Ankylosing spondylitis (AS) combined with lower cervical fracture is often categorized into unstable fracture, with a high incidence of neurological injury and a high rate of disability and morbidity. As factors such as shoulder occlusion may affect the accuracy of X-ray imaging diagnosis, it is often easily misdiagnosed at the primary diagnosis. Non-operative treatment has complications such as bone nonunion and the possibility of secondary neurological damage, while the timing, access and choice of surgical treatment are still controversial. Currently, there are no clinical practice guidelines for the treatment of AS combined with lower cervical fracture with or without dislocation. To this end, the Spinal Trauma Group of Orthopedics Branch of Chinese Medical Doctor Association organized experts to formulate Clinical guidelines for the treatment of ankylosing spondylitis combined with lower cervical fracture in adults ( version 2024) in accordance with the principles of evidence-based medicine, scientificity and practicality, in which 11 recommendations were put forward in terms of the diagnosis, imaging evaluation, typing and treatment, etc, to provide guidance for the diagnosis and treatment of AS combined with lower cervical fracture.

Ankylosing spondylitis (AS) combined with spinal fractures with thoracic and lumbar fracture as the most common type shows characteristics of unstable fracture, high incidence of nerve injury, high mortality and high disability rate. The diagnosis may be missed because it is mostly caused by low-energy injury, when spinal rigidity and osteoporosis have a great impact on the accuracy of imaging examination. At the same time, the treatment choices are controversial, with no relevant specifications. Non-operative treatments can easily lead to bone nonunion, pseudoarthrosis and delayed nerve injury, while surgeries may be failed due to internal fixation failure. At present, there are no evidence-based guidelines for the diagnosis and treatment of AS combined with thoracic and lumbar fracture. In this context, the Spinal Trauma Academic Group of Orthopedics Branch of Chinese Medical Doctor Association organized experts to formulate the Clinical guideline for the diagnosis and treatment of adult ankylosing spondylitis combined with thoracolumbar fracture ( version 2023) by following the principles of evidence-based medicine and systematically review related literatures. Ten recommendations on the diagnosis, imaging evaluation, classification and treatment of AS combined with thoracic and lumbar fracture were put forward, aiming to standardize the clinical diagnosis and treatment of such disorder.

The acute combination fractures of the atlas and axis in adults have a higher rate of neurological injury and early death compared with atlas or axial fractures alone. Currently, the diagnosis and treatment choices of acute combination fractures of the atlas and axis in adults are controversial because of the lack of standards for implementation. Non-operative treatments have a high incidence of bone nonunion and complications, while surgeries may easily lead to the injury of the vertebral artery, spinal cord and nerve root. At present, there are no evidence-based Chinese guidelines for the diagnosis and treatment of acute combination fractures of the atlas and axis in adults. To provide orthopedic surgeons with the most up-to-date and effective information in treating acute combination fractures of the atlas and axis in adults, the Spinal Trauma Group of Orthopedic Branch of Chinese Medical Doctor Association organized experts in the field of spinal trauma to develop the Evidence-based guideline for clinical diagnosis and treatment of acute combination fractures of the atlas and axis in adults ( version 2023) by referring to the "Management of acute combination fractures of the atlas and axis in adults" published by American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) in 2013 and the relevant Chinese and English literatures. Ten recommendations were made concerning the radiological diagnosis, stability judgment, treatment rules, treatment options and complications based on medical evidence, aiming to provide a reference for the diagnosis and treatment of acute combination fractures of the atlas and axis in adults.

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.

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 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.

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 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 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.

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.