【作者】 刘颖；

【导师】 宁宁；

【作者基本信息】 四川大学 ， 护理学， 2021， 硕士

【摘要】 背景:骨肿瘤指在骨内发生或起源于骨组织成分(骨及附属组织)的肿瘤,根据肿瘤的组织来源可分为原发性和继发性(或转移性)骨肿瘤。骨肿瘤发病率相对较低,仅占全部肿瘤的1%～2%。骨组织也是恶性肿瘤好发的第3大部位(仅次于肺和肝脏)。随着近年来医疗的发展,骨肿瘤患者的治疗手段也不断革新,但手术治疗始终是骨肿瘤患者在治疗阶段均会经历的一个事件及过程。通过各种改良的治疗方式,骨恶性肿瘤患者的5年生存率也得以大幅度上升,当前的生存率已从原有的20%上升到60%～80%。然而,手术是具有创伤性的,且恶性骨肿瘤患者术后还需面临系统的化疗/放疗,往往会引起较多的不良反应,降低患者的舒适度,容易造成术后一系列心理问题,故患者术后的心理状况仍然需要我们持续关注。近年来,越来越多研究者关注到了患者心理状态的正向改变:患者在经历了疾病的诊断、治疗等一系列医疗干预后,不仅会出现负性心理状态,同时,也会出现正向改变或成长。创伤后成长则是其中之一。创伤后成长(post-traumatic growth,PTG)指在与具有创伤性的情景/情境或者事件作出抗争后,个体所体验到的心理积极转变的集合。在经历过各类创伤的人群中,均证实了PTG的存在。肿瘤患者中产生PTG的人群,往往会有更佳的预后情况,其生存质量、疾病康复情况都远高于未产生PTG的人群。通过阅读大量文献后,总结国内外研究现状如下:(1)国内外较多的研究关注了骨肿瘤患者的负面心理,如焦虑、抑郁等,但是对PTG的报道较少。虽有部分研究报道了骨肿瘤患者中存在PTG,但仅考虑了疾病诊断及放化疗过程对其带来的伤害,并未聚焦于术后这一特殊阶段。对于良性骨肿瘤患者、交界性骨肿瘤患者以及恶性骨肿瘤患者在经历疾病诊断、放/化疗以及手术治疗多重创伤打击后,是否都会出现PTG现象,成长水平如何,仍待进一步研究。(2)最新研究表明在经历创伤后的短期内出现的PTG往往更有意义,会影响患者远期的PTG水平、功能恢复情况以及生存质量。但现有研究较少关注疾病诊断或治疗后初期、短期内患者的PTG变化,多数研究仍停留于横断面研究,短期的纵向研究较为罕见。(3)由于较少研究聚焦于术后这一特殊阶段,故较难得知手术事件对骨肿瘤患者的心理影响程度如何。(4)直接引起PTG的创伤性事件对个体的心理影响程度,与PTG之间的关系尚未有定论。(5)骨肿瘤患者术后PTG水平高低与哪些因素相关也仍需要不断探索。目的:1.了解骨肿瘤患者术后是否存在PTG现象,以及PTG的水平2.了解在经历手术的初期(术后1个月内),骨肿瘤患者PTG的变化轨迹3.了解手术事件对骨肿瘤患者的心理影响程度4.探讨手术事件对患者的心理影响程度与PTG的关系5.分析骨肿瘤患者术后1个月内PTG水平的影响因素方法:本研究为前瞻性队列研究。采用方便抽样,对2019年11月-2020年12月四川省某三甲医院骨科,符合纳排标准的患者进行全部纳入,剔除其中满足剔除标准的患者。根据患者在手术完成后的第2天的中文版事件影响量表修订版的得分,将研究对象分为两组,以有无显著的应激反应的零界点26分为分组标准,低于26分的患者纳入手术对个人的心理影响程度较小组,高于26分的患者则纳入手术事件对个人心理影响程度较大组。本研究的主要结局指标为术后1个月时骨肿瘤患者的PTG水平,为连续性变量;主要影响因素为手术事件对骨肿瘤患者的影响程度。故样本量的计算采用两独立样本t检验的计算方式,选择预试验20例患者术后30天的中文版创伤后成长量表得分进行计算,得出所需样本量为150例。研究工具包括由研究者自行设计的患者一般资料调查表,其中包括社会人口学资料及疾病相关信息;中文版创伤后成长量表(PTGI-C),用于评定创伤后成长水平;中文版事件影响量表修订版(CIES-R),用于评定手术事件对患者的心理影响程度,并作为分组依据,也是本研究纳入的PTG最主要影响因素之一;特质应对方式量表(TCSQ)用于评定患者对手术事件,即创伤性事件,采取的应对方式类型,作为纳入研究的影响因素之一;疾病不确定感量表(MUIS-A),用于评定患者在治疗过程中的不确定感程度,也是本研究纳入的PTG的影响因素;疼痛数字评分表(NRS)用于评价患者的疼痛程度,是探讨的PTG影响因素之一。研究资料收集时间点为术前3天、术后2天、术后15天以及术后30天,分别发放相应的研究工具并进行填写。术前3天发放的资料为一般资料调查表、中文版事件影响量表修订版、中文版创伤后成长量表、特质应对方式量表、疾病不确定感量表以及疼痛数字评分表;术后2天、15天以及30天时发放中文版事件影响量表修订版、中文版创伤后成长量表、疾病不确定感量表以及疼痛数字评分表。随访时间的确定来源于患者的康复进程。一般患者于术前3天入院,此时收集数据可确保资料的完整性。术后2天患者麻醉基本清醒,可以独立完成自评量表。术后15天,患者将完成伤口拆线,此时医护人员会鼓励患者进行充分的功能锻炼,故该阶段为康复的重要节点。术后30天伤口及软组织基本愈合,且该时间段内为骨科各类手术并发症的高发时期,应当重点关注;部分恶性骨肿瘤患者于术后30天开始化疗,可能会引入新的创伤性事件,因此该时间为随访的终点。数据录入采用Epidata软件(双人录入)以及电子问卷录入的方式。统计分析软件选择SPSS26.0进行处理。针对计量资料的统计描述采取均数±标准差、中位数以及四分位数间距等,统计分析采取t检验、方差分析、重复测量方差分析、协方差分析、秩和检验等检验方法。针对分类资料采用构成比、发病率等进行统计描述,采用卡方检验、fisher确切概率法等方法进行统计分析。本研究在实施过程中严格执行质量控制方法。在研究设计阶段已咨询科研设计专家,对研究设计方案进行了反复修改和确认。资料收集阶段,当场检查问卷是否完整作答,并及时询问未填写的条目,将内容补充,保证问卷资料的完整性和真实性。所有患者均需完成知情同意书,且有退出研究的权力。分析阶段由至少两名研究者进行资料的录入,有利于在录入数据的过程中发现异常值。采用正确的统计分析方法,并及时请统计学专家对统计方法进行校正。本研究已完成伦理审批,伦理备案号为2019年审(1091)号。结果:根据本研究的纳入和排除标准,共纳入研究对象154例。在术后1个月的随访过程中,有12例患者因失访等原因而剔除,最终实际纳入患者共142例。影响较小组患者共78例,影响较大组患者共64例。1.142例研究对象的人口学资料分析显示,患者的男、女性别构成比近似(50.7%和49.3%),年龄为33.34±12.63岁,BMI为22.30±3.31Kg/m~2,民族以汉族为主(95.1%),婚姻状况中已婚为主(58.4%)。在疾病相关资料方面,肿瘤部位以下肢为主(95例,66.9%),肿瘤类别以骨巨细胞瘤(33例,23.2%)及骨肉瘤(29例,20.4%)居多。纳入的研究对象包括了良性骨肿瘤83例(58.4%),恶性肿瘤59例(41.6%)。手术方式以骨肿瘤切除加骨重建术及骨肿瘤切除加肿瘤关节假体置换术为主(各占33.8%)。分组后两组患者的一般资料分析显示,两组患者在性别构成比、年龄、BMI、民族、婚姻状况、家庭收入状况等社会人口学信息方面,差异均无统计学意义(P>0.05),具有可比性;在疾病相关资料方面,两组患者在肿瘤部位、肿瘤类别、良/恶性、手术方式、有无手术史、术前有无化疗等方面,差异均无统计学意义(P>0.05),具有可比性。2.142例研究对象术前3d的PTGI-C得分为39.79±22.86分,术后2d的PTGI-C得分为43.30±24.16分,差异无统计学意义(t=-1.26,P=0.21)。3.142例患者术后2d、术后15d以及术后30d的PTGI-C得分分别为43.30±24.16分,39.54±23.31分,43.66±24.99分。重复测量方差分析计算F=2.70,P=0.02,提示术后2d、术后15d、术后30d各时间点PTGI-C得分差异具有统计学意义。对各时间点PTGI-C得分的两两比较发现,术后15d与术后30d的PTGI-C得分差异有统计学意义。4.142例患者术前3d的CIES-R得分为15.75±14.55分,术后2d的得分为21.44±17.08分,差异有统计学意义(P<0.05)。影响较小组患者术前CIES-R得分为9.69±8.72分,影响较大组患者CIES-R得分为23.14±16.72,差异有统计学意义(t=-6.16,P<0.05)。两组患者术后2d的CIES-R得分分别为8.47±5.86分和37.25±12.22分,差异具有统计学意义(P<0.05)。142例患者术后2d、术后15d以及术后30d的CIES-R得分分别为21.44±1.43分、12.42±1.01分以及10.64±1.00分,各时间点CIES-R得分差异具有统计学意义(F=63.49,P<0.05)。5.两组患者围术期PTGI-C得分的统计分析显示,影响较小组患者术前3d PTGI-C得分为34.59±22.08分,影响较大组PTGI-C得分为46.13±22.35分,二者具有统计学差异(t=-3.09,P<0.05)。影响较小组患者术后2d PTGI-C得分为34.95±25.96分,影响较大组患者PTGI-C得分为53.48±17.70分,差异有统计学意义(t=-4.91,P<0.05)。术后15d影响较小组患者的PTGI-C得分为31.96±22.20分,影响较大组患者的PTGI-C得分为48.78±21.47分;术后30d影响较小组患者PTGI-C得分为37.77±25.32分,影响较大组PTGI-C得分为50.84±22.80分。两组患者术后1个月内PTGI-C得分的重复测量方差分析显示,分组与时间因素对各时间点PTGI-C得分不存在交互作用(F=0.95,P>0.05),说明手术事件影响程度的大小对PTGI-C的作用不随时间变化而变化;但各个时点PTGI-C得分存在差异(F=3.92,P<0.05),且手术事件对患者的影响大小也会引起PTGI-C得分的差异(F=27.03,P<0.05),差异均具有统计学意义。心理影响较大组患者的术后各时间段的PTG水平均高于影响较小组。6.两组患者术后2d的PTG水平影响因素包括疾病不确定感得分以及疼痛程度,术后15d PTG水平的影响因素有术前3d PTGI-C得分、疾病不确定感得分、疼痛程度以及肿瘤良/恶性,术后30d PTG水平的影响因素有术前3d PTGI-C得分、疾病不确定感得分、疼痛程度以及肿瘤良/恶性。结论:1.本研究共调查了142例骨肿瘤手术患者,均发现术后2d患者存在PTG现象,PTGI-C得分为中等偏下的水平。2.骨肿瘤患者术后1个月内的PTG水平变化轨迹为先降低后升高,于术后15d降低,再于术后30d升高。因此术后15d是医护人员应该及时给予心理干预的重要节点。且医护人员应当尽早识别高危患者,即PTG一直处于低水平的人群。3.手术会在术前及术后对骨肿瘤患者造成心理影响,且术后的影响程度明显高于术前。随着时间的推进,手术事件对骨肿瘤患者的心理影响程度逐渐降低,其下降速度呈现先快后慢的趋势。提示手术对骨肿瘤患者的心理创伤有持续存在的可能性,护理人员应当及时发现患者的心理困扰,并给予指导。4.本研究重点讨论了PTG与手术事件对骨肿瘤患者的心理影响程度(CIES-R得分)、即创伤后应激反应(PTS)之间的关系,PTS越大,则对应越高水平的PTG。手术事件的影响程度与时间不存在交互作用,不会影响PTG随时间变化的结果;心理影响较大组与较小组产生的PTG水平都比较稳定。这提示患者的积极心理变化也许伴随着心理痛苦,因此医护人员在进行心理评估时,应将正面心理现象与负面心理现象同时考虑,行更有针对性的心理护理措施。5.通过对骨肿瘤患者术后1个月PTG的影响因素分析,得到了其术后1个月内PTG影响因素模式图:患者的性别、肿瘤的良/恶性、疼痛程度、术前3d的PTG水平以及疾病不确定感均有可能影响术后各时间点的PTG水平。这说明骨肿瘤手术患者全程的疼痛管理、全面的健康教育以及科学的延续性护理尤为重要,也为PTG的促进奠定了理论基础。更多还原

【Abstract】 Backgroud:Bone tumors refer to tumors that occur in bone or originate from bone tissue components(bone and accessory tissues).According to the tissue source of the tumor,it can be divided into primary and secondary(or metastatic)bone tumors.The incidence of bone tumors is relatively low,accounting for only 1%to 2%of all tumors,but 40%of them are malignant tumors.And bone tissues are also prone to malignant tumors.And bone is the third most common site for malignant tumors(after lung and liver).With the development of medical treatment in recent years,the treatmentmethods for patients with bone tumors have also been continuously innovated.Surgical is an event and process that patients with bone tumors will experience during the treatment stage.Through various improved treatment methods,the 5-year survival rate of patients with bone malignant tumors has also been greatly increased.And the current survival rate has increased from the original 20%to 60%～80%.However,surgery is traumatic.And patients with malignant bone tumors still need to face systematic chemotherapy/radiotherapy after surgery,which will cause a series of psychological problems for patients after surgery.So the psychological status of patients after surgery still requires our continuous attention.In recent years,more and more researchers have paid attention to the positive changes in the mental state of patients:after a series of medical interventions such as disease diagnosis and treatment,patients will not only develop negative mental states,but also positive changes.Post-traumatic growth is one of them.Post-traumatic growth(PTG)refers to the collection of positive psychological changes experienced by an individual after struggling with a traumatic situation or event.In people who have experienced various traumas,the existence of PTG has been confirmed.People with PTG in cancer patients tend to have a better prognosis.And their quality of life and disease recovery are much higher than those without PTG.After reviewing a large amount of literature,the current research status at home and abroad is summarized as follows:(1)Many domestic and foreign studies have focused on the negative psychology of patients with bone tumors,such as anxiety and depression.However,there are fewer reports on PTG.Although some studies have reported the existence of PTG in patients with bone tumors,they only considered the damage caused by disease diagnosis and the process of radiotherapy and chemotherapy.Most studies didn’t focus on this special stage of surgery.For patients with benign bone tumors,borderline bone tumors,and malignant bone tumors,whether PTG will occur after multiple traumas from disease diagnosis,radiotherapy/chemotherapy,and surgery,and the level of growth remains to be further studied.(2)The latest research shows that PTG that appears in the short term after trauma is often more meaningful,and it will affect the patient’s long-term PTG level,functional recovery and quality of life.However,the existing research pays little attention to the PTG changes of patients in the early and short-term after the diagnosis or treatment of the disease.Most of the research still stays in the cross-sectional study,and the short-term longitudinal study is relatively rare.(3)As less research focuses on this special stage after surgery,it is difficult to know the psychological impact of surgical events on patients with bone tumors.(4)The relationship between traumatic events that directly cause PTG and PTG has not yet been determined.(5)What factors are related to the level of PTG in patients with bone tumors still need to be explored continuously.Objective:1.Understand whether there is PTG phenomenon in patients with bone tumors after surgery,and the level of PTG2.Understand the change trajectory of PTG in patients with bone tumors in the early stage of surgery(within 1 month after surgery)3.Understand the psychological impact of surgical events on patients with bone tumors4.Explore the relationship between the degree of psychological impact of surgical events on patients and PTG5.Analyze the influencing factors of PTG levels in patients with bone tumors within 1 month after surgeryMethod:This study is a prospective cohort study.It is proposed to adopt convenient sampling to include all patients who meet the inclusion and exclusion criteria in the orthopedics department of a tertiary hospital in Sichuan Province from November 2019 to December 2020.And we excluded patients who meet the exclusion criteria.According to the evaluation results of the patient’s event impact scale after the completion of the operation,the study subjects were divided into two groups.One group was treated the surgical event with less impact on the patient,and the other group was the greater impact of the surgical event.The cutoff was 26 points.If the score was higher,it would be included in the group with greater impact of surgical events.If the score was below the cut-off line,it would be included in the group with less impact of surgery.The calculation of sample size adopted PASS 15.0 to calculate.According to the calculation method of the sample size of the two independent samples t-test,the scores of the Chinese version of the post-traumatic growth scale were calculated for each month after the operation of 20 patients in the pre-test,and the required sample size was 150cases.Research tools include general patient data survey forms designed by researchers,including sociodemographic data and disease-related information.Chinese version of the Post-traumatic Growth Inventory(PTGI-C),used to assess the level of post-traumatic growth;Chinese translation of the Impact of Event Scale-Revised(IES-R),used to assess the psychological impact of surgical events on patients,and used as a basis for grouping.It is also one of the PTG influencing factors included in this study;The Chinese Trait Coping Style Questionnaire(TCSQ)is used for evaluation The patient’s response to surgical events,that is,traumatic events,is one of the influencing factors included in the study;Mishel Uncertainty in Illness Scale for Adults(MUIS-A)is used to assess the patient’s degree of uncertainty during treatment,Which is also the influencing factor of PTG included in this study;and the Numerical Pain Score(NRS),which is used to evaluate the pain degree of patients,is one of the influencing factors of PTG..The research data collection time points were 3 days before the operation,2 days after the operation,15 days after the operation,and 30 days after the operation.The corresponding research tools were distributed and filled out.The data distributed before the operation are the General Information Questionnaire,Chinese translation of the Impact of Event Scale-Revised,Chinese version of the Post-traumatic Growth Inventory,The Chinese Trait Coping Style Questionnaire,Mishel Uncertainty in Illness Scale for Adults,and the Number Rating Scale.Chinese translation of the Impact of Event Scale-Revised,Chinese version of the Posttraumatic Growth Inventory,Mishel Uncertainty in Illness Scale for Adults,and the Number Rating Scale will be issued at 2 days,15 days and 30 days after the operation.The follow-up time was determined by the patient’s recovery process.Two days after the operation,the patient was basically conscious of anesthesia and could independently complete the self-rating scale.The patient will complete the wound suture removal and be encouraged to perform adequate functional exercises 15 days after surgery.So this stage was important for rehabilitation.Wounds and soft tissues are basically healed one month after surgery,and this time period was the time for the high incidence of various orthopedic surgical complications,which should be paid attention to.Some patients with malignant bone tumors start chemotherapy one month after surgery,and new ones may be introduced Traumatic event So 30d is the end of follow-up.Data entry adopts Epidata software(double entry)and electronic questionnaire entry.The statistical analysis software selects SPSS26.0 for processing.The statistical description of measurement data adopts mean±standard deviation,median and interquartile range,etc.,and statistical analysis adopts t-test,analysis of variance,repeated measures analysis of variance,analysis of covariance,rank sum test and other test methods.According to the classification data,the composition ratio,incidence rate,etc.are used for statistical description,and the chi-square test,fisher’s exact probability method and other methods are used for statistical analysis.During the implementation of this research,strict quality control methods were implemented.In the research and design stage,the experts had been consulted.The research and design plan had been revised and confirmed repeatedly.In the data collection stage,checked on the spot whether the questionnaire was fully answered,and promptly ask about the unfilled items,and supplement the content to ensure the completeness and authenticity of the questionnaire data.All patients needed to complete an informed consent form and had the right to withdraw from the study.In the analysis stage,at least two researchers entered the data,and deal with extreme values or outliers in a timely manner during the entry process.Used correct statistical analysis methods,and promptly invited statistical experts to calibrate statistical methods.The ethics approval of this study had been completed,and the ethics record number was 2019 Examination(1091).Result:According to the inclusion and exclusion criteria of this study,a total of154 subjects were included.During the 1-month follow-up,12 patients were excluded due to reasons such as loss to follow-up.A total of 142 patients were actually included.There were 78 patients in the less affected group and64 patients in the greater impact group.1.The analysis of demographic data of 142 study subjects showed that the gender ratios were similar(50.7%and 49.3%),and the age was 33.34±12.63years old,BMI was 22.30±3.31Kg/m~2,and the ethnic group was Han.Mainly(95.1%),married predominantly(58.4%)in marital status.In terms of disease-related data,the tumor is mainly in the lower limbs(95 cases,66.9%),and the tumor types are giant cell tumor of bone(33 cases,23.2%)and osteosarcoma(29 cases,20.4%).The included subjects included 83 cases(58.4%)of benign bone tumors and 59 cases(41.6%)of malignant tumors.The main surgical methods were bone tumor resection plus bone reconstruction and bone tumor resection plus tumor joint prosthesis replacement(33.8%each).After grouping,the general data analysis of the two groups of patients showed that there was no statistically significant difference between the two groups in terms of gender composition,age,BMI,ethnicity,marital status,family income status and other socio-demographic information(P>0.05).They were Comparable.In terms of disease-related data,the two groups of patients were not statistically different in terms of tumor location,tumor type,benign and malignant degree,surgical method,history of surgery,and chemotherapy before surgery(P>0.05),and they were comparable.2.The PTGI-C score of the 142 subjects was 39.79±22.86 points before the operation,and the PTGI-C score was 43.30±24.16 points 2 days after the operation,the difference was not statistically significant(t=-1.26,P=0.21).3.The PTGI-C scores of 142 patients were 43.30±24.16 points,39.54±23.31 points,and 43.66±24.99 points at 2d,15d and 30d after operation.Repeated measures analysis of variance calculated F value=2.70,P=0.02,suggesting that the difference in PTGI-C scores at each time point 2days after operation,15 days after operation,and 30 days after operation is statistically significant.Comparison of PTGI-C scores at each time point found that there was a difference between the PTGI-C scores on the 15 day after the operation and the 30 day after the operation.4.The CIES-R score of 142 patients was 15.75±14.55 points on the 3 day before operation and 21.44±17.08 points on the 2nd day after operation,the difference was statistically significant(P<0.01).The preoperative CIES-R score of patients in the less-affected group was 9.69±8.72 points,and the CIES-R score of patients in the more-affected group was 23.14±16.72,the difference was statistically significant(t=-6.16,P<0.05).The CIES-R scores of the two groups of patients were 8.47±5.86 points and 37.25±12.22 points 2days after operation,and the difference was statistically significant(P<0.01).The CIES-R scores of 142 patients were 21.44±1.43 points,12.42±1.01points,and 10.64±1.00 points at 2d,15d,and 30d after surgery.The difference in CIES-R scores at each time point was statistically significant(F=63.49,P<0.05).5.The statistical analysis of the perioperative PTGI-C scores of the two groups of patients showed that the preoperative 3d PTGI-C score of the less affected group was 34.59±22.08 points,and the PTGI-C score of the greater impact group was 46.13±22.35 points,both There are statistical differences(t=-3.09,P<0.05).The PTGI-C score of the patients in the less-affected group was 34.95±25.96 points after 2d,and the PTGI-C score of the patients in the more-affected group was 53.48±17.70 points,the difference was statistically significant(t=-4.91,P<0.05).15 days after operation,the PTGI-C score of patients in the less affected group was 31.96±22.20 points,and the PTGI-C score of patients in the more affected group was48.78±21.47 points;30 days after the operation,the PTGI-C score of patients in the less affected group was 37.77±25.32 points.The PTGI-C score of the more influential group is 50.84±22.80 points.The repeated measures analysis of variance of the PTGI-C scores of the two groups of patients within 1month after surgery showed that there was no interaction between grouping and time factors on the PTGI-C scores at each time point(F=0.95,P>0.39).It indicated that the impact of surgical events didn’t change with time.However,there were differences in PTGI-C scores at various time points(F=3.92,P<0.05),and the impact of surgical events on patients would also lead to different PTGI-C scores(F=27.03,P<0.05).The difference was statistically significant.The PTG levels of the patients in the greater psychological impact group were higher than those in the less influential group.6.Influencing factors of the 2 days after operation PTG level included the disease uncertainty score and pain degree.The influencing factors of the 15days after operation PTG level included the preoperative 3d PTGI-C score,disease uncertainty score,pain degree and tumor The degree of benign and malignant.The 30-day postoperative PTG level influencing factors included the 3d preoperative PTGI-C score,disease uncertainty score,pain degree,and tumor benign and malignant degree.Conclusion:1.In this study,a total of 142 patients undergoing bone tumor surgery were investigated,and it was found that the PTG phenomenon was present in the patients 2 days after the operation,and the PTGI-C score was at a moderately low level.2.The PTG level of bone tumor patients within 1 month after the operation decreased firstly,then increased.It decreased 15 days after the operation,and then increased 30 days after the operation.Therefore,15 days after operation is an important node where medical staff should give psychological intervention in time.And medical staff should identify high-risk patients as early as possible,that is,people whose PTG has been at a low level.3.Surgery will have a psychological impact on patients with bone tumors before and after surgery,and the degree of impact after surgery is significantly higher than before surgery.As time progresses,the psychological impact of surgical events on patients with bone tumors gradually decreases,and the rate of decline shows a trend of rapid first and then slower.It indicates that there is a possibility that the psychological trauma of patients with bone tumors will continue to exist during surgery.Nursing staff should find out the patients’psychological distress in time and give guidance.4.This study focused on the relationship between PTG and the psychological impact of surgical events on patients with bone tumors(CIES-R score),that is,the post-traumatic stress response(PTS).The larger the PTS,the higher the level of PTG.There is no interaction between the degree of influence of surgical events and time,and it will not affect the results of PTG changes over time;the PTG levels of the larger and smaller groups of psychological influence are relatively stable.This suggests that the patient’s positive psychological changes may be accompanied by psychological pain.Therefore,when performing psychological assessments,medical staff should consider both positive and negative psychological phenomena,and take more targeted psychological care measures.5.Through the analysis of the influencing factors of PTG in patients with bone tumor surgery one month after surgery,a pattern diagram of PTG influencing factors within one month after surgery was obtained:patient’s gender,tumor benign/malignant,pain degree,3 days before surgery The PTG level and the uncertainty of the disease may affect the PTG level at various time points after surgery.This shows that the whole process of pain management,comprehensive health education and scientific continuous care for patients with bone tumor surgery are particularly important,and it also lays a theoretical foundation for the promotion of PTG.更多还原