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.

Since the launch of the comprehensive public hospital reform in Zhejiang Province, the price of medical services has been adjusted, and the charging structure of medical services has been improved. Likewise, medical insurance policies have been optimized. Through several price adjustment strategies, such as the“loosen-re-strain” policy, the labor of medical personnel has been better valued, the operation of public medical institutions has been stabilized, and the allocation of medical resources has been optimized. Hence, this paper aims to measure the achievements and drawbacks of the medical service price adjustments by analyzing the various strategy. It is suggested that the comprehensive public hospital reform should be further intensified via the advancement of coordination of healthcare, medical insurance and medicine, the exploration of new procurement mechanisms for drugs and medical equipment, the establishment of dynamic adjustment mechanisms for medical service pricing, the exploration of new management mechanisms for medical services, and the strengthening of medical service supervision.

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 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 evaluate the efficacy and safety of ozone injection therapy for lumbar disc hemiation(LDH).Methods A computerized retrieval of academic papers concerning the randomized controlled trial(RCT)on ozone injection therapy for LDH from the databases of Embase,PubMed,Cochrane library and Web of science was conducted.The retrieval time period was from the establishment of the database to February 2023.The literature retrieval,screening,and data extraction were independently performed by two researchers.Cochrane bias risk assessment tool was used to assess the quality of the included literature.Stata 17.0 software was used to make meta-analysis.Results A total of 9 RCTs including 702 patients were finally included in this study.The results of meta-analysis showed that compared with radiofrequency thermocoagulation,percutaneous rotation and other treatments for LDH,the combination use of ozone injection could signifiicantly improve the effective rate based on Macnab efficacy evaluation criteria(RR=1.097,95％CI:1.038～1.159,P=0.001)and the excellent rate(RR=1.185～95％CI:1.074～1.309,P=0.001),and decrease the visual analog scale(VAS)pain score(WMD=-0.810～95％CI:-1.205～-0.414,P=0.000),and the differences in the above indexes were statistically significant.Conclusion Compared with the simple use of radiofrequency thermocoagulation,percutaneous rotation,and other treatment for LDH,the combination use of ozone injection therapy can significantly improve the effective rate and excellent rate based on Macnab efficacy evaluation criteria,decrease VAS score,with a high clinical safety.Limited by the quantity and quality of the original studies included in this study,the above conclusions need to be further verified by multi-center,large-sample and high-quality studies.

Objective To explore stigma in patients after breast modified radical mastectomy, and analyze the correlation of stigma with coping style and self-esteem.Methods From January 2015 to February 2017, totally 186 patients after breast modified radical mastectomy were selected by convenience sampling method and investigated by self-designed general demographic questionnaire, Social Impact Scale, Medical Coping Modes Questionnaire and Self-Esteem Scale. Pearson correlation analysis was used to investigate the correlation of breast cancer patients' stigma with coping style and self-esteem, and multiple linear regression was adopted to analyze the influencing factors of stigma.Results Patients' stigma after surgery was (61.04±11.99), which was at a moderate level. The stigma was negatively correlated with confrontation and self-esteem (r= -0.421, -0.574;P<0.05), and positively correlated with resignation and avoidance (r=0.564, 0.414;P<0.05). The result of multiple linear regression showed that age and resigned coping style were the influencing factors of stigma (β'=0.291,0.263;P<0.05).Conclusions The stigma of patients after breast modified radical mastectomy is at a moderate level, and should be paid attention. Nurses should encourage patients to face difficulties and challenges, and communicate with others actively. Besides, young adult patients should be taken into consideration.

Objective To clarify the role of BRAFV600E and TERT promoter mutations in cervical lymph node metastasis in papillary thyroid carcinoma.Methods The data of 432 patients with thyroid papillary carcinoma who underwent surgery from February 2017 to September 2017 at the First Affiliated Hospital of Zhengzhou University were analyzed retrospectively.The mutation of BRAFV600E and TERT promoter was detected by Sanger sequencing.The effect of BRAFV600E and TERT on cervical lymph node metastasis in patients with papillary thyroid carcinoma was analyzed by Chi-square test.Results The mutation rates of BRAFV600E and TERT promoter were 77.8％ (336/ 432) and 5.3％ (23/432) respectively in 432 papillary thyroid carcinoma patients.The probability of cervical lymph node metastasis in patients with BRAFV600E mutation was significantly higher than that in non-mutation patients (P ＜ 0.05).The probability of cervical lymph node metastasis in patients with TERT promoter mutation was significantly higher than that in non-mutated patients (P ＜ 0.05).Patients with both BRAFV600E and TERT promotermutation had a significantly higher incidence of cervical lymph node metastases than patients with the BRAFV600E mutation alone (P ＜ 0.05).Conclusions The mutations of BRAFV600E and TERT promoter are closely relevant to the occurrence of cervical lymph node metastasis in papillary thyroid carcinoma.Preoperative fine-needle aspiration cytology and postoperative routine pathological molecular diagnosis can help clinicians to develop a more rational treatment strategy,and a more accurate assessment of the risk of relapse.

Objective To investigate the effect of butylphthalide and sodium chloride injection on patients who received endovascular treatment for acute anterior circulation large vessel occlusive stroke.Methods A total of 173 patients were identified from February 2015 to December 2017 in the Department of Neurology of Jingling Hospital in this retrospective observational study.Propensity score-matching analysis was performed to balance differences in baseline characteristics between patients who received butylphthalide injection (butylphthalide group) and those who did not (control group).The modified Rankin Scale scores at 90 days were compared between the butylphthalide and control groups.Results A total of 144 patients who received endovascular treatment for acute anterior circulation large vessel occlusive stroke were finally analyzed,54 cases in the butylphthalide group and 90 cases in the control group.The proportion of good functional outcome at 90 days in the butylphthalide group was higher than that in the control group (63.0％ (34/54) vs 44.4％ (40/90);x2=4.633,P=0.031).Thirty-six pairs were matched successfully by the propensity score matching,36 patients in the butylphthalide group and 36 in the control group.There was no statistically significant difference in the 90-day functional outcome between the two groups (66.7％ (24/36) vs 44.4％ (16/36);x2=3.600,P=0.058).One hundred and fifteen patients were recanalized,47 cases in the butylphthalide group and 68 cases in the control group,and after the propensity score matching,30 pairs were analyzed.The proportion of good functional outcome at 90 days in the butylphthalide group was higher than that in the control group (73.3％ (22/30) vs 46.7％ (14/30);x2=4.444,P=0.035).Conclusion After propensity score-matching,butylphthalide and sodium chloride injection could improve 90-day functional outcome in patients with acute anterior circulation large vessel occlusive stroke and obtained recanalization by endovascular treatment while could not before propensity score-matching.