodenectomy, robot, DaVinci, Whipple, complication, fistula, pancreaticoduodenectomy, laparoscopy, robot, postoperative complications and pancreatic fistula, and the databases of CNKI, Wanfang, VIP, CBM, Cochrane Library, PubMed, EMBASE and web of science were searched until August 1, 2020 for retrospective cohort studies and randomized controlled trials comparing the efficacy of OPD, LPD and RPD. The articles were screened according to the pre-set inclusion and exclusion criteria, and the quality of the articles was evaluated and the data were extracted. Based on Bayesian framework, R4.0.2, Revman 5.3 and Stata 16.0 software were used to analyze the extracted data for mesh meta analysis.Results:Thirty articles involving 3 428 patients were included, including 26 retrospective cohort studies and 4 randomized controlled studies. Mesh meta-analysis showed that in the incidence of pancreatic fistula, there was no significant difference between LPD and OPD, between LPD and RPD ( OR=0.93, 95% CI 0.63-1.4; OR=1.4, 95% CI 0.87-2.2, P<0.05), but the incidence of postoperative pancreatic fistula was significantly lower than that of OPD ( OR=1.5, 95% CI 1.1-2.1, P<0.05), 95% CI 1.12.1; P>0.05). The risk probability of pancreatic fistula was ranked as RPD (0.00), LPD(0.34) and OPD(0.65), that is, for the risk of postoperative pancreatic fistula, the advantages and disadvantages of the three surgical methods were ranked as RPD, LPD and OPD. Conclusions:Compared with OPD, RPD can significantly reduce the risk of pancreatic fistula after PD and improve the quality of operation; there was no significant difference between LPD and RPD in the incidence of postoperative pancreatic fistula, and both of them were safe and feasible.

Objective: To investigate the application value of thrombelastography(TEG) in coagulation monitoring for ACS patients.Methods: Totally 255 ACS patients were selected with coagulation monitoring by TEG.The patients were divided into none ST-segment elevation myocardial infarction (NSTEMI) group and ST-segment elevation myocardial infarction (STEMI) group.The clotting characteristics in different types of ACS patients were compared and analyzed.Results: The ACS patients had higher intensity of thrombosis (MA) and Angle value.D-dimer and MA were significantly different between NSTEMI group and STEMI group(P＜0.01).The drug utilization in STEMI group was closer to the requirements of the guidelines.Conclusion: TEG shows high application value in coagulation monitoring for ACS patients.MA value and Angle value are more sensitive in evaluating hypercoaguable state.

Objective To compare the clinicopathological characteristics and prognosis of primary Waldeyer's ring non-Hodgkin lymphoma.Methods From Jan 2008 to Dcc 2013, 50 patients with primary Waldeyer's ring non-Hodgkin lymphoma were retrospectively analyzed.Kaplan-Meier method was used for survival analysis.Log-rank method was used for univariate analysis.Results Waldeyer's ring diffuse large B-cell lymphoma (DLBCL) and extranodal nasal-type NK/T-cell lymphoma (ENKTCL) were the common pathological types of primary Waldeyer's ring non-Hodgkin lymphoma accounting for 56 ％ (28/50) DLBCL and 34 ％ (17/50) ENKTCL, respectively.The age at onset of ENKTCL patients was younger than that of DLBCL patients.Two groups had different primary sites, including 50.0 ％ (14/28) of DLBCL with tonsillar disease and 88.2 ％ (15/17) of ENKTCL with nasopharynx disease.The short phase effect of DLBCL group was higher than that of ENKTCL group.The overall survival (OS) and progression-free survival (PFS) rates had significant differences between DLBCL and ENKTCL (x2 =4.45, P =0.035;x2=6.47, P =0.011).Conclusion DLBCL and ENKTCL are different in clinical characteristics.The short phase effect and prognosis of DLBCL are obviously better than those of the ENKTCL.

Critical care medicine has the characteristics of complex,a wide range of knowledge,and interdisciplinary,so standardized training is difficult.Intensive Care Unit explored a standardized training mode and evaluation system suitable for standardized training residents in the Intensive Care Unit,including generalizing training target,developing step by step teaching plans,establishment of entrance education,basic theory,basic skills,scientific thinking and doctor-patient communication training with diversity of teaching methods,including lecture-based learning,problem-based and casebased learning,implement the flexible and strict evaluation system.

The experience of various countries proves that the hierarchical diagnosis and treatment model can lead to reasonable resources allocation and utilization, however, the waste of China''s disordered treatment model has not been estimated.Nowadays, it is very important to establish a hierarchical diagnosis and treatment system during China''s healthcare system reform.Therefore, it is necessary to estimate the benefit the reform may bring.We take Zhejiang Province as an example, and adopted the system dynamics model to build the health delivery system, to emulate the hierarchical diagnosis and treatment model and the disordered model, and to evaluate the benefit.Results showed that if first option at the primary health institutions increased 10%, it could save 0.251 billion yuan, and if increased 15%, it could save 0.39 billion yuan.If the first option at the primary health institution reached 72.35% and the treatment in county reached 90%, the outpatient in tertiary hospital could reduce by 13 million, and those in primary healthcare institutions could increase by 74 million yuan.The direct healthcare cost could reduce 3.016 billion Yuan.

Objective To observe the effect of panretinal photocoagulation (PRP) on the expression of cyclooxygenase-2 (COX-2),vascular endothelial cell growth factor (VEGF) in epiretinal membrane of proliferative diabetic retinopathy (PDR).Methods A total of 35 patients (35 eyes) with PDR and underwent plana vitrectomy were enrolled in this study.The patients were divided into non-PRP group (19 patients,19 eyes) and PRP group (16 patients,16 eyes) depends on if they had received PRP before surgery.The epiretinal membranes stripped during operation were collected for pathological examination.The histopathological features was observed by haematoxylin and eosin stain.The expression of CD34,COX-2 and VEGF,and microvessel density (MVD) were measured by immunohistochemistry method.Results Many new dispersed capillary blood vessels were found in the thick epiretinal membranes of nonPRP group,while scattered small blood vessels were found in the relatively thin epiretinal membranes of PRP group.MVD value was (7.42± 1.39) in the non-PRP group and (4.56± 1.22) in the PRP group,which was lower than the non-PRP group (t=6.41,P＜0.01).The expression of CD34,COX-2 and VEGF in the tissues of epiretinal membrane in PRP group were obviously lower than the non-PRP group (t=6.147,5.944,7.445;P＜0.01).Conclusion PRP can effectively inhibit the expression of COX-2 and VEGF in epiretinal membrane of PRP patients.

Objective To investigate the correlation between chronic insomniacs' sleep quality and age,gender,education level,anxiety,depression and sympathetic skin response (SSR) in chronic insomniacs.Methods General information of 197 outpatients with chronic insomnia was recorded,including age,gender and education,etc.They were tested by Pittsburgh's Sleep Quality Index (PSQI),Hamilton's Anxiety Scale (14 item version) (HAMA14),Hamilton's Depression Scale (24 item version)(HAMD24) and Sympathetic Skin Response (SSR).Distribution properties of different age,gender and education groups were studied.Chronic insomniacs were divided into mild insomnia group (7 ≤ PSQI ＜ 14)and moderate-severe insomnia group (PSQI ≥ 14).Dependency relation analysis and stepwise linear regression analysis were conducted among indices of PSQI scores,HAMA14 scores and total score,HAMD24 scores and total score,SSR positive incidence.Results Among 197 chronic insomniacs (male,50 cases,25.4％;female,147 cases,74.6％),insomniacs aged over 40 accounted for 77.2％.Female patients were older than male patients with statistical significance,of whom those aged 40-60 years accounted for the highest proportion of 37.1％.Female patients with less education (junior high school and below)accounted for the highest proportion of 50.3％ (73/197),whose education level was generally lower than male patients.Among 197 chronic insomniacs,104 cases (52.8％,99/197) had mild insomnia and 93cases (47.2％) had moderate-severe insomnia.Total score of HAMA14 of patients with moderate-severe insomnia was significantly higher than that of patients with mild insomnia (16.47 ± 5.40 vs 12.51 ± 4.53;t =5.552,P＜0.01).There was statistically significanct difference in subitem HAMA14 scores of anxiety somatization factor (4.31 ± 2.26 vs 5.90-3.10,t =5.600,P ＜ 0.01) and spiritualized anxiety factor (10.5 ± 72.97 vs 8.20 ± 3.00,t =4.157,P ＜ 0.01) between mild and moderate-severe groups with insomnia.Total score of HAMD24 of patients with moderate-severe insomnia was significantly higher than that of patients with mild insomnia (18.04 ± 5.91 vs 13.41 ± 5.05;t=3.931,P＜ 0.01).There was statistically significanct difference in scores of most HAMD24 subitems including anxiety/somatization (3.56 ± 1.51 vs 2.94 ± 1.28;t =3.110,P =0.002),cognitive dysfunction (2.91 ± 1.68 vs 2.17 ± 1.57;t=3.191,P=0.002),retardation (2.331 ±1.31 vs 1.72 ±1.22;t=3.939,P=0.01),dyssomnia (4.51 ± 1.54 vs 3.01 ± 1.80;t =6.228,P ＜0.01) and hopelessness factor (2.29 ± 1.46 vs 1.66 ± 1.07,t =3.459,P =0.001;except body weight and diurnal variation factor) between groups with different degrees of insomnia.SSR abnormal incidences of moderate-severe insomniacs were significantly higher than that of mild insomniacs.The proportion of poorly differentiated waveform and not elicited waveform in SSR abnormal groups had statistically significant difference.The Pearson correlation analysis showed that PSQI scores in chronic insomnia patients and HAMA14,HAMD24 score as well as abnormal rate of SSR were positively correlated (r =0.439,0.465,0.249,all P ＜ 0.01).Conclusions Chronic insomnia was commonly seen in middle-aged women with education level of junor high school and below.The degree of sleep quality and anxiety,depression as well as the abnormal rate of SSR was positively correlated in patients with chronic insomnia.

Objective Investigate and intervene the psychological health state of clinical trainees in the hospital of Yuxi City, in order to explore the method to improve the psychological health and clinical quality of teaching. Methods From 2009 to 2013, clinical trainees were investigated by SCL-90. Intervention for interns included holding psychological health lectures and making psychological counseling for the serious interns. At the same time, the teachers were trained to carry out two-way intervention between the teachers and clinic interns and to improve clinical interns' psychological health. Results Before the intervention,among 216 interns,34 (15.74%) showed positive. Except fear factor, other factors were significantly different than national norms ( <0.05). After the intervention, among 149 interns, 20 ( 13.42%) showed positive. Obsessive-compulsive symptom, depression,anxiety,hostility, spirit factors and the mean scores were all lower than before ( <0.05),similar to the national norm.Conclusion Clinical trainees have prominent psychological problems. Teaching hospitals should pay more attention to psychological health of them. Intervention is necessary and effective in improving psychological health and quality of teaching.

Objective:To study influence factors on teaching quality,make use of ISO9000 to establish an evaluating system of teaching quality,make a model of teaching quality,offer a method for comprehensive management and offer a basis for continue improvement.Methods:Nominal group process,Delphi,and Cross-sectional study are adopted.Results:Making an evaluate index of system and establishing a model of teaching quality,the evaluating feedback etc.Conclusion:The principle of ISO9000 is embodied for the study method is scientific,the process of evaluation is feasible,index is all-sided and index system is flexible.

Objective To explore the MR features of granulomatous mastitis and to improve the diagnosis of the disease.Methods MR findings of 1 1 patients with granulomatous mastitis confirmed by pathology were retrospectively reviewed.Results Nine (81.82%)lesions showed regional or diffused hyperintensity on T2 WI with heterogeneous gridding features.2 (18.18%)lesions showed mass-like enhancement and 9 lesions showed non-mass-like enhancement.Of 9 (81.82%)lesions with non-mass-like en-hancement,the enhancement patterns included diffused in 2 (18.18%)cases,regional in 4 (36.36%)cases,multiple-regional in 2 (18.18%)cases,and focal in 1 (9.09%)case,respectively.All the lesions showed early heterogeneous enhancement,and clumped-ring enhancement was seen in 6 lesions.The signal intensity of the lesions was increased and more uniform in the later stage.The time-signal intensity curve was type I in 7(63.64%)cases,type II in 3 (27.27%)cases and type III in 1 (9.09%)case.The mean ADC value was (1.82±0.1 7)×10 -3 mm2/s,and there was no significant difference between lesions and normal regions (t=1.766, P >0.05).Concomitant signs included barymastia,thickening of skin,edema surrounding the lesions,and axillary lymph node en-largement.The BI-RADS category was 3 degree in 1 (9.09%)case,4a degree in 5 (45.45%)cases,4b degree in 2 (18.18%)ca-ses,4c degree in 2 (18.18%)cases and 5 degree in 1 (9.09%)case.The misdiagnosis ratio was 54.55%.Conclusion Granuloma-tous mastitis has certain characteristic MR features.The misdiagnosis ratio of granulomatous mastitis is high.Therefore,clinical data should be referred when making diagnosis.