Western developed countries have already made multi-site physician practice a mainstream in their physicians'regulatory system,which remains however at the beginning stage in China during the ongoing health reform since 2009.This article justified the significance of this practice,then analyzed its main roadblocks encountered in China,and in the end proposed countermeasures in terms of better awareness,better policy support and practicality of the practice.

In an effort to overcome the inherent setbacks of private hospitals in the upcoming healthcare reform, and empower them to build people-benefit hospitals by learning the concept of scientific development, a business model is proposed. This model is designed based on analysis of their development characteristics and in combination of the business specifics, advocating a pool of the guidance force of people-benefit concept, the force of business integrity, that of differentiated competition, and that of self restraint.

ObjectiveTo evaluate the diagnostic value of ultrasound or CT guided percutaneous Trucut needle biopsy on the diagnosis of pancreatic tumors.Methods One hundred and twenty-four patients clinically diagnosed as pancreatic cancer without pathological diagnosis underwent percutaneous pancreatic biopsy by using Trucut needle under ultrasound or CT guidance.ResultsOne hundred and nine procedures of ultrasound-guided biopsy and 15 procedures of CT-guided biopsy were performed,and one patient received 2.3times of punctures.Tissue samples were obtained in all 124 patients,the diagnostic accuracy was 95.2％,among them 115 were adenocarcinoma,5 were cystadenoma,2 were metastasis cancer,1 was cancer of unknown origin and 1 was normal.The sensitivity,specificity,and accuracy were 99.2％ 100％,and 99.2％,respectively.Transient serum amylase increase was observed in 3 patients; 5 patients' abdominal pain aggravated,but all recovered with conservative management.One patient was found to have tumor seeding on the spot of insertion after 34 days.No other major complications occurred.ConclusionsUltrasound or CTguided percutaneous pancreatic 16 ～ 18G Trucut needle biopsy is a safe and simple procedure with excellent diagnostic value for pancreatic cancer.

Objective To evaluate the efficacy of transarterial chemoembolization (TACE) and percutaneous cryosurgery sequential therapy for unresectable hepatocellular carcinoma (HCC).Methods Four hundred and twenty patients with unresectable HCC were divided into sequential TACE-cryosurgery sequential (sequential) group (n=290) and cryosurgery alone (cryoalone) group (n = 130). TACE was performed with the routine operation; the percutaneous cryosurgery was conducted 2 to 4 weeks after TACE. The patients were followed up at the first month and once every 2 to 3 month later. Liver ultrasound or both computer tomography and alpha fetal protein were examined during follow-up. Results During a mean follow-up of (42±17) months (range from 24 to 70 months), the local recurrence rate of ablated lesion was 17% for all the patients, 11% and 24% for patients in sequential group and cryoalone groups respectively (P=0. 001). The overall 1-, 2-, 3-, 4-and 5-year survival rate was 72%, 57%, 47%, 39% and 31%, respectively. The 1- and 2-year survival rates (71% and 61 % ) in sequential group were similar to those (73 % and 54 % ) in cryo-alone group (P=0.69 and 0. 147), while the 4- and 5-year survival rates were higher in sequential group (49 % and 39 % ) than those (29 % and 23 % ) in cryo-alone group (P= 0.001). Eighteen patients with large HCC (＞5 cm in diameter) in sequential group survived for more than 5 years while no one in cryo-alone group. Complication rate was 24% in all patients, 21% and 26% for the sequential and cryo-alone groups respectively (P=0. 06). The incidence of hepatic bleeding was higher in cryo-alone group than in sequential group (P=0. 02). Liver crack occurred in two patients of the cryoalone group. Conclusions Pre-cryosurgical TACE increased the cryoablation efficacy and decrease its complications, especially hepatic bleeding. TACE and cryosurgery sequential therapy may be a better treatment for unresectable HCC, especially for large HCC.

Objective:To investigate the clinical therapy of one-stage internal and external fixation combined with early perforator fiap for treatment of ankle fracture dislocation with soft tissue defects of Gustilo types Ⅲ.Methods:A retrospective study was conducted of the 20 patients with ankle fracture dislocation of Gustilo type Ⅲ who had been treated from May 2014 to July 2017 at Deparment of Traumatic Orthopaedics, the Second Hospital of Tangshan. There were 14 males and 6 famales among the patients, aged from 18 to 58 years (average, 40 years). There were 5 cases of Gustilo type ⅢA, 12 cases of type ⅢB, and 3 cases of type ⅢC; AO classification of ankle fractures: 4 cases of type A, 7 cases of type B, and 9 cases of type C; The wound size ranged from 4 cm×3 cm to 20 cm×9 cm. All patients were treated by primary internal and external fixation plus secondary transfer with a perforator flap. The times from injury to initial surgery ranged from 1 to 8 h (average, 5.5 h), the period from injury to secondary flap transfer ranged from 7 to 21days (average, 12 days). Among them, 11 cases of posterior tibial artery perforator flap, 5 cases of fibular artery perforator flap, 1 case of anterior ankle flap, and 3 cases of posterior tibial artery perforator flap combined with fibular artery perforator flap.Results:All 20 cases of limb preservation were successful, and there were no amputees. 9 patients showed superficial infection, no deep infection and osteomyelitis occurred. All 19 cases of flap survived, 1 case of distal part of posterior tibial artery perforator flap was necrosis, and the skin graft was cured later. All patients were followed up for 6 to 18 months (average, 12 months). The flap healed well. There was no sinus tract and bone exposure. The sensory recovery was S1 in 2 fiaps, S2 in 12 flaps, S3 in 6 flaps. The fracture healing time vanged from 4 to 10 months (average, 6.5 months), no bone disunion in patients. According to the American foot ankle surgery scoring system, the efficacy was assessed: 4 excellent cases, 11 good cases, 3 fair cases, 2 poor cases, yielding an excellent to good rate of 75%.Conclusions:One-stage internal and external fixation combined with early perforator fiap transfer is an effective strategy for treatment of ankle fracture dislocation with soft tissue defects of Gustilo types Ⅲ, due to its advantages of shortened treatment period, possibility for early rehabilitation, decreased complications and satisfactory functional recovery.

Objective This study compares a dual-freeze protocol with a triple freeze protocol for hepatic cryoablation in the Tibetan pig model.Method Cryoablation with a dual-(10-5-10-5 min)and triple-freeze (5-5-5-5-10-5 min) protocol for the normal livers of 9 Tibet pigs was performed under exposed operation.Temperature changes of cryoprobes and diameter changes of iceballs were measured during the ablation,and seven days later the pathological changes of cryozones were reviewed and the surface and depth cryolesions were measured.Results Compared with cryoablation with two freeze-thaw cycles,there was a greater iceball diameter for cryoablation by three freeze-thaw cycles.Also,seven days after cryosurgery,there were similar surface and deep cryolesions in dual-and triple-freeze protocols.Pathologically,the triple freezing protocol was associated with a longer zone of complete necrosis.Conclusions With the same freezing time (20 min),the triple-freeze protocol may become a more powerful liver-ablation method in cryosurgical application.