Volume 102 ·  Issue 41 ·  2022

The rights and health problems of physicians have been wildly concerned, which affects the career satisfaction and career achievement of physicians. The occupational environment of physicians in the nation and abroad, as well as the differences in work caused by gender was described. On behalf of gastroenterology, by analysing of pressures and challenges faced by physicians and their occupational status in different genders to understand their work feelings can implement targeted improvement measures in the future medical environment, and encouraging female medical professionals play a better role in healthcare.

At the beginning of clinical application, unilateral biportal endoscopy (UBE) was mainly applied to lumbar degenerative diseases, and lumbar disc herniation or lumbar spinal stenosis accounted for the majority. With the improvement of technology and equipment, the range of diseases being treated continues to expand, and the indications are extended to cervical and thoracic spinal decompression, and it can also be used in conjunction with minimally invasive techniques such as percutaneous pedicle screws and oblique lumbar interbody fusion, which plays an important role in lumbar interbody fusion. However, the development of unilateral biportal endoscopic technology is still in its initial stage in China and has not been widely applied. There are still relevant issues that need to be clarified and further studied. Therefore, this paper discusses the technical superiority, the application expansion and the shortcomings of UBE technique and related issues.

Iron deficiency and iron deficiency anemia are the most common nutritional deficiencies worldwide, with high incidence, and different diagnostic criteria and management principles for different ages and different disease states. Accordingly, the Red Blood Cell Disease (Anemia) Group of Hematology Branch of Chinese Medical Association organized experts from various related majors in China, and combined with the latest research progress, revised the 2018 edition of the Multidisciplinary Expert Consensus on Diagnosis, Treatment and Prevention of Iron Deficiency and Iron Deficiency Anemia, and added the related contents of functional iron deficiency and heart failure combined with iron deficiency, aiming at standardizing and improving the diagnosis and treatment of iron deficiency and iron deficiency anemia in China and improving the quality of life of patients.

There is relatively little evidence-based medical evidence for accelerated rehabilitation surgery (ERAS) in the field of neurosurgery, and the current guidelines in the same field lack systematic guidance for ERAS in patients with unruptured intracranial aneurysms. This guideline is based on the clinical research and practical experience of ERAS in patients with unruptured intracranial aneurysm, and cooperates with multidisciplinary experts such as neurosurgery, anesthesiology, nutrition and nursing to formulate clinical practice guidelines for ERAS in patients with surgical clipping of unruptured intracranial aneurysm from several aspects: preadmission management, preoperative management, intraoperative management and postoperative management. In order to accelerate the rehabilitation of postoperative patients and reduce surgical complications by promoting the application of ERAS technology in the field of neurosurgery.

To investigate the incidence, characteristics and risk factors of spinal epidural hematoma after unilateral biportal endoscopic (UBE) lumbar spine surgery.

The clinical data of 105 patients who underwent lumbar spine surgery under UBE in Guangdong Provincial People′s Hospital from February 2020 to March 2021 were retrospectively reviewed. Of the patients, 48(45.7%) were male and 57(54.3%) were female, the mean age was (60.1±11.4) years (ranged 26 to 85 years). The MRI images at the third day post-surgery were observed, and the occurrence of hematoma was counted. Patients were assigned to normal group and hematoma group based on the presence of hematoma or not. The related clinical indicators of each patients were collected and used for comparison between two different groups. Logistic stepwise regression model was used to analyze whether each index was a risk factor for hematoma after the UBE lumbar fusion.

The total hematoma incidence rate was 28.6%(30/105), the symptomatic hematoma rate was 6.7%(7/105), and the hematoma reoperation rate was 0.9%(1/105). Univariate logistic regression analysis showed that hypertension (OR=3.368, 95%CI: 1.389-8.171), diabetes (OR=3.589, 95%CI: 1.230-10.476), admission systolic blood pressure>140 mmHg (1 mmHg=0.133 kPa,OR=3.687, 95%CI: 1.493-9.017), platelets<200×10⁹/L (OR=0.300, 95%CI: 0.119-0.785), preoperative blood calcium<2.25 mmol/L (OR=0.340, 95%CI: 0.142-0.818), spinal stenosis grade D (OR=4.462, 95%CI: 1.810-10.996) were possible risk factors for spinal hematoma after UBE lumbar fusion. Multivariate logistic regression analysis showed that admission blood pressure systolic blood pressure>140 mmHg (OR=3.788, 95%CI:1.055-13.606), preoperative blood calcium<2.25 mmol/L (OR=78.544, 95%CI:3.895-1 584.058) and spinal stenosis grade D (OR=3.698, 95%CI:1.110-12.325) were risk factors for spinal hematoma after UBE lumbar fusion (all P<0.05).

The types of spinal canal hematoma after UBE lumbar fusion include localized and extended type. The risk factors for hematoma include high systolic blood pressure on admission, low preoperative blood calcium and severe spinal stenosis.

To compare the efficacy of unilateral biportal endoscopy (UBE) and coaxial large channel endoscopy for lumbar spinal stenosis.

A total of 176 patients with lumbar spinal stenosis treated in Tianjin Hospital from March 2015 to October 2021 were included in this study. Of the patients, 110 cases were treated with UBE, including 52 males and 58 females, with a mean age of (75.1±10.4) years; while 66 cases were treated with coaxial large channel endoscopy, including 31 males and 35 females, with an average age of (77.2±13.1) years. The visual analogue scale (VAS) score of pain and Oswestry disability index (ODI) were compared before and after surgery between the two groups, with the improvement rate calculated. The operation time, intraoperative blood loss, perioperative conditions and complications were compared. The operation efficacy was evaluated according to MacNab scale and was compared between the two groups.

There was no significant differences in age, gender, disease course, VAS of pain, ODI and index levels between the two groups before operation (all P>0.05). The operation time and postoperative drainage in UBE group and coaxial large channel endoscopy group were comparable [(60.1±12.4)min, (62.5±13.2)min and (103.8±20.7)ml, (98.5±22.1)ml, respectively, both P>0.05]. After the operation, the VAS score of low back pain, VAS score of leg pain and ODI of the two groups were all lower than those before operation, and decreased continuously during follow-up; and under the repeated measures analysis of variance, significant differences were found between different time points (all P<0.05), no significant difference was found between the two groups (all P>0.05), nor interaction between groups and time points was detected (all P>0.05). The patients were followed-up for (18.0±4.2) months (6 to 30 months). There was no significant difference in VAS and ODI improvement rates and excellent rate of efficacy between the two groups at the last follow-up (all P>0.05).

Both UBE and coaxial large channel endoscopy can provide excellent results for lumbar spinal stenosis. UBE has sufficient decompression and is convenient to explore and remove the herniated disc.

To compare the clinical efficacy of unilateral biportal endoscopy unilateral laminotomy for bilateral decompression (UBE-ULBD) to posterior lumbar interbody fusion (PLIF) in the treatment of severe lumbar spinal stenosis (SLSS).

The clinical data of 64 patients with SLSS treated with PLIF and UBE-ULBD in Dalian Central Hospital Affiliated to Dalian Medical University from April 2018 to April 2021 were collected and divided into UBE group and PLIF group according to the different surgical procedures. There were 30 cases in the UBE group, including 12 males and 18 females, aged (69.8±6.8) years. There were 34 patients in the PLIF group, including 15 males and 19 females, aged (69.3±6.3) years. The operation time, intraoperative blood loss, surgical complications, the volume of drainage, transfusion, post-operative bed rest time, postoperative hospital stay, surgical costs of both groups were recorded and analyzed. The visual analogue scales (VAS) of back/leg pain (pre-operation and 1 d, 1 month, 6 month, 12 month post-operation) and Oswestry disability index (ODI) (pre-operation and 1 month, 6 month, 12 month post-operation) were used to determine the outcome. And the dural sac cross-sectional area (DSCA) and Schizas grade of both groups preoperatively and 6 month postoperatively were recorded.

The operation time in the UBE group was (69.2±8.0) min, it was lower than that in the PLIF group (139.0±15.3) min (P<0.05). The intraoperative blood loss and drainage in the UBE group were (19.5±5.6) ml and (15.0±10.8) ml, which were both lower than those in the PILF group [(212.4±34.1) ml and (169.6±43.8) ml] (both P<0.05). The postoperative bed rest time and hospital stay in the UBE group were (1.8±0.7) days and (3.0±0.9) days, which were both shorter than those in the PLIF group [(4.5±1.4) days and (7.1±1.7) days] (both P<0.05). The surgical cost was also lower in the UBE group than that in the PLIF group [RMB,(18.4±1.0) thousands yuan vs (33.9±2.4) thousands yuan, P<0.05]. In addition, no patient received blood transfusion in the UBE group. Dural sac tear occurred in 2 cases in the UBE group and in 3 cases in PLIF group; nerve root injury and infection occurred in one case in the PLIF group, respectively. In the PLIF group, the VAS of back pain was not significantly improved 1 day after operation when compared with that before the operation, but it significantly improved 1 month, 6 months and 1 year after operation (all P<0.05). The VAS for back pain at 1 day after operation and ODI at 1 month after operation in the UBE group were significantly superior to those in the PLIF group (both P<0.05), while there was no significant difference between the two groups in the VAS for back pain at 1 month, 6 months and 1 year after operation and ODI at 6 months and 1 year after operation. Both groups got significant canal expansion after the surgery and the PLIF group showed larger canal expansion extent (all P<0.05). Both groups improved significantly after surgery in the Schizas grade, there were 25 cases in UBE group improved to grade A, 5 cases to grade B while 30 cases in PLIF group improved to grade A, 4 cases to grade B, but there was no significant difference between the two groups (P>0.05).

ULBD-UBE could achieve full decompression of the whole spinal canal with limited structures damage in treating SLSS. Compared with PLIF, UBE-ULBD could get complete decompression as well as less iatrogenic damage, it may be an ideal alternative surgical technique for SLSS with less invasion.

To evaluate the preliminary clinical outcomes of biportal endoscopic lumbar interbody fusion (BE-LIF), decompression and pedicle screw insertion assisted with endoscopic technique for lumbar spinal stenosis combined with spondylolisthesis or instability.

The data of 9 patients with single-level lumbar spinal stenosis who underwent BE-LIF, decompression and pedicle screw insertion assisted with biportal endoscopy in Xinjiang Production and Construction Corps Hospital from March 1st 2022 to April 30th 2022 were analyzed retrospectively. The visual analogue scales (VAS) for pain in back and legs, and the Oswestry disability index (ODI) of all the patients were collected before operation, on the third day after operation and at the last follow-up. Moreover, the operation time, intra-operation blood loss, radiation shots for pedicle screw insertion, post-operation drainage and ambulation time were recorded. The screw position was checked with CT after the operation.

All the patients were female with a mean age of (70.3±8.4) years (ranged 56-84 years); the patients were followed-up for 12-16 weeks. All 9 patients had good clinical results. The VAS scores for back pain on the third day after operation and at the last follow-up were both significantly lower than that preoperatively[(2.9±0.6), (1.8±0.4) vs (6.4±1.1) points, both P<0.05]. The VAS scores for leg pain on the third day after operation and at the last follow-up were both significantly lower than that preoperatively[(1.9±0.3), (1.4±0.5) vs (7.3±1.6) points, P<0.05]. The ODI scores at last follow-up was significantly lower than that before the operation ((24.0%±6.5% vs 55.7%±12.8%, P<0.05). The intra-operative blood loss was (177±103) ml, the drainage amounts post-operation was (122±56) ml, the operation time was (207.8±32.7)min, the ambulation time was (2.3±0.5) days. The total radiation shots for pedicle screw insertion were 20-42 times, the average radiation shots per screw was (6.9±1.5) times. No severe complications or adverse events occurred. No nerve root injury or dural tear occurred in the operation, and no revision surgery needed.

The pedicle screw insertion assisted with biportal endoscopic technique can decrease the radiation exposure with good feasibility and safety during the BE-LIF. The BE-LIF combined with the pedicle screw insertion assisted with biportal endoscopy is an effective and safe surgery for lumbar spinal stenosis with good early results.

To analyze the survival and prognosis of Hodgkin lymphoma (HL) patients receiving standard first-line therapy.

Data of clinical characteristics and treatment outcomes of patients with HL diagnosed in Cancer Hospital Chinese Academy of Medical Sciences (CHCAMS) from January 1st, 2000 to December 31st, 2018 who received standard first-line treatment were retrospectively analyzed and compared with that of HL patients who received treatment in the Surveillance, Epidemiology and End Results (SEER) database in the United States during the same period. Factors associated with freedom from progression (FFP) of patients in CHCAMS were analyzed. Treatment and survival data of patients with relapsed/refractory HL (r/rHL) who had failed the standard first-line treatment during the corresponding period in CHCAMS were collected to analyze the outcomes of salvage therapy.

A total of 764 HL patients in CHCAMS were included in this study. The median age was 30 years (range, 14-83 years), with 424 males and 340 females. By February 26th, 2022, the patients were followed-up for a median time of 111 months(range, 0.3-262.0 months). Lymphoma-specific survival (LSS) rate and overall survival (OS) rate at 10 years for HL patients in CHCAMS was 91.7% (95%CI: 89.5%-93.9%) and 87.1% (95%CI: 84.5%-89.8%), respectively. LSS and OS rate at 10 years for HL patients from SEER database was 86.8% (95%CI: 86.3%-87.2%) and 79.0% (95%CI: 78.5%-79.5%), respectively. The unadjusted LSS and OS rate for patients in CHCAMS were higher than those for patients from SEER database (both P<0.001). No significant difference was observed in LSS and OS rate (both P>0.05) between the two groups after adjustment. European Organization for Research and Treatment of Cancer staging system (early-stage unfavorable: HR=2.35, 95%CI: 1.13-4.89, P=0.023; advanced stage: HR=5.44, 95%CI: 2.62-11.30, P<0.001) and serum β2 microglobulin (HR=1.67, 95%CI: 1.08-2.58, P=0.021) were influencing factors of FFP for patients in CHCAMS. The complete remission rate, median progression-free survival (PFS), 5-year PFS rate and 5-year OS rate for the 116 patients with r/rHL was 37.9% (95%CI: 29.6%-47.0%), 15.0 months (95%CI: 9.9-20.1 months), 29.9% (95%CI: 20.9%-38.9%) and 62.9% (95%CI: 54.1%-71.7%), respectively.

The outcomes of HL patients receiving standard first-line treatment are excellent. However, the therapeutic effect of HL patients who incurrs disease progression or relapse after standard first-line treatment is not satisfying.

To investigate the efficacy and safety of daratumumab in relapsed/refractory multiple myeloma (RRMM) patients.

Fifty-two RRMM patients treated with daratumumab from September 2019 to November 2021 in West China Hospital were retrospectively enrolled, including 31 males and 21 females. The mean age of these patients at the first diagnosis of multiple myeloma was (58±10) years. According to the dosage of daratumumab, patients were divided into low dosage group (n=10) and high dosage group (n=42). Overall response rate (ORR), progression-free survival (PFS), overall survival (OS), and adverse event rates were investigated. Univariate and multivariate analysis of potential factors were conducted.

Of the 52 patients, 8 received daratumumab monotherapy, 27 received daratumumab plus immuno-modulatory drug (IMiD) treatment, 4 received daratumumab plus proteosome inhibitor (PI) treatment, and 11 received daratumumab plus dexamethasone treatment. The diagnosis age of high dosage group patients was (57±9) years, which was significantly younger than that of low dosage group [(66±10) years] (P=0.009). The baseline creatinine level of high dosage group patients [M (Q₁, Q₃)] was 91 (68, 196) μmol/L, which was significantly higher than that of low dosage group [66 (51, 76) μmol/L] (P=0.021). There was no significant difference in other baseline clinical characteristics, previous treatment regimens, previous lines of treatment, and regimen and cycles of daratumumab between the high dosage group and low dosage group (all P>0.05). The ORR for the 52 patients was 71.2% (37/52). The ORR for daratumumab plus IMiD group was 81.5% (22/27), which was significantly higher than that in monotherapy or dexamethasone group [ORR: 52.6% (10/19), P=0.036). With a median follow-up [M (Q₁, Q₃)] of 7 (5, 26) months, the median PFS for overall cohort was 17 (95%CI: 9.6-24.4) months. The median PFS for daratumumab plus IMiD group was 26 (95%CI: 6.0-46.0) months, which was significantly better than that in monotherapy or dexamethasone group [12 (95%CI: 3.5-20.5) months] (HR=0.231, 95%CI: 0.075-0.715, P=0.011). Higher diagnosis age was the risk factor of progression (HR=1.085, 95%CI: 1.016-1.158, P=0.014), while more cycles of daratumumab treatment was the protective factor of progression (HR=0.669, 95%CI: 0.495-0.904, P=0.009). There was no significant influence of daratumumab dosage on progression (high dosage vs low dosage, HR=1.016, 95%CI: 0.221-4.668, P=0.984). The median OS for overall cohort was 26 (95%CI: 13.1-38.9) months. Higher serum calcium was the independent risk factor of death (HR=12.190, 95%CI: 1.170-127.048, P=0.037). There was no significant influence of daratumumab dosage on death (high dosage vs low dosage, HR=0.818, 95%CI: 0.171-3.917, P=0.802). Adverse events included infections (43.2%, 16/37), infusion-associated reactions (29.7%, 11/37), and thrombocytopenia (27.0%, 10/37).

Daratumumab is effective to treat RRMM. The dosage of daratumumab has no significant influence on prognosis when used in combined treatment. The incidence of adverse events is relatively low, with a favorable safety profile.

To investigate the postoperative adverse events after primary anterior cruciate ligament reconstruction (ACLR) using the ligament advanced reinforcement system (LARS) for establishing grounds to standardize the clinical use of artificial ligaments.

The China Artificial Ligament Study Group (CALSG) was organized to follow up the cases of ACLR using the LARS(LARS-ACLR) at 20 orthopedic sports medicine centers in China between July 1, 2004 and December 31, 2010. Adverse events, including cumulative failures and complications, were identified through follow-up study and case screening. The cumulative failure was classified as graft rupture and clinical failure, with graft rupture confirmed by arthroscopy and clinical failure confirmed by either limited knee range of motion (>5° in extension and/or >15° in flexion, contralateral knee as control) or joint laxity (Lachman test ≥Ⅱ, pivot shift test ≥Ⅱ, side-to-side difference>5 mm). The demographic information and clinical data of cumulative failure cases were collected, and the cumulative failure rate, the complication rate, the composition ratio of different degrees of joint symptoms among cumulative failure cases, and the composition ratio of failure causes were statistically analyzed.

A total of 1 705 cases of LARS-ACLR were collected at 20 centers, of which 1 393 met the inclusion criteria of the study. Of the included cases, 1 146 completed the follow-up, with a follow-up rate of 83.3% (1 146/1 393) and a median follow-up time [M (Q₁, Q₃)] of 87.1 (68.2, 116.0) months. Ninety-eight adverse events were identified, including 51 cumulative failures and 47 complications, with a cumulative failure rate of 4.5% (51/1 146) and a complication rate of 4.1% (47/1 146). The median cumulative failure time [M (Q₁, Q₃)] was 12 (7, 24) months after surgery, with 44 patients (86.3%, 44/51) presenting with joint instability, 39 patients (76.5%, 39/51) with joint pain, 31 patients (60.8%, 31/51) with joint swelling, 25 patients (49.0%, 25/51) feeling knee catching and locking, 10 patients with flexion restriction greater than 15° (19.6%, 10/51), and 1 patients with extension restriction greater than 10° (2.0%, 1/51). The incorrect bone tunnel position were confirmed in 32 patients (62.7%, 32/51) and reinjury in 25 patients (49.0%, 25/51). The graft rupture was confirmed under arthroscopy in 21 patients (41.2%, 21/51) and screw loosening occurred in 8 patients(15.7%, 8/51). Complications were detected in 47 patients, with screw-related problems confirmed in 20 patients (1.7%, 20/1 146), synovitis in 18 patients (1.6%, 18/1 146), stiffness in 6 patients (0.5%, 6/1 146), and infection in 3 patients (0.3%, 3/1 146).

The long-term cumulative failure rate is 4.5% and the complication rate is 4.1% after LARS-ACLR. Joint instability and pain are the main joint symptoms in cumulative failure cases of LARS-ACLR. Incorrect bone tunnel positioning is the primary cause of failure and should be of great concern to clinicians.

To analyze the influence of intrinsic motivation on work burnout and the mediating effects of work stress.

In 2020, questionnaire survey was conducted in 1 655 gastroenterologists working in 28 provinces of China. Mediation model was used to analyze the mediating effects of work stress in the relationship between intrinsic motivation and burnout. Resutls 1655 valid questionnaires were collected, including 1 132 women and 523 men, with an average age of 39.26. Intrinsic motivation was related to reduced level of burnout, including emotional exhaustion, dehumanization and low sense of accomplishment (β=-2.06, -1, 77 and-4.20;P<0.001). Job stress partially mediated the negative correlation between intrinsic motivation and job burnout in three dimensions, accounting for 40%, 15% and 5% (β=-1.58, -0.36 and-0.21;P<0.05), respectively. In female physicians, the intrinsic motivation was more directly related to the reduction of burnout, especially in the dimension"emotional exhaustion"(direct effect accounting for 62% in female gastroenterologists and 46% in male).

Enhancing the intrinsic motivation of gastroenterologists can directly reduce burnout and indirectly reduce burnout by alleviating work stress. In the same work environment, female physicians′ intrinsic motivation had a greater and more direct effect on reducing burnout.

This paper summarizes the current situation of research on gender differences in work environment and work feelings of medical staff in different countries. Three kinds of topics, including internal reasons, external conditions and negative influences of gender differences, are integrated in this field. Suggestions or measures for improvement include pay equality, capacity strengthening and empowerment, increasing career flexibility, mentoring research or training projects, providing mentors, ensuring institutional fairness and transparency, and reducing unconscious gender bias. At present, there are a considerable number of research on gender differences of medical staff in the world, but there is a lack of high-quality research on intervention evaluation, and there is also a lack of research on gender perspective of health service staff in China. Some conclusions in the current research can provide inspirational suggestions for stabilizing the physician team and improving the work performance of physicians in China, but the certainty of the recommendation of evidence output policy still needs in-depth systematic review and literature methodology quality evaluation.

In recent years, unilateral dual-channel endoscopic (UBE) spinal surgery has been gradually used to treat lumbar degenerative diseases and other spinal diseases. It is generally believed that UBE surgery has the advantages of wide visual field, flexible operation, less trauma, sufficient nerve decompression and faster postoperative recovery. Even for skilled spinal surgeons, there are still many difficulties and risks in the early stages of performing UBE surgery. Understanding the learning curve of UBE has some instructive implications for most physicians who want to carry out this technique.

Dissection of the posterior edge of the lumbar vertebral body often requires surgery. In the past, open surgery has completely decompressed, but there are shortcomings such as large trauma, heavy bleeding and spinal instability. Fusion surgery can solve the problem of spinal instability at the same time, it is easy to lead to adjacent segment degeneration and lumbar failure syndrome. Although the technique of percutaneous spinal endoscopy has been applied to the posterior edge dissection of the lumbar vertebral body with less trauma and fast recovery, satisfactory decompression within the spinal canal remains a great challenge for spinal surgeons. Unilateral dual-channel endoscopy (UBE) is a good choice for the treatment of posterior edge dissection of lumbar vertebral body. UBE uses two channels for operation, and the working instrument and endoscope do not interfere with each other. The operation flexibility is better, and the range and degree of decompression are more thorough. Previous studies have shown that UBE has a good clinical effect in the treatment of lumbar disc herniation and lumbar spinal stenosis. However, this method has not been reported in the treatment of posterior vertebral dissection.