OBJECTIVE To evaluate the cost-utility of disitamab vedotin （DV） combined with toripalimab versus platinum-containing chemotherapy as first-line therapy for locally advanced or metastatic urothelial carcinoma（UC） with human epidermal growth factor receptor 2 （HER2） expression from the perspective of China’s health-care system.METHODS A cost-utility analysis was performed. A three-state partitioned survival model was constructed based on the RC48-C016 trial with a 1-week cycle length. The long-term health benefits [quality-adjusted life years（QALYs）] and costs of disitamab vedotin combined with toripalimab versus platinum-containing chemotherapy as first-line therapy for locally advanced or metastatic UC with HER2 expression were simulated. The simulation time horizon was set to 15 years， and the discount rate was 4.5%. The willingness-to-pay （WTP） threshold was defined as twice China’s per capita gross domestic product（GDP） in 2025 （199 330 yuan/QALY）. The incremental cost-effectiveness ratio （ICER） between the two groups was compared， and one-way sensitivity analysis and probabilistic sensitivity analysis were conducted.RESULTS Compared with platinum-containing chemotherapy regimen， the DV plus toripalimab regimen yielded an additional 1.01 QALYs with an incremental cost of 183 224.45 yuan， and the ICER was 181 728.15 yuan/QALY， which was below the WTP threshold. At the current threshold， the probability that the DV combination regimen had a cost-utility advantage was 79.9%.CONCLUSIONS Taking twice China’s per capita GDP in 2025 as the WTP threshold， DV combined with toripalimab exhibits a cost-utility advantage over platinum-containing chemotherapy as first-line treatment for HER2-expressing locally advanced or metastatic urothelial carcinoma.

Objective:To construct a set of evaluation indicator system of self-health management ability for elderly with multiple chronic conditions.Methods:Indicators were initially screened through literature retrieval to form the framework of evaluation system.The Delphi method was used to conduct two rounds of consultation with 15 experts in relevant fields, and the indicators were optimized by integrating the importance and accessibility scores of indicators as well as expert opinions.SPSS 26.0 software was used to statistically analyze the results of expert consultation, and the effectiveness of the consultation was evaluated by expert positive coefficient, authority coefficient and coordination coefficient.Yaahp 12.0 software was used to construct the hierarchical structure model, and conduct pairwise comparisons of indicators at the same level to form a judgment matrix according to the Saaty 1-9 scaling method. After consistency test, the product method was applied to aggregate and determine the weights of indicators at all levels.Results:The positive coefficients of the two rounds of expert consultation were both 100%, and the expert authority coefficients were 0.825 and 0.856.In the two rounds of assessment, the ICC of importance and accessibility scores of level 2 and level 3 indicators were higher than 0.90 ( P<0.05). Following screening and revision through two rounds of expert consultation, an evaluation indicators system of self-health management ability of elderly with multiple chronic conditions was formed, including 5 first-level indicators, 18 second-level indicators and 40 third-level indicators.The weights of 5 first-level indicators determined by the hierarchical analysis method were as follows: disease management(0.203), lifestyle (0.205), psychological adjustment (0.203), social support(0.200), and self-ability evaluation(0.189). Conclusion:The evaluation indicator system of self-health management ability of elderly with multiple chronic conditions has high reliability and scientificity, and its practical utility will be further examined.

Laparoscopic pancreaticoduodenectomy(LPD) poses a high risk of intraoperative bleeding due to the complex anatomy and rich blood supply in the pancreatic head region. This paper innovatively proposes a blood flow control technique system for LPD, adopting a strategy of “priority devascularization and pre-blocking”.By first addressing the peripheral collateral blood supply and the gastroduodenal artery, and then performing dual-system pre-blocking, the dorsal pancreatic artery and the inferior pancreaticoduodenal artery are treated in situ through a combined middle and left posterior approach. This progressive blood flow control method enhances surgical safety and oncological radicality, offering a new paradigm for the development of minimally invasive pancreatic surgery.

Objective:To construct a set of evaluation indicator system of self-health management ability for elderly with multiple chronic conditions.Methods:Indicators were initially screened through literature retrieval to form the framework of evaluation system.The Delphi method was used to conduct two rounds of consultation with 15 experts in relevant fields, and the indicators were optimized by integrating the importance and accessibility scores of indicators as well as expert opinions.SPSS 26.0 software was used to statistically analyze the results of expert consultation, and the effectiveness of the consultation was evaluated by expert positive coefficient, authority coefficient and coordination coefficient.Yaahp 12.0 software was used to construct the hierarchical structure model, and conduct pairwise comparisons of indicators at the same level to form a judgment matrix according to the Saaty 1-9 scaling method. After consistency test, the product method was applied to aggregate and determine the weights of indicators at all levels.Results:The positive coefficients of the two rounds of expert consultation were both 100%, and the expert authority coefficients were 0.825 and 0.856.In the two rounds of assessment, the ICC of importance and accessibility scores of level 2 and level 3 indicators were higher than 0.90 ( P<0.05). Following screening and revision through two rounds of expert consultation, an evaluation indicators system of self-health management ability of elderly with multiple chronic conditions was formed, including 5 first-level indicators, 18 second-level indicators and 40 third-level indicators.The weights of 5 first-level indicators determined by the hierarchical analysis method were as follows: disease management(0.203), lifestyle (0.205), psychological adjustment (0.203), social support(0.200), and self-ability evaluation(0.189). Conclusion:The evaluation indicator system of self-health management ability of elderly with multiple chronic conditions has high reliability and scientificity, and its practical utility will be further examined.

Laparoscopic pancreaticoduodenectomy(LPD) poses a high risk of intraoperative bleeding due to the complex anatomy and rich blood supply in the pancreatic head region. This paper innovatively proposes a blood flow control technique system for LPD, adopting a strategy of “priority devascularization and pre-blocking”.By first addressing the peripheral collateral blood supply and the gastroduodenal artery, and then performing dual-system pre-blocking, the dorsal pancreatic artery and the inferior pancreaticoduodenal artery are treated in situ through a combined middle and left posterior approach. This progressive blood flow control method enhances surgical safety and oncological radicality, offering a new paradigm for the development of minimally invasive pancreatic surgery.

Objective:To investigate the clinical effect of proper management of inferior pancreaticoduodenal artery (IPDA) in laparoscopic pancreaticoduodenectomy (LPD).Methods:This is a retrospective case series study. The clinical and pathological data of 70 patients who received LPD due to pancreatic head tumors, periampullary tumors, or distal common bile duct tumors in the Pancreatic Center of the Second Clinical College of Guangzhou University of Chinese Medicine from January to December 2022 were retrospectively collected. There were 47 males(67.1%) and 23 females(32.9%),aged (59.9±12.8)years(range:13 to 87 years).The procedure of IPDA exposure was as follows:a middle approach was utilized to expose the right half of superior mesenteric artery(SMA) and its right branches between the SMA and superior mesenteric vein(SMV) in superior colonic region. In the subcolonic region,SMA trunk exposure via dissection along the jejunal artery from feet to head and identification the association between IPDA and jejunal artery were prior to IPDA root ligation and dissection. The safety and efficacy of intraoperative IPDA handling were assessed based on surgical videos. Follow-up was carried out in outpatient clinic or by telephone, and outpatient follow-up was conducted once every 1 to 3 months after surgery.Results:The percentage of total LPD was 98.6%(69/70),with all patients achieving R0 resection. Nine cases(12.9%) were involved in combined vascular resection and reconstruction,with 1 case (1.4%) requiring additional upper abdominal incision for vascular and gastrointestinal reconstruction,while the remaining eight cases (11.4%) were completed laparoscopically. The operative time was (432.7±115.4)minutes(range:282 to 727 minutes), and the blood loss was (140.0±125.7)ml(range:20 to 800 ml). Only two patients(2.9%) received fresh frozen plasma transfusion,with an average volume of 650 ml. Reliable ligation and safe handling of the IPDA were achieved in 91.4%(64/70) of cases, with 8.6%(6/70) suffering from IPDA injury-related bleeding. No one was converted to opened surgery. Pathologically,the mean tumor size was (3.3±1.6)cm (range:1 to 7 cm),and the mean number of harvested lymph nodes was 17.0±7.3(range:0 to 46). Lymph node metastasis was observed in 13 cases (18.6%). Five cases (13.2%) developed grade B pancreatic fistula,while no grade C pancreatic fistula occurred. Other complications included bile leakage in one case(1.4%),delayed gastric emptying in two cases(2.9%), lymphatic leakage in 2 cases(2.9%),intra-abdominal infection in 9 cases(12.9%),and fat liquefaction of surgical incision in 1 case(1.4%). Two cases(2.9%) experienced postoperative intra-abdominal bleeding,one due to mesangial bleeding of lesser curvature of the stomach and the other due to oozing from the hepatic arterial sheath. These bleeding events were not concerned with IPDA. The average length of postoperative hospital stay was (15.2±4.6)days(range:9 to 28 days).Conclusion:Proper intraoperative management of IPDA in LPD might reduce IPDA-related bleeding during and after surgery and improve the safety of LPD.

Objective To understand the management status of emergency and life support medical equipment in town-ship health centers in Huazhou City,providing a reference for improving emergency service levels in grassroots medical institu-tions.Methods A convenience sampling method was used to conduct a questionnaire survey of physicians,nurses,medical technicians,public health personnel,and administrative and logistical staff in 24 township health centers in Huazhou City.The survey focused on seven aspects:procurement and configuration,upgrades,operational use,maintenance,emergency handling,management systems,and quality assessment and monitoring.Results Training on emergency and life support equipment was generally adequate in Huazhou City(65.2％).Health centers in northern and central Huazhou performed better than those in the urban and southern areas regarding equipment training,emergency handling procedures for equipment failures,regular emergency drills,meeting clinical treatment needs,management system completeness,routine maintenance and inspections,and regular quality assessments.Factor analysis revealed significant issues with equipment aging and quality in urban township health cen-ters,while northern township health centers urgently needed life-sustaining and therapeutic equipment.Conclusion There are regional disparities in the management levels of emergency and life support medical equipment in township health centers in Hua-zhou City.It is recommended to enhance the overall quality of personnel in township health centers,optimize"effective training"for staff,and improve annual management plans to further elevate grassroots emergency service capabilities.

Objective:To investigate the clinical effect of proper management of inferior pancreaticoduodenal artery (IPDA) in laparoscopic pancreaticoduodenectomy (LPD).Methods:This is a retrospective case series study. The clinical and pathological data of 70 patients who received LPD due to pancreatic head tumors, periampullary tumors, or distal common bile duct tumors in the Pancreatic Center of the Second Clinical College of Guangzhou University of Chinese Medicine from January to December 2022 were retrospectively collected. There were 47 males(67.1%) and 23 females(32.9%),aged (59.9±12.8)years(range:13 to 87 years).The procedure of IPDA exposure was as follows:a middle approach was utilized to expose the right half of superior mesenteric artery(SMA) and its right branches between the SMA and superior mesenteric vein(SMV) in superior colonic region. In the subcolonic region,SMA trunk exposure via dissection along the jejunal artery from feet to head and identification the association between IPDA and jejunal artery were prior to IPDA root ligation and dissection. The safety and efficacy of intraoperative IPDA handling were assessed based on surgical videos. Follow-up was carried out in outpatient clinic or by telephone, and outpatient follow-up was conducted once every 1 to 3 months after surgery.Results:The percentage of total LPD was 98.6%(69/70),with all patients achieving R0 resection. Nine cases(12.9%) were involved in combined vascular resection and reconstruction,with 1 case (1.4%) requiring additional upper abdominal incision for vascular and gastrointestinal reconstruction,while the remaining eight cases (11.4%) were completed laparoscopically. The operative time was (432.7±115.4)minutes(range:282 to 727 minutes), and the blood loss was (140.0±125.7)ml(range:20 to 800 ml). Only two patients(2.9%) received fresh frozen plasma transfusion,with an average volume of 650 ml. Reliable ligation and safe handling of the IPDA were achieved in 91.4%(64/70) of cases, with 8.6%(6/70) suffering from IPDA injury-related bleeding. No one was converted to opened surgery. Pathologically,the mean tumor size was (3.3±1.6)cm (range:1 to 7 cm),and the mean number of harvested lymph nodes was 17.0±7.3(range:0 to 46). Lymph node metastasis was observed in 13 cases (18.6%). Five cases (13.2%) developed grade B pancreatic fistula,while no grade C pancreatic fistula occurred. Other complications included bile leakage in one case(1.4%),delayed gastric emptying in two cases(2.9%), lymphatic leakage in 2 cases(2.9%),intra-abdominal infection in 9 cases(12.9%),and fat liquefaction of surgical incision in 1 case(1.4%). Two cases(2.9%) experienced postoperative intra-abdominal bleeding,one due to mesangial bleeding of lesser curvature of the stomach and the other due to oozing from the hepatic arterial sheath. These bleeding events were not concerned with IPDA. The average length of postoperative hospital stay was (15.2±4.6)days(range:9 to 28 days).Conclusion:Proper intraoperative management of IPDA in LPD might reduce IPDA-related bleeding during and after surgery and improve the safety of LPD.

Objective:To study the preliminary clinical results of the No-touch technique in laparoscopic pancreaticoduodenectomy for pancreatic head cancer.Methods:A retrospective analysis was consulted on 11 patients who underwent laparoscopic pancreaticoduodenectomy for pancreatic head cancer at the Pancreas Center of Guangdong Provincial Hospital of Traditional Chinese Medicine from April 2019 to April 2020. There were 5 males and 6 females, with a Mean±SD age of (63.6±12.2) years. Preoperative evaluation showed all patients were diagnosed to have resectable pancreatic head carcinoma with no local invasion into adjacent arteries and veins, and without metastasis. The surgical strategy consisted of no initial Kocher manoeuvre with no flipping or pulling of the pancreaticoduodenal area. Through unwinding of the pancreatic uncinate process, the pancreatic blood vessels, nerves and lymphatic vessels were completely detached to isolate the tumor. Finally, the pancreaticoduodenal area was totally resected and the digestive tract was reconstructed using the Child’s method. The operation time, intraoperative blood loss, postoperative complications, postoperative pathology and follow-up data of the patients were evaluated.Results:All patients completed the laparoscopic operation without any need for conversion to laparotomy. The operation time of the 11 patients was (422.2±102.2) min, and the bleeding volume was (102.7±65.4) ml. There were 2 patients who developed pancreatic fistula, with 1 patient having a biochemical fistula and 1 patient a grade B fistula. There was no grade C fistula. Other complications included 1 patient with delayed gastric emptying. There were no biliary fistula, no postoperative abdominal bleeding, and no perioperative death. Postoperative pathology showed 6 patients had lymph node metastases, with a positive lymph nodes rate of (4.8±4.4)%. All patients had R 0 resection. The follow-up survival data of the 11 patients showed one patient to develop intrahepatic metastasis 1 month after operation and he died 9 months after operation. Another patient developed liver metastases 2 months after operation. The remaining patients were tumor-free. Conclusion:Laparoscopic pancreaticoduodenectomy using the No-touch isolation and resection technique could achieve complete resection of tumors, and it can safely and effectively be applied to patients with pancreatic head cancer.

Objective:To examine the surgical approach, practical cognition as well as clinical effect of the orthotopic resection for laparoscopic pancreatoduodenectomy(OLPD).Methods:From March 2019 to December 2019, 32 cases were treated with laparoscopic pancreatoduodenectomy (LPD) in a novel approach without mobilization of pancreatoduodenum in Pancreas Center of the Second Affiliated Hospital of Guangzhou University of Chinese Medicine.There were 16 male patients and 16 female patients.The mean age was (64.8±9.5) years old.Body mass index was 14.9 to 31.0 kg/m 2.All patients were diagnosed as ampullary or pancreatic head tumors and were not unresectable cases.In the surgical strategy, Kocher′s dissociation, turning and pulling of the pancreaticoduodenal region, was not performed first.Anatomy in situ, separation of vessels which enter and exit from pancreas, separation of lymphatics and isolation of tumors were carried out in priority through the combined middle and left posterior approaches.Finally, the pancreatic head and duodenum region was mobilized and the entire resection of pancreas in situ was carried out.Digestive tract reconstruction was performed through Child method. Results:Postoperative pathology showed that 27 cases were pancreatic or ampullary malignant tumors and five cases were benign tumors among 32 patients.The operative time was (357.3±64.3) minutes.The diameter of pancreatic ducts was (3.0±1.0) mm. The pancreas of 20 cases (62.5%) were soft. Five patients suffered from pancreatic fistula (Grade B) and one patient suffered from intra-abdominal hemorrhage postoperatively.No other complications like pancreatic fistula (Grade C) or biliary fistula delayed gastric emptying or mortality were encountered.The postoperative hospital day was (13.7±3.6) days.Conclusions:Combining the multi-angle of the laparoscopic approaches and excising the pancreaticoduodenal specimen in situ, OLPD is a kind of surgical method which can realize the concept of no touch tumor surgery.Patients who undergo the OLPD can receive better treatments and results.