近年来,浙江省按照以人为本的整合型服务体系理念,针对医疗服务资源“头重脚轻”、医疗体系“碎片化”、大医院“高峰不高”和基层能力不强等制约卫生健康事业高质量高水平发展的短板,系统谋划整体推进,探索实践出一条具有浙江特色的整合型医疗卫生服务体系的新路径.

提供全方位全周期健康服务,需要医疗服务体系重构,近年来,浙江省通过扎实推进县域医共体建设,探索建立整合型医疗服务体系,由“强县级”向“强县域”转变. 一次集约利用 自2017年9月起,浙江省在11个地市开展了县域医共体试点建设,11个试点县(市、区)把39家县级医院和170家乡镇医疗机构优化整合成27个医共体.试点工作明确了“三统一、三统筹、三强化”的建设原则,包括统一机构设置、人员招聘、资源配置,统筹财务管理、医保支付、信息共享,强化分级诊疗、家庭医生签约和公共卫生服务.

BACKGROUND:Upper gastrointestinal hemorrhage (UGH) is a life-threatening complication in patients with cirrhosis; however, data regarding the role of UGH in acute-on-chronic liver failure (ACLF) are limited. METHODS:A prospective, observational cohort study was performed from February 2014 to Mach 2015. RESULTS:UGH was identified in 170 of 492 cirrhotic patients with acute decompensation (AD) at the time of admission. Logistic regression analysis showed that fecal occult blood test positivity was an independent risk factor for UGH in patients with or without ACLF [OR(95%CI): 8.31(4.89-14.10), p < 0.001; and 6.29 (1.48-26.76), p = 0.031]. Other independent risk factors were a history of gastrointestinal bleeding [OR(95% CI): 13.43 (7.17-25.15), p < 0.001], older age [OR(95% CI): 0.98(0.96-0.99), p = 0.003], greater INR level [OR(95% CI): 0.48(0.28-0.81), p = 0.007] in patients without ACLF. Multivariate Cox proportional hazard model analysis indicated that UGH did not increase mortality at different times in cirrhotic patients with acute decompensation. CONCLUSIONS:UGH is a frequent complication in cirrhotic patients with AD, even those with ACLF. Positive fecal occult blood tests and previous GI bleeding were shown to be associated with the risk of UGH. UGH did not significantly increase the risk of mortality in cirrhotic patients with AD or ACLF.

浙江省卫生健康委紧紧扭住城市大医院“看病难”“看病烦”和基层服务能力弱等“关键小事”,用“跑”的理念、作风和效率,治“痛点”、攻“难点”、疏“堵点”,让群众看病就医“近跑”“少跑”“不跑”,推动形成诊疗更安全、就诊更便利、沟通更有效、体验更舒适的医疗卫生服务新模式,不断提升群众就医获得感和满意度.

新一轮医改启动以来,浙江省以"双下沉、两提升"为主要抓手,着力构建城乡优质医疗资源上下贯通、均衡发展新格局.其中,"双下沉"是指医学人才下沉、城市医院下沉."两提升"是指县域医疗服务能力提升、群众满意率提升.从2013年试点开始,目前浙江省"双下沉、两提升"模式已进入长效机制建设阶段.

Malakoplakia is a rare granulomatous inflammatory condition, which is usually mistaken as malignant because prostatic malakoplakia can cause the formation of a prostatic mass and thickening of the bladder wall. The diagnosis of malakoplakia requires a histopathologic examination and is strongly supported by the presence of Michaelis-Gutmann bodies. It has been reported that malakoplakia of the prostate (prostatic malakoplakia) may be accompanied by a tumor. We report a case of malakoplakia which was initially diagnosed as prostate carcinoma but revised based on a perineal biopsy. We did not find prostate carcinoma with a 4 year follow-up.

BACKGROUND:The aim of the present study was to determine the specific role of different types of bacterial infections (BIs) on the prognosis of cirrhotic patients with acute decompensation (AD).METHODS:We performed a prospective, observational cohort study consisting of 492 cirrhotic patients with AD at our center from February 2014 to March 2015. Clinical, laboratory and survival data were collected. The relationship between BIs and mortality was analyzed.RESULTS:BIs were identified in 157 of 492 patients at the time of admission or during the hospital stay. Among the patients, 65 had community-acquired (CA) or healthcare-associated (HCA) BIs, 54 developed hospital-acquired (HA) BIs, and 38 had CA/HCA with HA BIs. Patients with CA/HCA BIs had higher 90-day, 1-year and 2-year mortality rates (29.2%, 44.6% and 52.3%, respectively) and CA/HCA BIs remained an independent risk factor for long-term mortality on multivariate analysis (1 year: hazard ratio = 1.60; 95% CI: 1.07-2.41; P = 0.023 and 2 year: hazard ratio = 1.54; 95% CI: 1.05-2.25; P = 0.026). In contrast, patients with HA BIs had a higher 28-day mortality rate than patients with CA/HCA BIs. Logistic regression analysis showed previous ascites and prior BIs within 3 months were independent risk factors for CA/HCA BIs, whereas invasive minor surgical procedures with acute-on-chronic liver failure throughout the hospital stay and high chronic liver failure-sequential organ failure assessment scores were associated with nosocomial BIs.CONCLUSIONS:CA/HCA BIs were associated with increased long-term mortality in cirrhotic patients with AD, whereas nosocomial BIs may be related to poor short-term prognosis.

Objective:To date, few studies are available on autoimmune liver disease-associated acute-on-chronic liver failure (ACLF). The aim of this study is to investigate bacterial infection and predictors of mortality in these patients. Methods:We retrospectively studied patients with autoimmune liver disease from August 2012 to August 2017. Clinical data of the patients were retrieved for analysis. Results:There were 53 ACLF patients and 53 patients without ACLF in this study. The ACLF group had a higher prevalence of complications (P < 0.05). The 28-day and 90-day mortality rates were also obviously high in patients with ACLF (38.3% and 74.5%, resp.) (P < 0.05). No predictor was significantly associated with 28-day and 90-day transplant-free mortality. In 53ACLF patients, 40 (75.5%) patients showed bacterial infection. ACLF patients with bacterial infection showed high Child-Pugh score, MELD score, CLIF-SOFA score, 28-day mortality, and 90-day mortality (P > 0.05). Moreover, C-reactive protein (CRP) using 12.15 mg/L cut-off value proved to be more accurate than procalcitonin in identifying patients with infection. Conclusions:Autoimmune liver disease-associated ACLF showed more complications and high mortality. Bacterial infection patients displayed a more severe condition than those without infection. Elevated CRP is an accurate marker for diagnosing bacterial infection in autoimmune liver disease-associated ACLF patients.

Cirrhosis always goes with profound immunity compromise, and makes those patients easily be the target of pneumonia. Cirrhotic patients with pneumonia have a dramatically increased mortality. To recognize the risk factors of mortality and to optimize stratification are critical for improving survival rate.

The paper covered the initial success of Zhejiang province in furthering its development of a basic healthcare system in alignment of social and economic growth. Such progress has been achieved by adhering to the principles of coordinated arrangement,highlighting key points and step-by-step progress. Also presented are the methods and experiences of the province in its reform and perspectives for furthering the ongoing reform.

Described in the paper is the reform made at public hospitals in Zhejiang province,with analysis of its problems and causes. Based on such,the authors proposed the following actions:to accelerate the reform of public hospitals centering on health promotion, and encourage such hospitals to shoulder the health care responsibility on behalf of the government; to proceed with hierarchical medical system and contract-based service focusing on capacity building of general practitioners; to attract private capital into building the healthcare system; and to motivate non-governmental organizations to cater to diversified healthcare needs of the people.

浙江省宁波市北仑区是我国航运枢纽宁波舟山港沿线的重要港口城市，行政区内拥有5个国家级开发区，现有常住人口90万人，是典型的县域市级经济规模的沿海强区。但2009年以前，北仑区域内只有1家二级甲等县级公立医院，开放床位400张，远不能满足群众的就医需求，导致超过45%的患者外出就医，群众对医疗卫生服务的满意度不高。浙江大学医学院附属第一医院(以下简称“浙大一院”)从2009年起，全面托管宁波市北仑区人民医院，行使行政、人事调配权和经营决策权，形成了以县级医院为支点、以“大院带县院”“县院带乡镇”“乡镇带村社”，省县乡村四级联动的医疗资源下沉模式。经过8年的合作发展，取得了一定的成效[1-2]。

2011年,浙江省政府下发《浙江省县级公立医院综合改革试点指导意见》,并在年底前实施了以药品零差率为抓手的县级公立医院综合改革,本次医改的目标是“群众得实惠、医院得发展、政府得民心”.2011年12月26日,绍兴市中心医院率先启动县级公立医院综合改革试点工作,改革内容包括探索建立医院经济运行新机制,也即破除“以药补医”机制,按照医药费用“总量控制、结构调整”的原则,调整医疗服务价格,完善收费结构;加强医院的综合管理,主要是优化门急诊环境和流程、开展预约诊疗服务、深入开展“志工”活动、推广优质护理服务、开展抗菌药物临床应用管理、实施医疗费用控制策略;开展运行机制改革试点,主要是完善院长负责制、完善医院人事和收入分配制度、增强医院运行效率.

To promote and preserve social harmony, social stability, and sustainable economic development, it is essential to carry out a study on the current development strategy for the prevention of infectious diseases in China. It is also necessary to propose a regulatory system and a prevention-and-control research strategy for infectious diseases that are adaptable to China’s specific national conditions. This paper analyzes the epidemic situation and the prevention and control of infectious diseases in China, and systematically expounds the significance of carrying out a study on the development strategy for the prevention of infectious diseases. Using international experience as a reference, this paper proposes strategic measures and suggestions for a regulatory system and for prevention-and-control research into infectious diseases in China. This study is based on China’s achievements and challenges of the current system.

浙江省现已全面取消药品加成，上调了医疗服务收费标准，积极探索补偿机制改革。但由于县级医院医疗服务能力不足，取消药品加成后，医疗服务价格调整并不能弥补药品加成取消后造成的收益下降，县级公立医院财务困境加剧，医院用于发展的再投入(人才引进和培养、设备更新、流程改造)不足[1-2]。为此，浙江省政府从2013年开始启动“双下沉、两提升”工程，通过“城市优质医疗资源下沉、医务人员下沉，提升县域内医疗卫生机构服务能力、提升群众就医满意度”[3-4]。经过4年的实践，基本实现了城市三级甲等医院优质医疗资源对26个重点县的全覆盖，以及县级医疗资源下沉实现乡镇全覆盖。浙江大学医学院附属第二医院(以下简称“浙医二院”)通过“文化植入、管理认证、学科整合”，对长兴县人民医院进行全面托管，取得了良好的效果。

2012年底,在推进公立医院综合改革的关键时期,省委、省政府作出了“双下沉、两提升”的重大工作部署,明确提出:“要让城市优质医疗资源下沉到基层,让年轻的医务人员下基层锻炼,以更好地服务百姓.”从而,浙江全面启动了医学人才、城市医院“双下沉”,促进县域医疗卫生服务能力和群众满意率“两提升”的工作,并成为了浙江综合医改的特色和亮点.

Zhejiang Provincial Committee of CPC and the provincial government considers the improvement of the county-wide medical service ability as a current important task, and makes the deployment of "sinking of medical talents, sinking of city hospitals, improvement of the county-wide medical service ability and improvement of the masses' satisfaction". In recent years, the"two sinking and two improvement" project linking the province, cities and counties made progress rapidly and achieved good results. The basic-level medical service ability has been improved, the construction of key disciplines has new development, there is new breakthrough in the cultivation of basic-level talents, and progress has been made in the all-around deepening of medical reform.

Zhejiang Province steadily carried out the pilot reform of “three-in-one” hierarchical medical, adopted the enhanced hierarchical medical system, implemented the "two sinking and two improvement" project, promoted the contracted service of responsible doctor and other main measures, and achieved good results. The allocation of medical resources tends to be reasonable, the dual referral mechanism has been preliminarily established, and the medical insurance payment policy was optimized. On the basis of the analysis on the current situation, the overall idea of continuously advancing the hierarchical medical is put forward. Joint Reformation for Public Health Services, Medical Insurance and Medical Production-Circulation shall be adhered to, the basic-level service ability shall be improved, the "Internet+ hierarchical medical " mode shall be innovated, and the propaganda and guidance shall be strengthened.

浙江省杭州市庆春路是医疗一条街.沿西湖从西向东,会经过浙江大学医学院附属儿童医院、妇产医院、第一医院、邵逸夫医院,还有杭州市的红会医院,可见这条街上的优质医疗资源有多么集中.当时浙江省委书记就提出,这么多的大医院集中在一条街上,说明我们的资源规划不合理.省委、省政府下决心改变这一不合理现状,要实现医学人才下沉、城市医院下沉、县域医疗服务能力提升、群众满意率提升,即“双下沉、两提升”.

Studied in the paper are three forms of reform attempts for public hospital governance in Zhejiang province . "board of directors" governance model ,regional medical group model ,and public hospital mandatory administration model.Based on an analysis and summary of the experiences and inspirations of public hospital governance reforms of the province in the past 20 years ,the authors raised such proposals as systematic reorganization of the governance system ,interactions between external environment and hospital organization among others in view of enabling effective incentives in public hospitals.These proposals were raised as references for public hospital reforms .