The article reviewed the current status, reform measures and progress of the tiered medical services in Zhejiang province, and analyzed main roadblocks in such a system.Proposals made in the paper include such reform measures as further expanding quality medical resources of better talents and equipments to enhance primary medical institutions;forming the gatekeeper practice featuring firstvisit at community health centers with enhanced primary capabilities;insisting on joint reform of medical treatment, medical insurance and drugs, promoting the development of tiered medical services and utilization efficiency of medical resources in the province.

Objective To study the prognosis of gastroesophageal reflux disease ( GERD) in children, and explore the factors which impacts on the prognosis of GERD. Methods One hundred and thirteen children with GERD were enrolled on the basis of positive result of 24-hour pH-monitoring between January 2007 and November 2011. The number of patients who were followed up was 87,and the parents of children were contacted with the telephone. The prognosis was evaluated by comparing the degree of patients′symptom relief,and the cumulative symptom relief rate was calculated by Kaplan-meier product limit method. The univariate Log-rank test and the COX proportional hazardmodel multivariate analysis were applied to detect the factors impacting on the prognosis,including age,gender,the regularity of treatment,reflux index,and Boix-Ochoa standard score,with esophageal hiatal hernia or without,receiving surgical treatment or not,the diet and lifestyle improved or not,receiving anti-acid treatment or not,as well as with allergies his-tory or without. Results At last,76 out of 87 children had symptom relieved. Survival curve showed the cumulative symptom relief rate at different time points,the median cumulative symptom relief rate reached 6 months,the final relief rate was close to 90. 0%,and the continuous treatment time was 44 months. The study showed that 14. 9% (13/87 ca-ses) of children′s growth and development were affected and the life and learning in 16. 1% (14/87 cases) of children were impacted. Age (P=0. 012,Wald=6. 376) and the regularity of treatment (P=0. 000,Wald=13. 059) were the risk factors in the prognosis of GERD. Conclusions Age and the treatment regularity were the factors in the prognosis. The children aged more than 1-year old have poor prognosis compared with those less than 1-year old,and the irregular treatment is the risk factor in the prognosis.

Objective To summarize the clinical features of the pancreaticopleural fistula (PPF) in children in order to improve the understanding of PPF and to make early diagnosis and treatment of the disease.Methods Five cases of pediatric PPF in Beijing Children's Hospital Affiliated to Capital Medical University from December 2007 to March 2014 were studied by retrospective analysis.The clinical features, laboratory results, image characteristics, treatment and prognosis were reviewed.Results Five cases of PPF were diagnosed aged between 2 years to 10 years and 5 months old, history from more than 1 month to 6 months.The main symptoms were chest tightness (3 cases), chest pain (3 cases) , fever(3 cases) , wheeze (1 case) , dyspnea (1 case).Only 1 case was with abdominal pain and abdominal distension when he was admitted to hospital.All patients had massive pleural effusions, included right side (3 cases),left side(1 case) ,bilateral sides(1 case), 1 case complicated with massive ascites.Pleural fluid amylase of all the cases was significantly elevated (＞ 1 000 U/L) ,the highest was more than 50 000 U/L.Four cases had positive findings of pancreas by transabdominal ultrasound.Five cases had morphological changes in pancreas by magnetic resonance cholangiopancreatography (MRCP).Four cases had PPF and pancreatic pseudocysts respectively.Conservative treatment was given to 5 cases, but further 3 cases reveived stent insertion by endoscopic retrograde cholangiopanereatography, and 2 cases reveived surgical therapy.Conclusions PPF is rare in children, the main clinical feature is massive pleural effusion with respiratory symptoms.Pleural fluid amylase would be significantly elevated.The diagnosis of PPF generally relies on imaging, MRCP is considered the imaging study of choice for PPF due to its superiority in identifying a fistula in the pancreatic region and its noninvasiveness as compared to endoscopic retrograde cholangio pancreatography.Endoscopic and surgical therapy can be used if internal therapy is not satisfactory.

Objective To investigate the etiology and clinical characteristics of chronic pancreatitis (CP) in children,so as to improve its diagnosis and treatment.Methods The etiology,clinical characteristics,radiological records and therapy were retrospectively analyzed in children with CP who were admitted to Beijing Children's Hospital Affiliated to Capital Medical University from July 2006 to May 2014.Results A total of 29 medical records of children with CP,including 19 male and 10 female,with a mean age of (8.5 ± 3.7) years,and the youngest case was a 2-year-old child,the oldest case was a 15-year-and-2-month-old child.The main etiological factor was idiopathic pancreatitis (51.7％,15/29 cases),and 9 cases were caused by anatomical anomalies (31.0％,9/29 cases).The main symptoms included abdominal pain (89.7％,26/29 cases),malnutrition (48.3％,14/29 cases),nausea and vomiting (31.0％,9/29 cases),and chest distress and dyspnea (17.2％,5/29 cases).The serum amylase level in 18 cases (62.1％) increased.The positive diagnostic rate of transabdominal ultrasound was 96.6％ (28/29 cases),and dilations of pancreatic ducts or/and intraductal stones were 82.8％ (24/29 cases).The positive rate by magnetic resonance cholangio-pancreatography (MRCP) for morphological changes in pancreas was 88.5％ (23/26 cases),and dilations of the pancreatic ducts were 80.8％ (21/26 cases).A total of 10 endoscopic retrograde cholangio-pancreatography (ERCP) procedures were performed on 6 children,and pancreatic ductal stenosis or dilations were detected in them.All the patients were treated conservatively at first,and then 7 cases of them had surgical therapy (oledochojejunostomy,choledochoduodenostomy,choledochocystectomy,etc.),aud 6 cases had stent insertion by ERCP.Conclusions The main causes of CP in children are idiopathic and anatomical anomaly,and its diagnosis is based on symptoms and imaging changes;surgical or endoscopic therapy can be used if internal therapy is not effective.

Covered in the paper are the policies and progress of the county-level public hospital reform in the province,and a summarized analysis of the self-appraisal reports and hospital reform statements submitted by the health authorities and up to 300 hospitals in 79 counties of the province.As found in the papers,the ongoing reform in Zhejiang is focused on reforming the business models in place,seeking breakthroughs from the zero mark-up policy on drug sales,in addition to such policies as reducing drug costs,adjusting medical service pricing,financial subsidies,and medical insurance payment reforms.Despite the initial success,further policy studies are needed in terms of internal management,upper and lower linkage,and personnel incentives.

Objective To explore the clinical features,efficacy and prognosis of different treatments for children with achalasia of cardia(AC).Methods In this retrospective study,the clinical features,laboratory examination and treatment of 36 children with AC who had been admitted to Department of Gastroenterology,Beijing Children's Hospital,Capital Medical University from August 2006 to September 2015 were reviewed,and the efficacy and prognosis of different treatments were compared.The symptoms of the children were graded using the AC clinical symptom score(Eckardt score),and the Eckardt score ≤ 3 scores was defined as the effective treatment.SPSS 19.0 statistical software was used to analyze the data,and P<0.05 for the difference was statistically significant.Results Thirty-six children with AC included 24 boys and 12 girls.Ages ranged from 1.4 to 15.5 years old,with a mean age of(10.0±3.4)years old.Course of disease ranged from 1 month to 9 years,with a mean course of 0.5(0.2,3.0)years.In the 36 children,33 cases(91.7％)had vomiting,23 cases(63.9％)had dysphagia,16 cases(44.4％)had weight loss,and 9 cases(25.0％)had chest pain.The effective rates of treatment in surgical treatment group and drug treatment group were 100.0％(13/13 cases)and 71.4％(5/7 cases),respectively in 3 months,and there was no significant difference between the 2 groups(P=0.111).The effective rates of treatment were 100.0％(13/13 cases)and 50.0％(3/6 cases),respectively in 6 months,and the difference was statistically significant between the 2 groups(P=0.021).Within 12 months,there was no recurrence in surgical treatment group and the effective rate was 100.0％.Children in drug treatment group had 1 case who stopped taking medicine,while the other children received surgical treatment in other hospitals due to poor drug treatment.Conclusions Drug and surgical treatment of AC both have good short-term effect,however,the medium and long-term efficacy of surgical treatment is higher than that of drug treatment in children.Symptomatic relief is more stable,and symptom is not easy to relapse for the children with surgical treatment.

Objective:To evaluate the clinical efficacy and safety of Infliximab (IFX) in pediatric Crohn′s disease (CD).Methods:The efficacy of IFX therapy in 30 patients suffering from active CD who were not completely improved with traditional medicine and enteral nutrition or had intolerance to the medicine in Beijing Children′s Hospital Affiliated to Capital Medical University from December 2014 to December 2019 were retrospectively analyzed.Pediatric Crohn′s Disease Activity Index (PCDAI), blood biochemistry indices, mucosal healing, nutritional status, and adverse reactions were compared and evaluated.Results:Thirty active CD cases, with 18 males and 12 females, were enrolled, and the average age was (8.63±4.76) years old.Three cases who didn′t complete 3 times of IFX injection and 1 case who lost to be followed up were excluded.A total of 26 cases of CD in active period were enrolled in this study on efficacy.The clinical remission and response rate of 26 cases were 61.5% and 84.6%, respectively, at 14-week of IFX therapy.The clinical remission and response rate of 21 cases were 71.4% and 85.7%, respectively, at 30-week.The clinical remission and response rate of 15 cases were 86.7% and 93.3%, respectively, at 54-week.At week 14 th, PCDAI score [(9.56±8.05) scores vs.(29.02±10.86) scores] decreased compared with before treatment ( t=7.339, P<0.05). The levels of erythrocyte sedimentation rate [(15.54±10.26) mm/1 h vs.(33.77±21.30) mm/1 h] and C-reactive protein [(4.79±12.94 ) mg/L vs.(16.33±23.43) mg/L] were obviously decreased, and the hemoglobin [(126.27±16.51) g/L vs.(110.58±16.45) g/L], hematocrit [(37.03±3.95)% vs.(33.52±4.32)%], and albumin levels [(42.30±3.03) g/L vs.(37.13±5.68) g/L] were remarkably increased compared with those before treatment ( t=3.932, 1.993, -3.398, -3.060, -4.009, all P<0.05). Height for age Z score and body mass index Z score were increased after IFX treatment, without statistically significant differences (all P>0.05). Conclusions:IFX therapy had good clinical efficacy in controlling inflammatorys and inducing clinical remission in pediatric CD.

Objective To investigate the predictive value of conventional ultrasound combined with elastography in male breast cancer.Methods One hundred and five male patients with breast tumors were included,with a total of 108 lesions(53 benign masses and 55malignant masses).Conventional ultrasound and elastography were performed on breast masses.Univariate and multivariate logistic regression were used to analyze the independent predictors of male breast cancer.The two-dimensional ultrasound model was established using statistically significant conventional ultrasound parameters.The combined model was established by combining elastic score and two-dimensional ultrasound model using logistic regression algorithm,and evaluated and compared the diagnostic performance of the two models.Results Patient age(P=0.0001),tumor blood flow(P=0.0023),orientation(P=0.0075),and elasticity score(P=0.0002)were independent predictors of male breast cancer.The area under the curve(AUC)of the combined model and the two-di-mensional ultrasound model were 0.911 and 0.855,respectively,with statistically significant difference(P=0.0311).The results of decision curve analysis(DCA)indicated that the combined model had strong practicality in clinical practice.Conclusion Elasticity score is an independent predictor of male breast cancer,and conventional ultrasound combined with elastography can improve the diagnos-tic efficacy of male breast cancer.

Objective To summarize the clinical data of the children with inflammatory bowel diseases (IBD),including Crohn's disease (CD) and ulcerative colitis (UC),and to analyze and compare the clinical features of very early-onset IBD (VEO-IBD) and late-onset IBD (LO-IBD).Methods A retrospective analysis of the clinical data of 184 cases of IBD hospitalized children diagnosed at Beijing Children's Hospital,Capital Medical University from January 2000 to December 2014.According to their ages of onset,the patients were divided into VEO-IBD group (＜6 years old) and LO-IBD group (6-16 years old);the patients with CD were divided into VEO-CD group (＜ 6 years old) and LO-CD group (6-16 years old);UC were divided into VEO-UC group (＜ 6 years old) and LO-UC group (6-16 years old).The clinical features among each group were analyzed and compared.Results A total of 184 IBD patients were included in the study,77 cases(41.8％) were VEO-IBD and 107 cases(58.2％) were LO-IBD.Comparison between VEO-CD group and LO-CD group indicated that abdominal pain was more common in LO-CD group (P ＜ 0.05),while diarrhea and hematochezia were more common in VEO-CD group (all P ＜ 0.05).In addition,comparison between VEO-UC group and LO-UC group indicated that abdominal pain was more common in LO-UC group(P ＜ 0.001),while diarrhea,fever,and oral ulcers were more common in VEO-UC group (all P ＜0.05).Both VEO-CD and LO-CD group were mainly ileocolonic[15/27 cases (55.6％),20/47 cases (42.6％)],non-narrow,non-penetrating [20/27 cases (74.1％),30/47 cases (63.8％)] and moderate-to-severe activity[23/27 cases(85.2％),37/47 cases (78.7％)].The incidence of perianal lesions in the VEO-CD group was as high as 51.9％ (14/27 cases),which was significantly higher than that in the LO-CD group (9/47 cases,19.1％) (P ＜ 0.05).Left-sided UC and severe UC were more common in VEO-UC group(all P ＜ 0.05),while pancolitis and mild UC were more common in LO-UC group (all P ＜ 0.05).The incidence of intestinal perforation in the VEO-UC group was significantly higher than that in the LO-UC group (P ＜0.05).The incidence of surgical rate,intestinal obstruction,and intestinal perforation in the LO-CD group were significantly higher than those in the LO-UC group (all P ＜ 0.05).Conclusions Compared between VEO-IBD and LO-IBD,VEO-IBD patients are more severe,with perianal lesions more common,and the incidence of intestinal perforation is higher.

Objective:To investigate the clinical characteristics of Epstein-Barr(EB)virus associated gastroenteritis, aiming to improve the diagnosis and treatment.Methods:The clinical data of 8 patients diagnosed as EB virus associated gastroenteritis in Department of Gastroenterology, Beijing Children′s Hospital were retrospectively analyzed from January 2017 to December 2021 including the clinical data, laboratory examination, endoscopic and imaging findings, medications and clinical prognosis.Results:There were eight cases with the male: female ratio 6: 2, the average age 7.46 years, and history 20 d to 3 years.Main clinical manifestations were abdominal pain(7/8), diarrhea(4/8), bloody stools(3/8), fever(2/8), hematemesis(1/8), with the high load of serum EB virus DNA in 4 cases.The endoscopic features were rough mucosa, edema, erosion, boundary clear shallow ulcer.The EB virus-encoded small RNA(EBER)was positive in situ hybridization(8/8).The frequently affected sites were upper gastrointestinal tract(3/8), small intestine(2/8)and colon(4/8).The common complications were sepsis(3/8)and mild malnutrition(3/8).All patients became better by the enteral nutrition and antiviral therapy.Conclusion:The EB virus associated gastroenteritis is rare with the serious complications, the non-specific clinical manifestations.The clinical doctors should improve the understanding of this disease in order to improve the diagnosis and therapy.Clinicians should pay more attention to the test of EB virus in serum and membrane, then carry out the accurate treatment.