关键词： 重复保险   他保条款   责任   分摊  

摘要： 我国《保险法》第五十六条第二款允许当事人约定重复保险中各保险人的赔偿方式,但是多个其他保险条款竞合时如何处理则缺乏立法指引。解决该问题应当秉持“尽最大可能满足合同约定”和“遵循现行法体系”的原则。首先从社会性和强制性层面分出第一线责任承担者,其次在同一责任顺位中依约定初步确定各方应付保险金,总和超过被保险人应得保险金的,以实际保险金数额比例分担法确定最终赔偿责任;总和低于被保险人应得保险金的,不足部分依《保险法》第五十六条确定剩余赔偿责任。

关键词： RCEP   CPTPP   递归动态GTAP模型   区域贸易协定   对冲效应   贸易关税  

摘要： 采用递归动态GTA P模型,基于各国货物贸易实际关税减让承诺表确定各国彼此之间具体的关税减让程度,从宏观和微观角度定量预测模拟比较2021—2025年间RCE P与CPTPP对不同成员国产生的经济效应,评估RCEP对CPTPP所造成负面影响的对冲效果,发现RCEP与CPTPP对各自区域内成员国无论是宏观经济指标还是各行业产出较基准情形均有明显提升作用,但同时也会对非区域内成员国经济造成一定负面冲击;RCEP对CP T PP在宏观和微观经济方面所造成的不利影响有明显冲抵效果。针对模型运行结果,中国下一步需要积极消除非关税技术壁垒,充分做好加入CPTPP的各项准备工作,加快提升技术密集型产业的竞争优势,持续推动高技术产业升级优化。

关键词： 地质灾害   海洋灾害   地震灾害   水旱灾害   自然灾害   引发因素   气象灾害   森林火灾  

摘要： 地质灾害是指在自然或者人为因素的作用下形成的,对人类生命财产造成损失、对环境造成破坏的地质作用或地质现象。本文从气象灾害、水旱灾害、地震灾害、森林火灾、海洋灾害方面探讨了地质灾害与其的关系,可以说,其他自然灾害的动力作用常常成为地质灾害的引发因素。

关键词： hypospadias   pediatrics   testosterone   testosterone supplementation   glans diameter  

摘要： Purpose: Testosterone (T) administration prior to hypospadias surgery to increase glans size remains controversial. Understanding T's effect on glans width (GW) is essential to understanding its potential impact on surgical outcomes. We hypothesized that preoperative T in prepubertal boys significantly increases GW at the time of hypospadias surgery. Materials and Methods: Our single institutional database was queried to identify patients who underwent hypospadias surgery from 2016 to 2020, in which data for T administration and GW were available. Descriptive, nonparametric and categorical statistics were performed as indicated. Results: A total of 579 patients were eligible for analysis. Median age at surgery was 0.9 years (IQR 0.6-1.6). A total of 247/579 patients (42.7%) received T. The median GW at surgery was 15 mm (IQR 13-17). When comparing patients who had T administered to those who did not, we found a significant difference in GW at surgery (16 mm vs 14 mm, p <0.001). The median change in GW from the office to surgery was 4 mm for those receiving T vs 0 mm for those not receiving T (p <0.001). We identified a greater change in GW from preoperative to intraoperative measurements in patients who received 2 doses of T vs 1 dose (4 mm vs 2 mm, p <0.001). A histogram plot revealed the distribution of GW change at surgery. Conclusions: In our prospectively collected cohort of patients undergoing hypospadias surgery, we were able to quantitate the change in GW from preoperative T. Two doses of T resulted in a significant increase in GW vs 1 dose.

关键词： spectroscopy   near-infrared   brain mapping   urination   urodynamics  

摘要： Purpose: We explored the central pathogenesis of overactive bladder (OAB) and the central mechanism of action of sacral neuromodulation (SNM). Materials and Methods: We prospectively enrolled patients with OAB who chose SNM and healthy controls (HCs). At baseline, all subjects completed a 72-hour voiding diary, OAB symptom score and prefrontal cortex functional near-infrared spectroscopy scan synchronous urodynamic monitoring. All OAB patients were tested after implantation of the SNM electrode, and both success and failure groups were reevaluated. NIRS_KIT software was used to analyze prefrontal activity (p <0.05 and corrected by false discovery rate). SPSS(R) 22.0 was used to analyze clinical parameters, and p <0.05 was considered statistically significant. Results: A total of 16 HC and 20 OAB patients were enrolled. SNM treatment was successful in 18 OAB patients and failed in 2. The parameters of the voiding diary, OAB symptom score and urodynamic monitoring of OAB group were significantly improved after SNM treatment in success group, not in the failure group. Compared with HCs, Brodmann's area 9 (left dorsolateral prefrontal cortex [DLPFC]) was significantly deactivated in the preoperative OAB success group and significantly activated after SNM treatment. Before surgery, compared with the success group, the failure group showed significantly deactivated Brodmann's area 9 (left DLPFC). Conclusions: Our study provides novel neuroimaging evidence for the possible central pathogenesis of OAB (ie abnormal deactivation of the left DLPFC) and the possible central mechanism of action of SNM(ie restore activation of the left DLPFC).

关键词： lower urinary tract symptoms   mortality   cohort studies  

摘要： Purpose: The utility of male lower urinary tract symptoms (LUTS) as mortality risk factors remains unclear. We explored LUTS-associated mortality among Finnish men, evaluating the association of symptom severity and bother with risk of death. Materials and Methods: A questionnaire including the Danish Prostatic Symptom Score was mailed to a population-based cohort of 3,143 men aged 50, 60 and 70 years in 1994, with repeat surveys in 1999, 2004, 2009 and 2015. The men were followed until the end of 2018. Mortality associated with LUTS was analyzed using time-dependent Cox regression adjusted for age and comorbidity, updating symptom data every 5 years, including interaction terms between symptoms and associated bother. Results: Of the 1,167 men in the analysis, 591 (50.6%) died during the 24-year followup. In analyses of moderate and severe symptoms disregarding bother, overall voiding and storage LUTS, daytime frequency and urgency incontinence were associated with increased mortality: the multivariable-adjusted hazard ratios were 1.19 (95% CI 1.00-1.40), 1.35 (1.13-1.62), 1.31 (1.09-1.58) and 2.19 (1.42-3.37), respectively. In analyses disregarding symptom severity and bother, voiding LUTS were associated with decreased mortality, while daytime frequency and nocturia were associated with increased mortality: the HRs were 0.82 (95% CI 0.67-1.00), 1.31 (95% CI 1.09-1.58) and 1.52 (95% CI 1.21-1.91), respectively. Excess mortality associated with bothersome daytime frequency and nocturia tended to be slightly higher: the HRs were 1.86 (95% CI 1.41-2.47) and 1.88 (95% CI 1.38-2.58), respectively. No significant interactions were found between symptoms and associated bother, however. Conclusions: Moderate and severe LUTS are potential risk factors for mortality, independently of their bother.

关键词： prostatic neoplasms   radiotherapy   lymph nodes  

摘要： Purpose: Men with unfavorable intermediate-risk (UIR-PCa) or high-risk prostate cancer (HR-PCa) are often treated with definitive external beam radiotherapy (EBRT) plus androgen deprivation therapy. Treatment is frequently intensified by electively treating the pelvic lymph nodes (LNs) with whole pelvis radiotherapy (WPRT), but practice patterns and the benefits of WPRT are not well defined. We hypothesized that men treated with WPRT would have improved overall survival (OS) relative to men treated with prostate-only radiotherapy. Materials and Methods: National Cancer Database records of men diagnosed between 2008-2015 with UIR-PCa or HR-PCa and treated with prostate EBRT androgen deprivation therapy (72-86.4 Gy) with (15,175) or without (13,549) WPRT were reviewed. Risk of LN involvement was calculated using the Memorial Sloan Kettering Cancer Center nomogram. Measured confounders were balanced with inverse probability of treatment weighting and OS hazard ratios (HRs) were generated using multivariable Cox regression. Results: Of the men, 53% received WPRT. Every 1% increase in risk of LN involvement correlated with a 1% increase in risk of death (p <0.001). WPRT trended toward improved OS in all men with UIR-PCa and HR-PCa (HR: 0.95 =95% CI: 0.90-1.006], p=0.055). WPRT correlated with improved OS in men with Gleason 9 and 10 disease (HR: 0.87 =0.78-0.98], p=0.02) or risk of LN involvement >= 10% (HR: 0.93 =0.87-0.99], p=0.03). Conclusions: Men with higher LN risk scores and Gleason grade benefited from WPRT. These results complement the recent POP-RT randomized trial in mostly positron emission tomography/computerized tomography-staged patients, demonstrating that a more heterogeneous population of men staged without functional imaging benefits from WPRT.

关键词： hematuria   prostatic neoplasms   prostatectomy   quality of life   radiotherapy  

摘要： Purpose: Hematuria following post-prostatectomy radiotherapy (PPRT) is inadequately characterized. We performed a consecutive cohort study of patients treated with PPRT at our institution to characterize this complication including impact on patient-reported quality of life. Materials and Methods: Patients with potential followup >= 4 years following PPRT were identified. Freedom from >= grade 2 hematuria (FFG2H;macroscopic blood) was estimated using the Kaplan-Meier method. Predictors of >= grade 2 hematuria (G2H) were assessed via log-rank tests and the Cox model. Urinary patient-reported quality of life by EPIC-26 (26-question Expanded Prostate Cancer Index Composite) was compared for patients with/without hematuria using mixed-effects regression. Results: A total of 216 men received PPRT (median 68.4 Gy, IQR 68.0-68.4) from 2007 to 2016 at a median of 20 months (IQR 9-45) after prostatectomy. Median followup was 72 months (IQR 54-99). A total of 85 men developed hematuria, of whom 49 (58%) underwent cystoscopy, 13 (15%) required intervention and 26 (31%) experienced recurrent hematuria. Eight-year FFG2H was 55%. G2H was highest in men treated with anticoagulation/antiplatelet therapy (HR 3.24, p < 0.001), men with bladder V65 Gy >= 43% (HR 1.97, p=0.004) and men with medication allergies (HR 1.73, p=0.049). Age <65 years (HR 0.81, p=0.374) and diabetes mellitus (HR 0.49, p=0.098) were not associated with G2H. Change in urinary continence (mean -3.5, 95% CI: 10.1, 3.1) and irritation/obstruction (mean -3.0, 95% CI: 5.8, -0.3) domain scores did not exceed the minimally clinically important difference for men with/without hematuria. Conclusions: Hematuria following PPRT is common, especially among men with medication allergies and those on anticoagulation/antiplatelet therapy;however, PPRT-related hematuria is typically self-limited. Limiting bladder V65 Gy may reduce PPRT-related hematuria.

关键词： urinary sphincter   artificial   urinary incontinence   stress   radiotherapy   equipment failure   reoperation  

摘要： Purpose: In order to accurately characterize how a history of radiation therapy affects the lifespan of replacement artificial urinary sphincters (AUSs), all possible sources of device failure must be considered. We assessed the competing risks of device failure based on radiation history in men with replacement AUSs. Materials and Methods: We identified men who had a replacement AUS in a single institutional, retrospective database. To assess survival from all-cause device failure based on radiation history and other factors, we conducted Kaplan-Meier, Cox proportional-hazards and competing risks analyses. Results: Among 247 men who had a first replacement AUS, men with a history of radiation had shorter time to all-cause device failure (median 1.4 vs 3.5 years for men with radiation vs without radiation history, p=0.02). On multivariable Coxproportional hazards analysis, previous radiation was associated with increased risk of all-cause device failure (HR: 2.12, 95% CI: 1.30-3.43, p=0.002). On multivariable cause-specific hazards analysis, prior radiation was associated with a higher risk of erosion/infection (HR: 7.57, 95% CI: 2.27-25.2, p <0.001), but was not associated with risk of urethral atrophy (p=0.5) or mechanical failure (p=0.15). Conclusions: Among men with a replacement AUS, a history of pelvic radiation was associated with shorter time to device failure of any cause. Radiation was also specifically associated with a sevenfold increase in the risk of erosion or infection of replacement AUS, but not with urethral atrophy or mechanical failure. Patients with a replacement AUS should be appropriately counseled on how radiation history may impact outcomes of future revisions.