OBJECTIVE To analyze the deep-seated impeding factors in the implementation process of the policy integrating retail pharmacies into the outpatient pooling system， and explore practical paths to improve policy implementation efficiency. METHODS Based on Smith’s policy implementation process model， an analytical framework was constructed. Selecting Hunan province as a typical sample， this study combined policy text analysis and semi-structured interviews to conduct an in-depth interpretation of relevant policy documents and interviewed a total of 42 key stakeholders from multiple parties， including medical insurance administrative departments， designated medical institutions， retail pharmacies， and insured persons， and the interview texts were analyzed. RESULTS & CONCLUSIONS The study indicated that the effective implementation of this policy faces four dimensions of impediments： first， the policy itself suffered from systemic design problems and insufficient coordination， leading to source-based constraints； second， there was a lack of effective synergy mechanisms among implementing agencies， resulting in fragmented service and supervision capabilities， and their behaviors were distorted by interest-driven motives； third， there were cognitive biases regarding the policy among the target group， and their behaviors were distorted by interest-driven motives； fourth， environmental factors such as pressure on medical insurance funds and traditional medical-seeking concepts overlapped to restrict the space for policy implementation. Therefore， the following optimization strategies are proposed： strengthening top-level design to eliminate rule ambiguity and implementation deviation； improving multi-party synergy mechanisms to enhance policy operational efficiency； deepening policy interpretation and interest coordination to guide rational behavior among the target group； and breaking environmental barriers to build an external ecosystem adaptable to policy development， thereby promoting the high quality development of incorporating retail pharmacies into the outpatient pooling system.

[摘 要] 目的：基于噬菌体展示靶向锚定蛋白文库，以人白细胞抗原G（HLA-G）为靶点筛选锚定序列作为HLA-G结合蛋白（HGBP）并评价其功能。方法：利用TCGA、GTEx等数据库分析肿瘤组织中HLA-G表达与临床预后和免疫浸润的相关性。利用噬菌体展示靶向锚定蛋白文库对HLA-G胞外片段进行生物淘选并随机挑取单克隆进行测序。通过ELISA、免疫荧光染色鉴定优势噬菌体克隆的功能。利用原核体系生产纯化HGBP，通过ELISA、表面等离子共振（SPR）、免疫荧光染色法评价其亲和力及肿瘤特异性结合能力。结果：生物信息学分析发现，HLA-G在肿瘤组织中普遍呈高表达，其与临床总生存期、免疫细胞浸润水平具有相关性（P < 0.05）。5轮噬菌体文库筛选后获得优势克隆，ELISA及免疫荧光染色结果均显示，优势噬菌体对HLA-G阳性细胞结合显著强于阴性细胞（P < 0.05, P < 0.001）。经纯化生产的HGBP与HLA-G之间的亲和力可达17 nmol/L，ELISA结果显示，HGBP与HLA-G分子的结合显著（P < 0.05）；免疫荧光染色结果表明，HGBP能与HLA-G阳性细胞特异性结合（P < 0.01）。结论：经噬菌体展示文库筛选出的HGBP对HLA-G具有高亲和力，可特异性结合肿瘤细胞表达的HLA-G。

Objective To evaluate the application value of superb microvascular imaging(SMI)in pre-dicting ovarian cancer staging.Methods One hundred and thirty-six patients with ovarian cancer who under-went surgical treatment in our hospital from March 2019 to May 2024 were enrolled.Transvaginal,transab-dominal low-frequency,and transabdominal high-frequency two-dimensional grayscale imaging,Color Doppler Flow Imaging(CDFI),and SMI were performed before surgery for staging prediction.Taking surgical-patho-logical staging as the gold standard,the sensitivity,specificity,and accuracy of the combined application of transvaginal SMI,transabdominal low-frequency SMI,and transabdominal high-frequency SMI for predicting ovarian cancer staging were calculated.The receiver operating characteristic(ROC)curve was established,the area under the ROC curve(AUC)was calculated,and the diagnostic efficacy of SMI for predicting ovarian cancer staging was determined.Results The combined application of transvaginal SMI,transabdominal low-frequency SMI,and transabdominal high-frequency SMI for predicting ovarian cancer staging showed that sen-sitivity was 89.35%,92.36%,81.65%,and 83.21%for stages Ⅰ,Ⅱ,Ⅲ,Ⅳ,respectively;specificity was 86.93%,84.29%,83.39%,and 82.88%;accuracy was 92.50%,94.38%,80.15%,and 84.96%;and AUC was 0.799,0.760,0.695,and 0.727.Conclusion SMI has a high application value in predicting the stage of ovarian cancer,especially for stage Ⅰ and stage Ⅱ ovarian cancer.

To investigate the evaluation and management of gastrointestinal fistula after upper gastrointestinal tunnel endoscopic surgery, a retrospective analysis was performed on 15 patients with gastrointestinal fistula after upper gastrointestinal tunnel endoscopic surgery, who were treated at the Endoscopy Center of Zhongshan Hospital, Fudan University from January 2012 to October 2022. All patients were treated successfully after comprehensive treatment. Three patients received metal clipping and gastric tube drainage; 10 patients received gastric tube drainage combined with jejunal nutritional tube placement, and 7 of them had gastric tube directly put into the fistula cavity; 2 patients received covered esophageal stent placement combined with jejunal nutritional tube placement. Five patients received wound tissue glue spraying; 2 patients underwent purse-string suture with nylon loops and metal clips after reduced fistula burned by hot biopsy forcep or argon plasma coagulation. The gastrointestinal fistula after tunnel endoscopic surgery is a complex postoperative complication, which needs early detection, careful evaluation and comprehensive treatment.

To investigate the feasibility and safety of endoscopic trans-gastric cholecystolithotomy(ETGC) combined with endoscopic retrograde cholangiopancreatography (ERCP) for cholecystolithiasis and choledocholithiasis. Data of patients with cholecystolithiasis and choledocholithiasis who underwent ETGC after ERCP in Zhongshan Hospital Affiliated to Fudan University from November 2018 to April 2019 were analyzed. Six patients with cholecystolithiasis and choledocholithiasis, 4 males and 2 females, were included in this study.The interval between ERCP and ETGC ranged from 1 to 77 days (median 5 days). All the 6 patients successfully completed ETGC after ERCP, with a surgical success rate of 100%. All the patients had multiple cholecystolithiasis and one patient was complicated with gallbladder polyps.The ETGC operation time was 22-100 min (median 65 min), and the length of hospital stay was 3-9 d (median 6.5 d). Two patients had dull pain in the upper abdomen and increased body temperature after surgery. Abdominal ultrasound in one patient suggested local effusion in the right upper abdomen.Both patients improved after conservative treatment.None of the patients had cholecystitis and cholangitis related symptoms such as right upper abdominal pain or fever during postoperative follow-up, and the follow-up rate was 100%with median follow-up time of 18 month.All the 6 patients underwent abdominal ultrasound examination after surgery. No recurrence occurred in 5 patients. One of the patients showed cholesterol crystals in the gallbladder wall and bile mud deposition.ETGC combined with ERCP is safe and feasible for cholecystolithiasis and choledocholithiasis.

Objective:To evaluate the safety, efficacy and long-term survival of endoscopic submucosal dissection (ESD) for colorectal precancerous lesions and early cancer in the elderly over 80 years old.Methods:Clinical data of colorectal precancerous lesions and early cancer treated with ESD from January 2007 to December 2014 at Endoscopy Center of Zhongshan Hospital, Fudan University were retrospectively analyzed. A total of 721 patients with 778 lesions were included in this study. These patients were stratified by age: the super-elderly group (≥80 years old, 55 patients, 7.6%) and the non-super-elderly group (<80 years old, 666 patients, 92.4%). The outcomes of ESD, complication incidences, pathological characteristics, and long-term survival were compared between the two groups.Results:Except that the incidence of chronic concomitant diseases in the super-elderly group was significantly higher than that in the non-super-elderly group [54.5% (30/55) VS 31.5% (210/666), P<0.001], other baseline characteristics were not significantly different ( P>0.05). There were no significant differences in the complete resection rate [93.1%(54/58) VS 95.3%(686/720)], the R0 resection rate [89.7% (52/58) VS 93.2% (671/720)], the curative resection rate [84.5% (49/58) VS 90.3% (650/720)], the complication incidence [5.5% (3/55) VS 2.7%(18/666)], or the median hospitalization (2.98 days VS 2.54 days) between the two groups (all P>0.05). The three-year overall survival rates of the super-elderly group and non-super-elderly group were 95.8% and 98.0%, respectively, and the five-year overall survival rates were 85.1% and 97.4%, respectively. Conclusion:Colorectal ESD is safe and effective for elderly patients (age ≥80 years old) despite a significantly higher incidence of chronic concomitant diseases than that in the non-super-elderly patients.

Objective:To explore the effect of Gubi Decoction on serum related inflammatory factors and PI3K/Akt/mTOR signaling pathway in osteoarthritis model rats. Methods:Seventy SPF rats were randomly divided into the blank group, sham operation group, Glucosamine sulfate group, and the low, medium and high dose Gubi Decoction groups. Except the blank group and sham operation group, knee osteoarthritis animal models were prepared by the modified Hulth method in each group. On the 28th day after successful model preparation, the high, medium and low dose Gubi Decoction groups were given Gubi Decoction 24, 12 and 6 g/kg by gavage respectively; glucosamine sulfate group was given glucosamine sulfate tablet suspension 3 g/L by gavage, once a day for 28 days. The levels of TNF-α and IL-1β in serum were detected by ELISA. The gene expressions of PI3K, Akt and mTOR in cartilage tissue were detected by Real-PCR. The protein expressions of PI3K, Akt, p-PI3K, p-Akt and mTOR were detected by Western blot. Results:Compared with the model group, the knee joint diameter[(11.17 ± 1.81) mm, (11.60 ± 1.38) mm, (10.80 ± 1.17) mm vs. (12.57 ± 0.98) mm] of the rats in the glucosamine sulfate group and the medium and high dose Gubi Decoction groups significantly decreased ( P<0.05). The content of TNF-α [(111.43 ± 21.98) ng/L, (53.42 ± 13.25) ng/L vs. (157.89 ± 23.60) ng/L], IL-1β [(67.50 ± 18.44) ng/L, (48.22 ± 9.63) ng/L vs. (96.11 ± 14.85) ng/L] in the medium and high dose Gubi Decoction groups significantly decreased ( P<0.05), and the expression of PI3K (1.87 ± 0.17, 1.24 ± 0.49 vs. 2.19 ± 0.47), Akt (1.50 ± 0.51, 1.10 ± 0.32 vs. 2.68 ± 0.63), and mTOR (1.32 ± 0.54, 1.10 ± 0.33 vs. 2.94 ± 0.55) mRNA in the medium and high dose Gubi Decoction groups significantly decreased ( P<0.05). The expression of PI3K, Akt, p-PI3K, p-Akt in the low, medium and high dose Gubi Decoction groups significantly decreased ( P<0.05), and the expression of mTOR in the medium dose Gubi Decoction group significantly decreased ( P<0.05). Conclusion:Gubi Decoction can significantly reduce the level of inflammatory factors in the serum of osteoarthritis model rats, and its anti-inflammatory and analgesic effects may be related to PI3K/Akt/mTOR signaling pathway.

To study the clinical effect of non-ampullary duodenal mucosal lesions treated by endoscopic resection. A retrospective analysis was performed on the data of 58 cases of duodenal non-ampullary mucosal lesions treated by endoscopic resection from January 2016 to June 2019 from 3 hospitals. Among 58 cases, 27 lesions (46.6%) were located in the duodenal bulb and 31 (53.4%) in the duodenal descending part (including the ball-drop boundary). Forty-six patients (79.3%) received endoscopic mucosal resection, 7 (12.1%) received endoscopic submucosal dissection and 5 (8.6%) received pre-cut endoscopic mucosal resection. Few postoperative complications were found except for 1 case of intraoperative bleeding, 1 case of delayed bleeding 2 days after surgery, 1 case of lesion residual and 2 cases of postoperative abdominal pain. No perforation occurred. Endoscopic treatment of non-ampullary duodenal mucosal lesions is safe and effective.

Objective:To explore the necessity and safety of selective endoscopy to detect gastrointestinal (GI) malignancy during the outbreak of coronavirus disease 2019 (COVID-19).Methods:A retrospective cohort study was carried out to analyze the clinical data of selective endoscopy performed at the Endoscopic Center, Zhongshan Hospital of Fudan University from February 20 to March 6, 2020. Clinical data included epidemiological questionnaire, chief complaints, endoscopic findings and biopsy pathology results, etc. All medical staff had blood test for IgM/IgG antibodies of COVID-19. Patients and their families were followed up by phone to determine whether they were infected with COVID-19. Meanwhile, the clinical data of selective endoscopy during the same period from February 20 to March 6, 2019 were collected as the control group to compare the overall results of endoscopy examinations during the epidemic and the detection rate of GI malignancy.Results:A total of 911 patients underwent endoscopy in the epidemic period group, and a total of 5746 cases in the control group, which was 6.3 times over the epidemic period group. In the epidemic period group, 544 cases received gastroscopy and 367 cases received colonoscopy, while 3433 cases received gastroscopy and 2313 cases received colonoscopy in the control group, which were both 6.3 times of epidemic period group. Gastroscopy revealed that 39 patients (7.2%) were diagnosed with upper GI malignancies in the epidemic period group and 77 patients (2.2%) in the control group with significant difference (χ 2=40.243, P<0.001). The detection rate of gastric cancer in these two groups was 3.3% ( n=18) and 1.7% ( n=59) respectively with significant difference (χ 2=6.254, P=0.012). The detection rate of esophageal cancer was 3.7% ( n=20) and 0.5% ( n=18) respectively with significant difference (χ 2=49.303, P<0.001). Colonoscopy revealed that colorectal cancer was found in 32 cases (8.7%) of the epidemic period group and 88 cases (3.8%) of the control group with significant difference (χ 2=17.888, P<0.001). During the epidemic period, no infection of medical staff was found through the blood test of IgM/IgG antibodies on COVID-19. No patient and family members were infected with COVID-19 by phone follow-up. Conclusion:Compared with the same period in 2019, the number of selective endoscopy decreases sharply during the epidemic period, while the detection rate of various GI malignant tumors increases significantly, which indicates that patients with high-risk symptoms of GI malignancies should still receive endoscopy as soon as possible. Provided strict adherence to the epidemic prevention standards formulated by the state and professional societies, it is necessary to carry out clinical diagnosis and treatment as soon as possible.

Objective:To explore the necessity and safety of selective endoscopy to detect gastrointestinal (GI) malignancy during the outbreak of coronavirus disease 2019 (COVID-19).Methods:A retrospective cohort study was carried out to analyze the clinical data of selective endoscopy performed at the Endoscopic Center, Zhongshan Hospital of Fudan University from February 20 to March 6, 2020. Clinical data included epidemiological questionnaire, chief complaints, endoscopic findings and biopsy pathology results, etc. All medical staff had blood test for IgM/IgG antibodies of COVID-19. Patients and their families were followed up by phone to determine whether they were infected with COVID-19. Meanwhile, the clinical data of selective endoscopy during the same period from February 20 to March 6, 2019 were collected as the control group to compare the overall results of endoscopy examinations during the epidemic and the detection rate of GI malignancy.Results:A total of 911 patients underwent endoscopy in the epidemic period group, and a total of 5746 cases in the control group, which was 6.3 times over the epidemic period group. In the epidemic period group, 544 cases received gastroscopy and 367 cases received colonoscopy, while 3433 cases received gastroscopy and 2313 cases received colonoscopy in the control group, which were both 6.3 times of epidemic period group. Gastroscopy revealed that 39 patients (7.2%) were diagnosed with upper GI malignancies in the epidemic period group and 77 patients (2.2%) in the control group with significant difference (χ 2=40.243, P<0.001). The detection rate of gastric cancer in these two groups was 3.3% ( n=18) and 1.7% ( n=59) respectively with significant difference (χ 2=6.254, P=0.012). The detection rate of esophageal cancer was 3.7% ( n=20) and 0.5% ( n=18) respectively with significant difference (χ 2=49.303, P<0.001). Colonoscopy revealed that colorectal cancer was found in 32 cases (8.7%) of the epidemic period group and 88 cases (3.8%) of the control group with significant difference (χ 2=17.888, P<0.001). During the epidemic period, no infection of medical staff was found through the blood test of IgM/IgG antibodies on COVID-19. No patient and family members were infected with COVID-19 by phone follow-up. Conclusion:Compared with the same period in 2019, the number of selective endoscopy decreases sharply during the epidemic period, while the detection rate of various GI malignant tumors increases significantly, which indicates that patients with high-risk symptoms of GI malignancies should still receive endoscopy as soon as possible. Provided strict adherence to the epidemic prevention standards formulated by the state and professional societies, it is necessary to carry out clinical diagnosis and treatment as soon as possible.