Objective To evaluate the clinical significance of juxtapaillary duodenal diverticula (JPDD) in patients of acute calculous cholangitis (AC) with different severity grade.Methods A retrospective analysis was carried out for 488 AC cases of different severity from January 2011 to December 2013 who underwent duodenoscopy in Dongyang People's Hospital.Results Of the 488 patients, the JPDD was found in 2.87％, 6.15％ and 4.10％ in patients with mild, moderate and severe AC, respectively.The prevalence of JPDD in severe AC were significantly higher in the moderate and mild AC (x2 =4.486, P =0.034;x2 =14.686, P ＜ 0.001);Procalcitonin (PCT) concentrations in severe AC of JPDD were significantly higher in moderate and mild AC of JPDD (t =10.420 9, P ＜ 0.001;t =4.870 4, P ＜ 0.001).The cannulation failure rate and the amylase were significantly higher in JPDD patients compares to patients without JPDD (x2 =36.95, P ＜ 0.001;t =8.29, P ＜ 0.001).Conclusions JPDD detection rate increases with aging and seems to be associated with acute cholangitis (AC) with different severity grade and PCT concentration.JPDD predicts a higher cannulation failure rate and the amylase level after duodenoscopy.

Objective To evaluate the role of procalcitonin in patients with different severity grades of acute cholangitis (AC).Methods A retrospective study was carried out on 147 patients with different severity grades of AC who were treated from May 2012 to November 2013 at the Dongyang People's Hospital.Results Of 147 patients,the PCT concentrations were (165.63 ± 32.67) pg/ml,(348.97 ± 45.78) pg/ml,(758.91 ± 28.94) pg/ml for patients with mild,moderate and severe AC respectively.The PCT concentrations were significantly higher in patients with severe AC than those with moderate AC (P ＜ 0.05),and also in patients with moderate AC than those with mild AC (P ＜ 0.05).The top three bacteria obtained from blood culture from the different severity grades of AC showed no significant diferences (P ＞ 0.05).Conclusion Serum PCT concentrations were elevated in patients with AC and it may be used as a parameter to assess the severity of AC.

Objective To explore the risk factors of postoperative liver dysfunction in cirrhotic patients with Child-Pugh A liver function after splenorenal shunt and esophagogastric devascularization.Methods 128 Child-Pugh A cirrhotics undergoing splenorenal shunt and portal-azygous disconnection in our hospital from February,2014 to February,2016 were evaluated for risk factors of postoperative liver dysfunction.Results 22 cases (17.2％) developed postoperative liver dysfunction.By single factor analysis,age,history of upper gastrointestinal hemorrhage,ascites,serum prealbumin,serum albumin,mechanical ventilation time after surgery,postoperative serum albumin were associated with postoperative liver dysfunction.Non-conditional Logistic regression showed that age ＞ 60,serum prealbumin ＜ 170 g/L and serum albumin ＜ 30 g/L was independent risk factors for postoperative liver dysfunction.Conclusion Patients' age ＞ 60,serum prealbumin ＜ 170 g/L and serum albumin ＜ 30 g/L was independent risk factors for postoperative liver dysfunction after splenorenal shunt and portal-azygous disconnection.

Objective To evaluate the clinical significance of different localizations of juxtapaillary duodenal diverticula of patients with endoscopic retrograde cholangiopancreatography for pancreaticobiliare disease.Methods We studied patients in whom juxtapaillary duodenal diverticula was detected during endoscopic retrograde cholangiopancreatography form January 2010 to April 2016 in Department of Hepatobiliary Surgery,Dongyang People's Hospital of Zhejiang Province.The influence of juxtapaillary duodenal diverticula on the success rate of endoscopic retrograde cholangiopancreatography and the incidence of associated complications was analyzed.Measurement date were represented as ((x) ± s) comparison between the groups was analyzed by the t test.Count date were evaluated by the frequency and percentage,comparison between the groups was analyzed by the chisquare test or Fisher exact probability method.Results Juxtapaillary duodenal diverticula were present in 67 (14.11％) of the 475 patients undergoing endoscopic retrograde cholangiopancreatography for various indictions.Of the 67 patients,38 (56.72％) patients were peridiverticular papilla and 29 (43.28％) patients were intradiverticular papilla.The presence of cannulation success on first attempt was signicantly different between juxtapaillary duodenal diverticula group and non-juxtapaillary duodenal diverticula group(P =0.022),whereas the presence of c annulation success on total attempt was no-different between two groups(P =0.086).The presence of cannulation success on first attempt and total attempt was signicantly different between peridiverticular papilla group and intradiverticular papilla group(P =0.002,P =0.001).The presence of post-ERCP pancreatitis and bleed were more frequently in juxtapaillary duodenal diverticula group (P =O.023,P =0.003),but the different was non-signicantly between peridiverticular papilla group and intradiverticular papilla group (P =1.000,P =1.000).Conclusion Juxtapaillary duodenal diverticula detection rate and different location increase the difficulty of endoscopic retrograde cholangiopancreatography and maybe increase the presence of complications.

Optimizing the drug price management mechanism and improving the availability and affordability of drugs are important in deepening the medical and health reform. The price of drugs in the United States has always been higher than the world average. The price of drugs, the total expenditure on drugs and the personal burden of patients have shown an increasing trend. By exploring the causes of high drug prices in the United States, the author found that there were four main reasons for the current situation of drug prices in the United States, including the interests of enterprises, the limited competition mechanism of the US drug market, relatively insufficient market bargaining power of the US payers, and opaque mechanism of price formation.Firstly, pharmaceutical companies try to achieve their interests by raising drug prices. Secondly, the price formation mechanism of the United States drug market is affected by the price strategy of pharmaceutical companies, and government policies also indirectly affect the role of the market. Thirdly, the payers in the United States are relatively scattered, so that the market bargaining power is relatively insufficient.Fourthly, due to the numerous drug circulation links and stakeholders, the drug price formation mechanism is opaque and lacks supervision. Therefore, when strengthening drug price management in China, we should build a coordination mechanism between the government and the market on the basis of the existing basic economic system and drug management mechanism, establish the strategic purchase and negotiation position of medical insurance for drugs, enhance the transparency of drug circulation and trading, and establish a scientific pricing system. It is also important to promote drug innovation and ensure drug quality.

Objective To evaluate the value of semi-quantitative indices of 68Ga-prostate specific membrane antigen (PSMA)-11 PET/CT in differentiating malignant and benign prostate lesions.Methods From November 2017 to June 2018,30 patients (age:52-86 years) who underwent 68Ga-PSMA-11 PET/CT imaging in the Third Affiliated Hospital of Sun Yat-sen University were retrospectively analyzed,and the serum total prostate specific antigen (tPSA) and free prostate specific antigen (fPSA) were examined within 1 week before PET/CT imaging.Semi-quantitative indices of 68Ga-PSMA-11 PET/CT on prostate lesions were measured by automatic segmentation algorithm method,including PSMA-related lesion volume (VPSMA),maximum standardized uptake value (SUVmax),mean standardized uptake value (SUVmean),peak standardized uptake value (SUVpeak) and total lesion uptake value of PSMA (TLUPSMA).The indices were compared between malignant and benign prostate lesions,and the optimal cut-off values for differentiating malignant and benign prostate lesions were obtained by receiver operating characteristic (ROC) curve analysis.Results According to the pathological results,19 patients had malignant lesions and 11 were with benign diseases.The differences of tPSA,SUVmax,SUVmean SUVpeak and TLUPSMA between malignant and benign prostate lesions were statistically significant (u values:17.00-48.00,all P＜0.05),but there were no significant differences of fPSA,fPSA/tPSA and VPSMA between 2 groups (u values:64.00-99.00,all P＞0.05).The optimal cut-off value of tPSA was 18.30 μg/L for differentiating malignant and benign prostate lesions,with sensitivity of 13/17 (PSA of 2 patients were missing),specificity of 9/11 and area under curve (AUC) of 0.743.The optimal cut-off values of SUVmax,SUVmean and SUVpeak were 5.50,3.09 and 3.56,respectively,with all corresponding sensitivity of 18/19,all specificity of 9/11,and AUC of 0.902,0.907 and 0.919,respectively.The optimal cut-off value of TLUPSMA was 54.81 cm3,with sensitivity of 14/19,specificity of 9/11 and AUC of 0.804.Conclusion The semi-quantitative indices of 68Ga-PSMA-11 PET/CT are valuable for differentiating malignant and benign prostate lesions,in which SUVpeak is superior to other indices.

OBJECTIVETo evaluate the efficacy of radiofrequency ablation(RFA) combined with endoscopic resection(ER) for eradicating widespread early non-flat type esophageal squamous cell carcinoma (ESCC) and precancerous lesions.

METHODSRetrospective analysis was performed on the clinical data of 4 patients with early non-flat type ESCC and precancerous lesions in January 2010 at the Cancer Institute and Hospital, Chinese Academy of Medical Sciences. Proportion of patients with histological complete response (CR) 3 months, 12 months to 5 years after operation and adverse events were observed.

RESULTSThese 4 patients were all male, aged from 47 to 71 (mean age 62) years, including 2 of ESCC, 1 of HGIN, 1 of MGIN confirmed by pathology. USL length was 6-12 (mean 8.5) cm. Treatment area (TA) length was 8-14 (mean 10.5) cm. Three cases were 0-II a (mean length 2 cm), and 1 case 0-II c (mean length 4 cm). Lesions of 2 cases were complete cycle, and other 2 cases occupied 3/4 circumference. Four patients completed their operations successfully. Total operation time was 42-105 (mean 66.8) min, RFA time was 3-12 (mean 8.25) min, and ER time was 6-20 (10.25) min, without bleeding and perforation. The mean hospital stay was 3 days. Pathology examination showed that 2 cases were ESCC G2 (lesion length 12, 8 cm; non-flat type lesion length 3, 4 cm), 1 was HGIN (lesion length 12 cm; non-flat type lesion length 1 cm) and 1 was MGIN (lesion length 6 cm; non-flat type lesion length 2 cm). Three cases were CR 3 months, 1 to 5 years after operation. One case had HGIN at 3-month and MGIN at 1-year and 3-year during follow up, and was CR after treatment with HALO. Postoperative esophageal stenosis occurred in 4 cases. Among them, 2 cases were mild without treatment, and 2 were severe, who were relieved by endoscopic water sac dilation for 5-8 (mean 6.5) times.

CONCLUSIONRFA combined with ER is effective and safe in the treatment of patients with early non-flat esophageal squamous cell carcinoma and precancerous lesions.

Aged ; Carcinoma, Squamous Cell ; surgery ; Catheter Ablation ; Esophageal Neoplasms ; surgery ; Esophageal Stenosis ; Esophagoscopy ; Humans ; Male ; Middle Aged ; Operative Time ; Retrospective Studies ; Treatment Outcome

Objective:To determine the potential risk factors of delayed hemorrhage after endoscopic submucosal dissection (ESD) in patients with early gastric carcinomas or precancerous lesions.Methods:The clinical data of 637 patients with early gastric carcinomas (EGC) who treated with ESD in Department of Endoscopy at Cancer Hospital, Chinese Academy of Medical Sciences, from August 2013 to August 2019, were retrospectively analyzed. Univariate analysis and multivariate logistic analysis were conducted to evaluate the risk factors associated with delayed bleeding.Results:A total of 699 lesions in 637 patients, of which 696 lesions were resected enbloc, the curative resection rate was 92.1% (644/699). The pathological diagnosis after ESD showed that 46 cases were low-grade intraepithelial neoplasia, 71 were high-grade intraepithelial neoplasia, and 582 were cancer. Delayed bleeding occurred in 74 lesions, while other 625 lesions without postoperative bleeding. The incidence was 10.6%. Compared with the non-bleeding group, there were statistically significant differences in the maximum length of the lesion, the gross shape of the lesion, the control of intra operative bleeding, and the operation time in the delayed bleeding group ( P<0.05). Multivariate logistic regression analysis showed that the maximum length of the lesion and the gross shape of the lesion were independent factors of delayed bleeding after ESD. Delayed bleeding was inclined to occur in patients with lesion size ≥3.0 cm ( OR=1.958, 95% CI: 1.162-3.299) and the superficial and flat lesion ( OR=10.598, 95% CI: 1.313-85.532) after ESD. Conclusions:The maximum length of the lesion and the gross shape of the lesion are independent impact factors of delayed bleeding occurring in patients with EGC and precancerous lesions after ESD. Patients with lesion size≥3 cm, or superficial flat lesion should be paid attention after ESD operation. It needs to take timely measures to prevent the very likely bleeding in order to ensure postoperative recovery and improve the quality of life for postoperative patients.

OBJECTIVE To learn from 340B drug pricing program （short for 340B program） in the United States， and provide reference for optimizing the operation and management of designated retail pharmacies under the “dual channel” policy in China. METHODS The status quos of the implementation of out-of-hospital pharmacies under the 340B program in the United States was reviewed to summarize the experience of the management of out-of-hospital pharmacies under the program in the United States， and to propose thoughts of management and possible problems for designated retail pharmacies under the “dual channel” policy in China. RESULTS & CONCLUSIONS Out-of-hospital pharmacies under the 340B program lacked sufficient basic information and medical insurance status of patients compared to medical institutions， which easily led to duplicate discounts and drug diversion issues. Due to the separation of out-of-hospital pharmacies from the management and restrictions on the use of drugs in medical institutions， coupled with the economic incentives brought by the sale of drugs， the 340B program in the United States faced high medical expenditure and adverse selection risks for out-of-hospital pharmacies. In this regard， when China is carrying out the construction of designated retail pharmacies under the “dual channel” policy， it is necessary to clarify the selection criteria for designated retail pharmacies， enhance the financial transparency of medical institutions and designated retail pharmacies， establish a scientific prescription circulation mechanism， strengthen the review and certification of insured patients and prescriptions， and improve the supervision and management mechanism. Meanwhile， the drug sales situation of designated retail pharmacies should be reasonably incorporated into the drug use management of medical institutions， so as to achieve the availability of drugs without abuse， and effectively control costs.

Objective:To evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) for early hypopharyngeal carcinoma and precancerous lesions.Methods:Clinical data of 41 patients who received ESD for early hypopharyngeal carcinoma and precancerous lesions from August 2013 to August 2019 in the Department of Endoscopy of Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College were retrospectively analyzed. Main outcome measurements included operation completion rate, operation time, en bloc resection rate, R0 resection rate, complication rate and recurrence.Results:ESD was successfully completed in all 41 cases, with a success rate of 100.0% and a mean time of 49.1 min (ranged 10-110 min). Fifty-four lesions underwent en bloc resection, with an en bloc resection rate of 98.2% (54/55), of which 41 had negative horizontal and vertical margins, and the R0 resection rate was 74.5% (41/55). During the operation of 55 lesions, there was a small amount of blood oozing on the wound surface, and electrocoagulation with thermal biopsy forceps could successfully stop the bleeding. No perforation occurred, and 2 cases (4.3%) had delayed bleeding after ESD, and hemostasis was successful under emergency endoscopy. Postoperative endoscopy showed that 1 case (2.2%) had esophageal entrance stenosis, and the obstruction was relieved after repeated water balloon dilatation. The follow-up period ranged from 3 to 72 months, and the median time was 18 months. One case was found to have mucosal lesions in the same part of the hypopharynx and received ESD treatment again. Follow-up to October 2020, no residual lesions and recurrence were found.Conclusion:ESD is a safe and effective option for the treatment of early hypopharyngeal carcinoma and precancerous lesions, which is worthy of clinical application.