The hierarchical medical system is to match and balance the medical service demand and supply. This article probed into main problems encountered in introducing such a system, discussed the mechanism of action for the system which was based on diseases, and proposed the driver model for a disease-based hierarchical medical system.

Objective To understand the influence of the disease-based hierarchical medical system on inpatients flow covered by the new rural cooperative medical system ( NRCMS) , and that on the funding diversion and medical costs so incurred. Methods One county was selected from the eastern, central and western regions of China respectively, where the disease-based hierarchical medical system has been in place. Policy documents of the three counties were reviewed to analyze such changes as NRCMS inpatients flow, inpatients subsidy diversion, NRCMS fund surplus rate of the current year and medical costs per hospitalization before and after the system was in place. Results A comparison with 2014 found a 1. 26%drop of the out-of-county inpatients of county W of the western region, a 2. 00% increase of township hospitals inpatients of county D in the middle region, and the same ratio of out-of-county and in-county inpatients in county F of the eastern region in 2015. Compared with 2014, the fund surplus rate of county W increased 10. 46%, and the inpatient subsidy ratio of county D decreased 2. 51% for those in out-of-county medical institutions in 2015. Thanks for the quota payment of specific diseases under global budget in county W, the inpatient medical costs per hospitalization dropped at both county and township medical institutions. Conclusions The disease-based hierarchical medical system could optimize the NRCMS inpatients distribution among various medical institutions, conducive for establishment and operation of such a system.

Objective To learn the behaviorist changes of county and township hospitals in their care of the diseases categorized in the hierarchical system before and after the system was in place. Methods Descriptive statistics and correlation analysis were used to analyze the changes of the diseases categorized in the hierarchical system which were cared at both county and township levels. Results The inpatients coverage of such diseases in county W in the western region at county and township hospitals was 44. 97%and 59. 28% respectively. These data were higher than that in county F in the eastern region, which were 18. 32% and 15. 58% respectively. As discovered in the Spearmen rank correlation analysis, the inpatients growth of diseases under the hierarchical system of counties F and W in 2015 was positively correlated to the difference between the pricing for the disease in question and the average hospitalization fee for the same disease in 2014 (r=0. 462, P<0. 001;r=0. 304, P=0. 018 ). In county W where the quota payment of specific diseases was in place, the increase of the average cost per hospitalization in 2015 was positively correlated to the above mentioned difference in 2014 and 2015(r=0. 447, P<0. 001). Conclusions The coverage of such diseases should be expanded. Changes in the pricing for such diseases will influence inpatients flow, while quota payment per disease can curb the increase of costs per hospitalization.

Objective: To analyze the effects of the catastrophic disease insurance of New Rural Cooperative Med-ical Scheme ( NRCMS) on alleviating the economic burden of patients in Beijing, and evaluate the effect of the policy implementation. Methods: Based on high, middle and low economic development levels and the implementation pro-ceedings of catastrophic disease insurance of NRCMS, this paper selects 3 districts of Beijing, from which it chooses two or three villages and towns with the highest numbers of catastrophic disease patients, in order to understand the opera-tional status quo of the catastrophic disease insurance through in-depth interviews with managers. This paper conducts questionnaire survey among all catastrophic disease patients from the sampled villages and towns, and uses 497 valid questionnaires received to understand patients' subjective feelings and collect relevant data of family income and medical expenditure of catastrophic disease patients in 2013. Then it carries out data docking with the platform of NRCMS man-agement centers and measure the economic burden of catastrophic disease patients. In this paper, quantitative and qualitative data are analyzed using statistical and thematic analyses, respectively. Results: The catastrophic disease in-surance of NRCMS has significantly played an important role in reducing the average medical expenditure of catastroph-ic disease patients and improving the actual compensation ratio in varying degrees. However, the incidence of cata-strophic health expenditures has not significantly improved. Conclusion: This paper suggests to increase deductibles and reimbursement ratios of catastrophic disease insurance in order to broaden reimbursement directory and other initiatives to improve the compensation level and focus on alleviating the economic burden of catastrophic disease patients.

Objective:To understand the patients'satisfaction on catastrophic medical insurance of New Rural Cooperative Medical Scheme ( NRCMS ) , and provide references for effective management and policy improvement. Methods:According to the principles of representative sampling, a questionnaire survey conducted. 484 patients got compensation for catastrophic insurance in 2013 were surveyed, and information of medical costs was analyzed. Re-sults:The average medical cost accounts for 84. 57% of total household expenditure. Mandatory medical expenditure is still high and economic burden of diseases is heavy. This policy has increased the compensation rate, and the actu-al compensation rate increases 4. 79% in three districts. The average score of patients' attitude toward catastrophic medical insurance is (3.95±1.05) points, 88. 43% of patients continue to participate in medical insurance. Con-clusions and suggestions:Patients' satisfaction on catastrophic medical insurance of NRCMS is high. It is suggested that the existing financing modes should maintain stability in the short term, and the compensatory rate should be im-proved reasonably.

Background and purpose:Ovarian cancer-associated ifbroblasts (CAF) are known to promote epithelial malignancy. The chemoattractant cytokine growth-regulated oncogene alpha (Gro-α) secreted from CAF has been reported to mediate the stroma-epithelia interaction in tumor microenvironment, leading to the development of epithelial ovarian cancer, however, the detailed mechanism is unknown.This study was to determine whether Gro-αcould promote ovarian tumorigenesis through activating NF-кB nuclear translocation and VEGF expression in stromal ifbroblasts. Methods:ELISA was used to measure the levels of Gro-αin two cancer-associated ifbroblasts (CAF) and normal ifbroblasts (NF) isolated from high-grade serous ovarian cancer or normal ovarian tissues. CAF conditioned medium (CM) or Gro-αwas used to treat NF, while PS1145, the inhibitor of NF-кB, was used as control. NF-кB subunit p65 and vascular endothelial growth factor (VEGF) were detected by Western blot in cells after treatment. Xenograft tumors from nude mice were generated by injection of CAF, NF, or OVCA429 alone or OVCA429 mixed with CAF or NF, and by injection of OVCA429 mixed with NF cells that were treated with or without CAF-CM or Gro-α, or with NF cells that were treated with CAF-CM or Gro-αplus PS1145. The tumor growth curve was measured and the blood vessel density in xenograft tumor tissues was examined by histopathological analysis. Results:The levels of Gro-αwere 5-6 folds higher in CAF than in NF. Treatment of NF with CAF-CM or Gro-αstimulated the nuclear translocation of NF-кB subunit p65, and the expression of VEGF, but suppressed the expression of thrombospondin 1, the anti-angiogenesis factor, compared with control cells. However, treatment of NF with the NF-кB inhibitor PS1145 reversed these results. The animal assay revealed that CAF stimulated tumor growth stronger than NF, and NF treated with CAF-CM or Gro-α, but not along with PS1145, enhanced xenograft tumor growth through promoting angiogenesis. Conclusion:Ovarian CAF promotes the nuclear translocation of NF-кB and the expression of VEGF through Gro-αautocrine in tumor microenvironment to facilitate angiogenesis and ovarian cancer development.

Background and purpose: Cancer-associated fibroblasts (CAFs) are known to promote the invasion and metastasis of epithelial cancers. The cytokine IL-6 may mediate the interaction between stromal cells and epithelia in tumor microenvironment to facilitate the invasiveness and metastasis of cancer, however, such mechanism has not been fully covered yet.Methods:We used cervical cancer cell line HeLa as a model for this study. ELISA was used to measure the levels of IL-6 in CAFs and normal ifbroblasts (NFs) isolated from squamous cervical cancer or normal cervical tissues. CAFs conditioned medium or IL-6 was used to treat cervical cancer HeLa cell line. The epithelial-mesenchymal transition (EMT) markers such as N-Cadherin and Vimentin were detected by Western blot in cells before and after treatment. Scratches and transwell chambers were used to test the abilities of cell migration and invasion. Results:The levels of IL-6 were 4-5 folds higher in CAFs than in NFs. Treatment of HeLa cells with CAF conditioned medium or IL-6 upregulated N-Cadherin and Vimentin, but down-regulated E-Cadherin and cytokeratin, compared with control cells, indicating that IL-6 may stimulate HeLa cells to EMT. Further study found that Snail 1, the featured transcription factor for stem cells, was increased along with the enhanced phosphorylation of STAT3. Meanwhile, the migration and invasion of HeLa cells treated with IL-6 or CAF conditioned medium were markedly increased. Conclusion:CAF induces the EMT of cervical epithelial cancer cells through IL-6/STAT3/Snail pathway, which thereby promotes the invasiveness and metastasis cervical epithelial cancer.

Objective To evaluate the efficacy and safety of sorafenib in the treatment of Chi-nese patients with metastatic renal cell carcinoma. Methods This muhicenter phase Ⅱ clinical trial was performed from May 2006 to December 2006. Sixty-two patients with metastatic renal cell carci-noma not suitable for curative treatment were enrolled. All patients received oral sorafenib as single a-gent at the dose of 400 mg twice a day until disease progression or intolerable toxicities occurred. Re-salts Partial responses were recorded as best response in 11 patients, while complete remission was found in 1 patient and stable diseases were found in another 35 patients. According to the intents-to-treatment population, the overall response rate was 19.4% (12/62), and the disease control rate was 77.4%(48/62). The median progression free survival time was 9.6 months with 1-year progression-free survival rate of 41.9%. However, the median survival time had not reached due to the short fol-low-up. The most frequent adverse events included alopecia (66.1%), diarrhea (62.9%), hand-foot syndrome (58.1%), anorexia (40.3%), rash(37.1%), fatigue (37.1%), hypertension (35.5%), hoarseness(32.3%), joint pain (25.8%), hypophosphatemia (21.0%), fever (19.4%), nausea (19.4%), abnormal transeaminase( 11.3% ), elevated total bilirubicin( 16.1% ), leucopenia( 12.9% ), bleeding under nail(16.1%), and gum bleeding(11.3%). Grade 3 adverse events included hand-foot syndrome (16.1%), hypertension (12.9%), diarrhea(6.5%), hypophosphatemia (4.8%), joint pain (3.2%), and leucopenia(3.2%). Conclusions Sorafenib has prominent anti-tumor activity in Chi-nese metastatic renal cell cancer patients with most adverse events being grade 1 or 2. More attention should be paid to hypertension and cardio-cerebral vascular events during the application of sorafenib.

To investigate the value of liver stiffness measurement (LSM) in the diagnosis of liver fibrosis degree in HBeAg-positive patients with chronic HBV infection. Methods A retrospective analysis was performed for the clinical data of 330 HBeAg-positive patients with chronic HBV infection who were hospitalized in Affiliated Hospital of Yan’an University from October 2013 to August 2018 and underwent liver biopsy, and according to liver pathological results, these patients were divided into mild liver fibrosis group (F0-F1) and significant liver fibrosis group (F2-F4). The t-test or the Mann-Whitney U test was used for comparison of continuous data between two groups, and the chi-square test was used for comparison of categorical data between two groups. Univariate and multivariate analyses were performed to screen out the indices for the diagnosis of significant liver fibrosis, and the receiver operating characteristic (ROC) curve was plotted for these indices to evaluate their value in the diagnosis of significant liver fibrosis. Results Of all 330 patients, 245 had mild liver fibrosis and 85 had significant liver fibrosis. There were significant differences between the two groups in HBV DNA, HBsAg, HBeAg, HBcAb, alanine aminotransferase, aspartate aminotransferase, total bilirubin, and LSM (all P＜0.05). The multivariate analysis showed that HBsAg and LSM were independent risk factors for significant liver fibrosis (both P＜0.05). The ROC curve analysis showed that only LSM had a diagnostic value, with an area under the ROC curve of 0.744 (95% confidence interval: 0.680-0.808). At the optimal cut-off value of 6.15 kPa, LSM had a sensitivity of 62.4%, a specificity of 76.3%, an accuracy of 72.1%, a positive predictive value of 72.5%, and a negative predictive value of 67.0% in predicting significant liver fibrosis. ConclusionLSM has a good value in predicting significant liver fibrosis in HBeAg-positive patients with chronic HBV infection.