Objective:To explore the construction of medical insurance high-quality development index evaluation system in Beijing,and to provide a reference and basis for the objective evaluation and continuous improvement of the development effect of medical insurance in Beijing.Methods:The index system was determined through two rounds of Delphi consultation,based on preliminary literature research and expert discussions,taking into account the national and Beijing’s "14th Five-Year Plan" medical security development goals.Results:A system of indicators for assessing the quality development of medical security in Beijing,consisting of five primary indicators,14 secondary indicators and 21 tertiary indicators of equity,safety,wisdom,synergy and value and their weights,was formed.The positive coefficient of experts in both rounds of consultation was 100%,and the authority coefficient of experts was 0.70 and 0.79.Conclusion:The evaluation index system for high-quality development of medical insurance in Beijing is reasonable,scientific and reliable,which can serve as a model for the development and implementation of policies aimed at promoting high-quality medical insurance development.

目的 探讨术中神经监测(IONM)信号异常在判断甲状腺癌手术喉返神经(RLN)损伤的类型与转归中的作用.方法 回顾性分析2018年1月至2020年12月在首都医科大学附属北京友谊医院普外科确诊行甲状腺癌根治术并应用IONM的705例甲状腺癌病人临床资料.根据IONM结果、手术记录、术后症状,以及喉镜检查结果,分析IONM信号异常原因、RLN损伤及类型,研究IONM信号异常在判断RLN损伤的类型与转归中的作用.结果 705例病人中,63例(8.9％)IONM信号异常,包括RLN真性损伤42例(5.9％),短暂性损伤11例(1.6％),假损伤10例(1.4％).与RLN短暂性损伤和假损伤相比,肿瘤侵犯或粘连(21.4％,9/42)是RLN真性损伤的重要原因(P＜0.05),后者均出现术后喉镜结果异常,64.3％出现术后声音嘶哑或饮水呛咳症状.此外,RLN显性损伤9例(1.3％),RLN非显性损伤44例(6.2％).RLN显性损伤均为真性损伤;非显性损伤者中,33例为真性损伤(4.6％)、11例为短暂性损伤(1.6％).此外,IONM 一过性信号异常占RLN真性损伤者21.4％,短暂性损伤者90.9％,假损伤者40.0％,差异有统计学意义(P＜0.05);IONM信号异常部位,信号衰减幅度与RLN损伤类型差异无统计学意义(P＞0.05).结论 甲状腺癌术中IONM信号异常可能源于RLN真性损伤、短暂性损伤或假损伤.即使RLN外观正常,术者应重视一过性IONM信号异常,如不及时终止操作,对RLN加以保护,短暂性损伤可能成为真性损伤.在未使用IONM情况下,RLN短暂性损伤可能被忽视,真性损伤可能增加.

目的 探讨甲状腺手术相关的非返喉神经(NRLN)的临床特征与预判策略.方法 回顾性分析首都医科大学附属北京友谊医院医疗保健中心综合外科(以下简称"我科")2009年8月至2022年2月因甲状腺良、恶性肿瘤行甲状腺手术的175例患者的临床资料;另外以"非返喉神经""喉不返神经""非返性喉下神经""喉返神经""喉下神经""non-recurrent laryngeal nerve""non recurrent laryngeal nerve""non-recurrent inferior laryngeal nerve""recurrent laryngeal nerve""inferior laryngeal nerve""NRLN""NRILN"为检索词在中国知网、万方、PubMed 及 Web of Science数据库检索研究对象为中国人的文献,检索时间为2012年1月至2022年2月,统计NRLN总发生率、右侧发生率、Stewart分型、损伤率,以及术前应用影像学预判NRLN的结果.结果 我科术中发现1条右侧NRLN,Stewart Ⅰ型,NRLN总发生率为0.32％,右侧发生率为0.63％,所有患者术中无损伤.meta分析显示,NRLN总发生率为 0.46％(95％CI:0.26％～0.66％);右侧发生率为 0.45％(95％CI:0.22％～0.68％);Stewart Ⅰ 型发生率为 76.47％(95％CI:58.61％～94.33％),Ⅱ型发生率为 23.53％(95％CI:5.67％～41.39％);损伤率为 10.20％(95％CI:2.93％～17.47％).影像学预判结果显示,90％(81/90)存在异形右侧锁骨下动脉;CT预测NRLN的漏诊率为19.23％,胸部X线预测NRLN误诊率为56.67％,超声预测NRLN漏诊率为7.25％.结论 NRLN为少见变异,术中损伤率高,术前可通过影像学预判,CT及超声预测NRLN准确性较高.

Objective:To compare the effectiveness of areola approach endoscopic thyroidectomy (AET) and conventional open thyroidectomy (OT) in treating papillary thyroid carcinoma.Methods:Four hundred and twenty-eight female patients with papillary thyroid carcinoma who were treated at the Department of General Surgery, Beijing Friendship Hospital between January 2017 and January 2020 were included according to the inclusion and exclusion criteria, of whom 183 underwent AET (AET group) and 245 underwent OT (OT group). Direct comparison and subsequent propensity score matching methodology were utilized to compare the differences between the two operation methods in terms of surgical time, intraoperative parathyroid transplantation rate, intraoperative nerve injury, postoperative complications, reoperation rate, number of lymph node dissections, postoperative lymph node metastasis at 2 years, and route tumor implantation. Data analysis was performed by using SPSS 25.0 software. The metric data of normal distribution was represented by mean ± standard deviation ( ± s), and the t-test was used for between-group comparison. The Chi-test was used for between-group comparison of count data. Results:The AET group had an age of (38.89±9.08) years, weight of (62.10±10.45) kg, and height of (161.97±5.31) cm; the OT group had an age of (45.88±12.47) years, weight of (65.11±12.72) kg, and height of (161.62±5.24) cm. The differences in age, weight, and body mass index between the two groups were statistically significant ( P<0.05). The surgical time in the AET group was (183.00±137.22) min, which was significantly longer than (87.94±28.25) min of the OT group ( t=16.67, P<0.001). The parathyroid transplantation rate in the OT group was significantly higher than that in the AET group (49.39% vs 34.97%, χ2=8.87, P=0.003). There were no statistically significant differences between the two groups in terms of intraoperative nerve injury, postoperative complications, reoperation rate, number of lymph node dissections, postoperative lymph node metastasis at 2 years, and route tumor implantation. After propensity score matching based on differences in age, weight, body mass index, and soon, 183 cases of AET (AET-PS group) and OT (OT-PS group) were obtained for statistical analysis. The surgical time in the AET-PS group was (137.22±32.77) min, which was significantly longer than (90.26±29.35) min of the OT-PS group ( t=14.44, P<0.001). The parathyroid transplantation rate in the OT-PS group was significantly higher than that in the AET-PS group (53.01% vs. 34.97%, χ2=12.08, P=0.001). There were no statistically significant differences between the two groups in terms of intraoperative nerve injury, postoperative complications, reoperation rate, number of lymph node dissections, postoperative lymph node metastasis at 2 years, and route tumor implantation. Conclusions:AET and OT are equally safe and effective in treating papillary thyroid carcinoma. AET surgery can be performed safely and feasibly under strict adherence to surgical principles.

随着生活环境的改变和检查技术的进步,甲状腺癌发病率近两年来不断上升,其中部分甲状腺癌伴有颈部淋巴结转移,颈侧区的淋巴结转移会影响患者的术后复发率和存活率,更是甲状腺肿瘤临床分期的重要标准.颈侧区淋巴结清扫术是治疗伴有颈部转移甲状腺癌手术中至关重要的环节,传统的Kocher低领式切口会在颈部留下较大的瘢痕难以满足患者美观微创的手术需求.近些年来不同颈部入路的甲状腺癌手术方式不断精进成熟,但伴随而来的是不同入路造成的手术并发症.手术并发症往往严重影响患者的就医体验,需要术者不断精益求精.本文讨论了不同入路颈侧区淋巴结清扫术后并发症的研究现状.

银屑病是一种具有多基因遗传背景的慢性炎症性皮肤病,免疫系统紊乱是银屑病炎症发展和持续的原因,目前认为IL-23/Th17轴的过度激活是其主要发病机制.银屑病以红斑、鳞屑、浸润为主要特征,部分患者反复发作,给个人带来巨大的心理和经济负担.2018版中国银屑病诊疗指南指出,银屑病基本证型为血热证、血瘀证、血燥证、热毒炽盛证、湿热蕴结证、风湿痹阻证,临床治疗需要依据不同证型辨证施治,因此银屑病的病证结合动物模型是研究中医治疗银屑病的重要基础.目前银屑病模型较多,而病证结合动物模型尚未形成体系,不能全面、整体的反映中医"证"的表现.本文对现有的病证结合模型进行了总结,以期为银屑病辨证论治研究提供较为全面的基础支持.

目的:观察健脾养血解毒方对咪喹莫特(IMQ)诱导的银屑病样小鼠皮损模型的作用,并探讨其机制.方法:将BALB/c小鼠随机分为正常对照组、模型组、甲氨蝶呤组及高、中、低剂量健脾养血解毒方组,采用背部涂抹IMQ的方法诱导小鼠银屑病样皮损模型.期间对皮损拍照并进行皮损严重程度指数(PASI)评分;HE染色观察皮肤病理学改变;免疫荧光染色法检测表皮Ki67的表达及Ly-6G+中性粒细胞的浸润;免疫组化法检测CD3+T淋巴细胞、CD11b+骨髓单核细胞和Ly-6C+巨噬细胞的浸润;Western blot法检测MAPK家族蛋白(p38 MAPK、ERK1/2、p-p38 MAPK和p-ERK1/2)的水平.结果:与模型组相比,健脾养血解毒方可减轻IMQ诱导的小鼠银屑病样皮损,降低PASI评分和表皮层厚度,减少表皮层Ki67的异常表达及CD3+T淋巴细胞、Ly-6C+巨噬细胞和Ly-6G+中性粒细胞的浸润,显著降低皮损中p-p38 MAPK蛋白水平.结论:健脾养血解毒方可能通过抑制CD3+T淋巴细胞、Ly-6G+中性粒细胞和Ly-6C+单核巨噬细胞在表皮中的浸润,减少炎症因子的大量释放,降低角质形成细胞过度增殖的诱导因素,从而减轻银屑病样增生肥厚的皮损.这表明健脾养血解毒方对炎症细胞浸润的抑制作用可能是其治疗银屑病的机制之一.

该文介绍了《住院医师规范化培训临床操作技能床旁教学指南(2021版)》(简称《临床操作技能床旁教学指南》)的发布背景与意义,分析了目前操作技能培训中床旁教学的来源和重要性,强调了操作技能培训中模拟教学和床旁教学的互补关系.特别强调了指导医师在操作技能床旁教学过程中采用的4种床旁教学模式以及操作后总结.最后围绕操作技能培训相关的认知科学基础进行解析,并对于如何建立操作技能培训的教学体系进行了阐述.

目的 应用系膜分层解剖法行全甲状腺切除术,通过评价术中上位甲状旁腺的保护效果和术后甲状旁腺功能监测,总结系膜分层解剖法在甲状腺手术中的应用效果.方法 回顾性总结2019年6月至2019年12月就诊于首都医科大学附属北京友谊医院的应用系膜分层解剖法行全甲状腺切除手术33例患者的临床资料,统计分析术中上位甲状旁腺的显露率、原位保留率及术后甲状旁腺素、钙离子水平,并对病例进行术后随访.结果 33例患者行全甲状腺切除,其中双侧中央区淋巴结清扫12例,单侧中央区淋巴结清扫21例.上位甲状旁腺显露率为93.9％(62/66),其中双侧均显露患者30例,单侧显露患者2例;上位原位保留率为96.8％(60/62).术后发生低钙血症7例,其中5例出现指端及口周麻木,2例无症状,无抽搐症状.随访1个月,复查血钙及甲状旁腺素水平均正常,无一例永久性低钙血症发生.结论 全甲状腺切除术中应用系膜分层解剖法处理甲状腺上极,能够提高上位甲状旁腺的识别和保护,提高原位保留率,减少术后低钙血症的发生率,获得良好的治疗效果.

该文介绍了《住院医师规范化培训手术操作指导教学指南(2022年版)》(简称《手术操作指导教学指南》)的发布背景与意义,分析在实施手术操作指导教学的实践环节中的主要问题.按照《手术操作指导教学指南》的章节顺序,对手术操作指导教学的目的、形式、组织安排、准备、实施、评价及注意事项进行了详细的论述,列举了手术操作指导教学的常见问题及解决方案,帮助指导医师深入理解《手术操作指导教学指南》的基础上,有效、安全地组织和实施这一教学活动,提升教学效果,达到教学目标.

Objective:To compare the diagnostic efficiency of colloidal gold dipstick method (PTH dipstick method) with that of doctors’ experience method based on nano-carbon method for rapid identification of parathyroid gland in thyroidectomy of thyroid cancer.Methods:From March to July 2020, 90 patients underwent thyroid surgery in the Friendship Hospital, Capital Medical University participated in the experimental study, and 155 samples underwent empirical judgment, parathyroid dipstick and pathological examination. All operations were performed by senior specialists. SPSS statistics 17.0 software was used for statistical analysis.Results:Seventy-four cases of parathyroid gland confirmed by both pathology and empirical judgment, and 81 cases of non-parathyroid gland confirmed by pathology; 130 cases of parathyroid glands confirmed by both PTH dipstick method and pathology, and 22 cases of non-parathyroid glands confirmed by pathology. The accuracy rate of PTH dipstick method was 85.53% which was much higher than that of empirical judgment method (47.74%). The data were statistically significant ( χ2=49.14, P<0.05). The sensitivity of PTH method was 95.89%, the specificity of PTH method was 75.94%, and the Youden index was 0.7183. The sensitivity of empirical judgment method was 81.3%, the specificity of empirical judgment method was 47.74%, and the Youden index was 0.2904. Conclusions:The diagnostic efficiency of the PTH method is higher than that of empirical judgment method to identify parathyroid gland in thyroid surgery. The two methods can be used together to increase the protection of parathyroid gland during operation.

Objective:To evaluate the effects of three endoscopic and open treatments for papillary thyroid carcinoma（PTC）.Methods:The clinical data of 109 female patients undergoing cT1N0 PTC surgery from October 2019 to October 2021 were retrospectively analyzed. They were divided into four groups according to different surgical methods，open group（n=34 cases），areola group（n=34 cases），oral group（n=26 cases）and axillary group（n=14 cases）. SPSS 26.0 statistical software was used. The perioperative indicators of different surgical procedures were expressed as（xˉ±s）. One-way ANOVA was used for comparison between groups. Postoperative complications were expressed by χ2 test，P<0.05 was considered statistically significant.Results:Among the three groups，the oral approach group had the longest operation time（t=151.1 min），followed by the axillary group（t=125.4 min），and the areola approach（t=99.9 min），but he three groups had longer operation time than the open group（t=75.6 min）（P<0.001）；There was no significant difference in the number of lymph node metastasis and daily drainage between the endoscopic surgery group and the open group（P>0.05），but the number of lymph node dissection in the axillary group（n=4.1）was not only lower than that in the oral group（n=7.7，P=0.004）and the areola group（n=6.9，P=0.034）. Even less than the open group（n=6.7，P=0.030）；The incidence of complications was 2.9% in the open group and 3.8% in the endoscopic oral group. No postoperative complications occurred in the other two groups，and there was no significant difference in the incidence of postoperative complications among the four groups（P>0.05）.Conclusion:Endoscopic surgery for cT1N0 thyroid cancer has the same effect as open surgery. In endoscopic surgery，the effect of axillary approach for thyroid surgery is still limited.

Objective:To compare the effect of layer dissection and traditional management in total thyroidectomy by comparing the levels of parathyroid hormone and calcium after operation.Methods:From January 2019 to June 2019, a total of 120 patients who underwent total thyroidectomy were retrospectively analyzed, in including 96 females and 24 males, aged from 24 to 72 years old, with the average of 52 years. There were 63 cases in layer dissection group and 57 cases in traditional management group. The main index was the level of parathyroid hormone and blood calciumon the 1st day after operation. The measurement data of non normal distribution were described by quartile [ M( P25, P75)]. T-test or nonparametric test were used for comparison between groups. The chi-square was used to conduct comparison between count data of groups. Results:On the first day after operation, the serum calcium level in the layer dissection group was significantly higher than that in the traditional management group, with a median of 2.15 mmol/L and 2.10 mmol/L, respectively ( Z=-2.019, P=0.043). The level of parathyroid hormone in layer dissection group was significantly higher than that in traditional management group [23.8 (16.2~34.8) pg/mL vs 15.3 (8.9~29.0) pg/mL, Z=-3.646, P<0.001]. The incidence of postoperative complications in the layer dissection group was lower than that in the traditional management group (6.3% vs 21.1%, χ2=5.599, P=0.018). One month after operation, the results of blood calcium and parathyroid hormone were both normal [blood calcium 2.31 (2.23~2.41) mmol/L vs 2.32 (2.26~2.37) mmol/L, Z=-0.657, P=0.648 and parathyroid hormone 37.6 (32.3~51.1) pg/m vs 35.8 (27.7~48.9) pg/mL, Z=-0.674, P=0.499], and there was no significant difference between the two groups. Conclusion:The layer dissection method for the superior pole thyroid capsule, compared with traditional management, can reduce the incidence rate of postoperative hypocalcemia and the incidence rate of postoperative complications, can improve the quality of patients′ life.

目的 探讨脾虚在银屑病炎症反应相关发病环节中的作用机制.方法 采用苦寒泻下结合营养限制法建立脾虚小鼠模型,采用咪喹莫特诱导银屑病样皮损模型.小鼠随机分为正常对照组(Ctrl)、脾虚组(PD)、银屑病样模型组(IMQ)、脾虚复合银屑病样模型组(PD-IMQ),实时定量荧光PCR检测皮损和小肠中银屑病相关基因表达水平,液相蛋白芯片检测外周血中银屑病相关细胞因子和趋化因子的含量,肠道菌群16S测序分析各组菌群多样性.结果 PD-IMQ组皮损红斑、鳞屑等炎症浸润表现更加严重,皮损中白介素(IL)-17a、IL-23、IL-6、TGF-β、IL-10和IL-18 mRNA较IMQ组显著升高;PD-IMQ组外周血中IL-17A、巨噬细胞炎性蛋白(MIP)-1α、MIP-1β、MIP-2、单核细胞趋化蛋白(MCP)-1、MCP-3、RANTES、IP-10和Eotaxin的含量明显高于IMQ组,ST2含量显著低于IMQ组;PD-IMQ组小肠中IL-17a和RORγt mRNA显著高于IMQ组;PD-IMQ组肠道菌群的丰富度和均匀度降低,与IMQ组比较,AF12菌属的相对丰度显著升高,TM7菌门、TM7-3菌纲、CW040菌目和F16菌科的相对丰度显著减低.结论 脾虚可加重咪喹莫特诱导的小鼠银屑病样模型对促炎因素的响应程度,通过上调IL-17相关细胞因子和趋化因子的表达水平及脂代谢紊乱相关菌属AF12的丰度,导致严重的银屑病样皮损改变.

目的 探讨全乳晕入路腔镜甲状腺切除术(areola approach endoscopic thyroidectomy,AET)的学习曲线,探索影响手术熟练度的关键步骤,指导训练重点.方法 回顾性分析开展AET技术初期95例因甲状腺乳头状癌行全乳晕入路腔镜单侧甲状腺切除术的患者资料,术中全程录像.按照AET十步法进行操作:切口定位、穿刺建腔、寻找喉返神经、入喉点解剖、喉上神经外支保护、甲状旁腺原位保留、颈中央区清扫、标本取出、甲状旁腺自体移植、缝合引流.记录手术总时间,依据手术步骤时间上的重叠进一步分为6个时间段进行计时.结果 手术总时间拟合曲线在前20例即有明显下降,在20例以后曲线趋于平稳.按手术日期分为5组,第1～4组20例、第5组15例;第1组手术总时间(121.25±24.32) min,明显长于第2～5组(P＜0.05);十步法的前3步操作时间在第1、2组间降低(P＜0.05),在第2组以后相邻各组间无降低(P＞0.05);十步法的后7步操作时间在相邻两组间均无降低(P＞0.05).各组间低钙血症、喉返神经损伤等并发症比较无差异(P＞0.05).结论 对于具有熟练开放甲状腺手术和腹腔镜手术基础的医师,按照AET十步法进行操作,经过20例的积累后手术总时间明显下降并趋于稳定,其中关键步骤是前3步:切口定位、穿刺建腔、寻找喉返神经.

With the development of endoscopic thyroidectomy, the complications of thyroidectomy and the formation of cervical scar are effectively reduced, which are recognized by surgeons and patients.However, with the development of artificial and robot endoscopic thyroid surgery, there are many kinds of operation methods and approaches.Different operation methods and approaches have their own advantages and disadvantages.In the scope of indications, endoscopic thyroidectomy with artificial and robot has the same effect as traditional thyroidectomy, and has a broader application prospect

Objective To investigate the ultrasonographic characteristics,pathological diagnosis and surgical treatment strategy of follicular thyroid carcinoma (FTC).Methods The clinical data of 10 patients with FTC confirmed by histopathology from Jul.2013 to Oct.2017 in Beijing Friendship Hospital,Capital Medical University were retrospectively analyzed including 3 males and 7 females with mean age of 41.5 (15 to 68) years old.The clinical data including preoperative ultrasonographic features,fine needle aspiration results,intraoperative frozen section examination and surgical treatments of these 10 patients were retrospectively analyzed.Descriptive methods were used for Statistical analysis.Results Ultrasonography was performed in all 10 patients,and frozen section examination was performed in 6 patients,of which,5 were considered capsular invasion.Ipsilateral centralcompartment neck dissection was performed in 2 patients,no node metastasis was found.Reoperation were performed in 5 patients with total or near total thyroidectomy.No severe complications such as persistent hypoparathyroidism and recurrent laryngeal nerve injury occurred in all 10 patients.The median follow-up time was 34.4 months,and no one died during the follow-up period.Conclusions Preoperative diagnosis of FTC is difficult.The reoperation rate is higher than that of papillary thyroid carcinoma.Lobectomy plus isthmusectomy should be the initial surgical procedure for follicular tumors,while neck dissection is not recommended.

Objective To analyze the correlation between the primary lesion of papillary thyroid microcarcinoma (PTMC) and the metastasis of cervical lymph node,explore the surgical method of PTMC.Methods From Jan.2013 to Nov.2016 in Beijing Friendship Hospital,Capital Medical University,there were 545 cases of PTMC treated with surgery,induded 432 females and 113 males (3.82 to 1),aged 14 to 80 years old (average 46.7 ±11.8 years).Surgical methods:the percent of total or near total resection was 70.6％ (385/545),lobectomy and isthmectomy was 29.4％ (160/545).There were 524 cases of lymph node dissection in the central region of the neck,of which 78.3％ (427/524) were unilateral swept,and 17.8％ (97/524) were swept on both sides.There were 14 cases of lymph node dissection in the neck area.There were 930 thyroid lobe specimens,622 lymph node specimens in central neck region and 14 lymph node specimens in lateral neck region.In this study,576 specimens of thyroid gland and the same side cervical lymph nodes were selected.The diameter was (0.58 ± 0.25) cm.There were 513 single lesion cases (89.1％) and 63 multiple lesion cases (10.9％).There were 441 cases (76.6％) without extrathyroid invasion and 135 cases (23.4％) with extrathyroid invasion.The number of cervical central area lymph nodes was 4.7 ± 3.8.The transfer rate of cervical central area lymph nodes was 31.8％.The number of cervical lateral area lymph nodes was 17.8 ± 10.0.The transfer rate of cervical lateral area lymph nodes was 2.4％.SPSS 19.0 statistical software was used.for statistical processing,and the standard deviation of the measurement data was expressed as the standard deviation.The counting data was expressed as a percentage,and the chi-square test was used for the comparison between groups.The single factor correlation was analyzed by Pearson.The statistical methods included independent sample t test,Pearson correlation analysis and x2 test.Results There was high positive correlation between diameter of PTMC and transfer rate of cervical central area lymph nodes (r =0.847).The transfer rate of cervical central area lymph nodes was significantly increased when focus diameter was greater than 0.8 cm.There was significant positive correlation between diameter of PTMC and transfer rate of cervical lateral area lymph nodes(r =O.557).The transfer rate of cervical lateral area lymph nodes was significantly increased when focus diameter was greater than 0.9 cm.The transfer rate of cervical central and lateral area lymph nodes to multi focus cases were similar to single focus cases.The transfer rate of cervical central and lateral area lymph nodes to thyroid capsule invaded cases were higher than thyroid capsule non-invaded cases.Conclusions The focus diameter and capsule invasion of PTMC were related to cervical lymph node metastasis.The number of cancer lesions is not related to cervical lymph node metastasis.As early as possible,surgical operation can lead to timely treatment of many PTMC cases,of which cervical lymph node metastasis has occurred,but preoperative diagnosis can not be obtained.Surgical methods of initial treatment were total/near total thyroidectomy or thyroid lobectomy plus unilateral/bilateral cervical central area lymph node dissection and/or add to cervical lateral area lymph node dissection.

<正>糖尿病性心脏病是由于糖尿病的发生、恶化所引发的心脏功能异常,其致病机制较为复杂,临床表现较为隐匿,且病变程度较重,是糖尿病患者的主要致死因素。临床治疗过程中,应用格列齐特缓释片联合盐酸地尔硫卓能显著维持患者的血糖稳定,改善心脏自主神经功能,提高心脏射血能力,已经被广泛应用于糖尿病心脏病的治疗,但是在使用过程中患者存在个体

目的评价早期乳腺癌保乳治疗的中、长期疗效。方法回顾性分析1999年1月1日至2005年12月31日接受保乳治疗的232例早期乳腺癌患者的临床特征、复发及生存资料。232例患者均接受肿块扩大切除或乳腺区段切除+腋窝淋巴结清扫术,术后根据情况行放疗、化疗、内分泌治疗等。结果中位随访时间为54个月,平均随访57.14个月（2～118个月）。局部复发3例,远处转移15例,死亡7例,1例局部复发后行乳房切除手术。发生远处转移的部位包括肺脏8例、肝脏5例、脑6例、骨8例。Kaplan-Meier生存分析显示,232例患者的3年、5年生存率分别为99.06%和96.98%,3年、5年无病生存率分别为97.01%和93.23%。171例肿瘤直径≤2cm患者的3年、5年生存率高于其余52例肿瘤直径＞2cm者（P＜0.05）;141例接受内分泌治疗患者的3年、5年生存率高于52例未接受内分泌治疗者（P＜0.05）;腋窝淋巴结阳性患者的3年、5年无病生存率低于腋窝淋巴结阴性者（P＜0.05）。结论在严格掌握保乳指征的前提下,早期乳腺癌病例进行保乳治疗安全可行。