【作者】 桂惠明；

【导师】 王志平；

【作者基本信息】 兰州大学 ， 外科学， 2013， 硕士

【摘要】 背景上尿路移行细胞癌(UTUC)起源于尿路上皮,位于肾盏肾盂或输尿管,发病率较低,UTUC的生物学特性和预后存在异质性。肾输尿管切除及膀胱袖状切除认为是治疗UTUC勺金标准。而美国国家癌症网指南认为UTUC高危患者需考虑行局部淋巴结清扫及新辅助化疗,而低危患者可行保守治疗(如内镜下肿瘤切除或部分切除)且获益更大。风险分级对指导治疗、随访、辅助化疗等起着不可替代的作用,因此研究预后因素进而对UTUC患者进行风险分级显得尤为重要。目的归纳总结可能影响UTUC勺预后因素,包括临床因素、手术因素、病理因素及肿瘤标记物。方法由第一作者检索2000年1月-2012年12月Pub Med数据库和中国知网数据库收录的与上尿路移行细胞癌预后因素研究相关的文献。英文检索词为"upper tract urothelial carcinoma或upper urinary tract carcinoma, prognosis或prognostic factor,markers, survival";中文检索词为“上尿路移行细胞癌或上尿路尿路上皮细胞癌,预后因素,预后,分子标记物,生存率”。根据纳入标准保留61篇文献进行论述。结果UTUC的预后因素可归纳为四类,分别为临床因素、手术因素、病理因素及肿瘤标记物。由于发病率较低,预后因素从前瞻性的随机试验获得的证据很少,而大部分信息来源于单中心或多中心的回顾性研究。肿瘤分期、分级是影响UTUC预后的独立因素基本得到认可,而肿瘤位置和肿瘤坏死能否作为影响预后的独立因素仍然存在争议。已经研究发现了很多肿瘤标志物与肿瘤侵袭性、复发、肿瘤生存率密切相关,但应用临床还需进一步的研究。UTUC患者预后风险的分级需综合考虑各个预后因素,而可用于指导临床评估的预后模型仍缺乏。结论在过去的十余年里,一些影响UTUC的预后因素得到进一步的认证,为临床医师治疗策略的制定提供了参考。UTUC预后因素的研究绝大部分都是回顾性研究,许多结论尚需前瞻性多中心研究进行明确,以进一步促进预后因素对临床治疗的指导作用。目的国家基本药物制度是一项惠民政策,本课题是“十一五”国家科技支撑计划重点项目“基本型乡镇卫生院技术集成综合示范”研究的子课题,要求探索欠发达地区乡镇卫生院的基本药物应用情况,并选择了一家能代表我国经济欠发达地区乡镇卫生院(甘肃省临洮县新添中心卫生院)为试点。通过调查新添中心卫生院基本药物(EML)政策一年来的实施绩效,了解该院EML实施存在的问题,为欠发达地区乡镇卫生院基本药物配送、存储、补偿机制等研究提供依据。方法采用问卷调查和专题访谈相结合的法,调查该院EML配备和使用情况、EML政策实施前后诊疗业务和收支变化等情况。结果①新添中心卫生院EML配备率呈递增趋势,由实施前的62.2%增至87.3%。EML药物所占药品销售额的比例也由39.3%增至90.6%。但存在配送品种不全、品种落后的问题。②EML实施后,l卫生院门诊人次数、出院人次数均有所上升,次均门诊费用、次均住院费用均有不同程度的下降。③EML实施后,医院总收入略有增加,但限于财政补助额度,卫生院经营尚处于亏损。④医药比持续降低,卫生院药品费用与检查费用比例呈上升趋势。尤其2010-2011年检查费用所占比例较2009年增长30%左右,且EML实施后检查费用并未降低。结论EML的实施并未根本改善“以药养医”的现状。药物零差价销售,卫生院补偿机制尚未健全,卫生院财务尚处于亏损。建议开展药物的循证遴选,并开展针对欠发达地区政府补偿机制的研究。更多还原

【Abstract】 Background Upper tract urothelial carcinoma (UTUC) is derived from the urothelium and located in the upper urinary tract (pyelocaliceal cavities, ureter), is a rare diseases and heterogeneous in biology and prognosis. Radical nephroureterectomy (RNU) with bladder-cuff removal is considered the gold standard treatment of UTUC. According to the American National Comprehensive Cancer Network guidelines, regional lymphadenectomy and neoadjuvant chemotherapy should also be considered in selected patients with high-risk disease. Conversely, some patients with low-risk disease may benefit from a more conservative approach (eg, endoscopic ablation, segmental resection). Risk classification plays an irreplaceable role in guiding treatment, follow-up, and adjuvant chemotherapy for UTUC.So it is particularly important to study prognostic factors and to predict the individual patient’s risk level.Objective Provide an overview of the currently available prognostic factors for UTUC, focusing on clinical, surgical and pathological factors, as well as on tumor markers.Methods A search of PubMed and CNKI databases (2000/1-2012/12) was performed by the first author for the literature of the upper tract urothelial carcinoma and prognostic factor. The keywords were "upper tract urothelial carcinoma or upper urinary tract carcinoma, prognosis or prognostic factor, markers, survival" in English and Chinese, respectively. Unrelated articles or repetitive articles were excluded, and finally61articles were included in result analysis.Results Prognostic factors can be divided into four categories:clinical factors, surgical factors, pathologic factors, and tumor markers. Because of the rarity of the disease, only a small amount information is from prospective randomized trials. Conversely information on various prognostic factors is from several single-institutional and multi-institutional retrospective studies. Several tumor markers were found to be associated with tumor aggressiveness, tumor recurrence and patient survival, but further studies evaluating their prognostic role in clinical practice are still needed. Risk classification should take all prognostic factors into consideration, and few prognostic models have been developed to provide clinical accurate risk estimates.Conclusion tn the past ten years, several prognostic factors have been identified to help clinicians dealing with patients with UTUC in the decision-making process. The vast majority studies of prognostic factors were retrospective studies, multi-institutional prospective studies are needed to confirm their prognostic role and to promote the use of these prognostic factors in clinical practice. Objective National Essential Medicines policy is good for our country and people. This study is from National Key Technology R&D Program in the11th Five year Plan of china-Integration and Demonstration of basic township health center. To investigate the performance of essential medicine policy in township hospital of less developed areas is one topic of this project. And we chose Xintian Township Health Center (XTHC) as the pilot, which is typical for the township hospitals in less developed areas. To investigate the performance of Essential Medicine List (EML) policy over the past one year in Xintian Township Health Center(XTHC),so as to provide references for the delivery,storage and compensation mechanism of essential medicine for township hospitals.Methods Focus interview combined with a questionnaire was carried out to investigate the supply and usage of EML, the situation of both diagnosis-treatment services and the income-expenditure changes before and after EML policy.Results a) It showed that there was an increasing trend with the preparation rate of EML from62.2%before implementation to87.3%after, and the proportion of EML income to total medicine expenses increased from39.3%to90.6%in XTHC. But problems still existed such as incomplete and old variety of medicine;b) The numbers of outpatient-time and inpatient-time kept growing, while medical cost for both average clinic cost and average hospitalization cost decreased to different extent;c) Although the gross income increased slightly, this center was still running in the red with the limited amount of financial assistance;d) The proportion of medical care and drug kept decreasing while the proportion of drug cost and examination cost kept increasing. Compared with the situation in2009, the proportion of examination cost from2010to2011had increased by30%, and it still remained at the previous level after EML implementation.Conclusion The implementation of EML does not completely change the predicament of "Make compensation for doctors by selling drugs" in township health center. Owing to the sale policy of zero price difference and the poor performance of compensation for township health centers. XTHC is still running under deficit. Evidence-based medicine selection and research on compensation mechanism for underdeveloped areas are urgent needed.更多还原