党的十九届五中全会提出,在"十四五"时期内实现优质医疗资源扩容和均衡布局.要实现这一目标,就要进一步提升一些省市依托医联体推进卫生资源下沉的改革效果,通过医生"下沉"和人力资本溢出加快基层医院的能力建设,使其诊疗能力尽快提升能级.同时,还要以有力的需求侧政策激励患者优先选择基层医院就诊,以需求侧牵引衔接供给侧诊疗能力提升,共同助力实现优质医疗资源均等化和高效利用的政策目标.

目的 探讨激励结构视角下的管理模式在口腔科中的应用价值.方法 对浙江省立同德医院口腔科2018年1月至2019年12月的90例口腔疾病患者进行研究,2018年1—12月45例为对照组,行常规管理;2019年1—12月45例为观察组,实施激励结构视角下的管理模式,两组均由同一批医生提供医疗服务(n=20),比较两组医生工作能力、服务质量、患者依从性、满意度和风险事件发生率.结果 观察组工作能力得分为(84.62±5.94)分,工作质量得分为(85.44±5.44)分,依从性为95.66％,满意度为97.78％,高于对照组的(75.02±6.06)分、(76.10±6.08)分、77.78％和80.00％,差异有统计学意义(P<0.05).结论 在口腔科管理工作中应用激励结构视角下的管理模式,可促进科室医生工作能力的提升,改善口腔科工作质量,利于提高患者依从性和满意度,存在推广价值.

目的 比较一次法和多次法根管治疗成功率、术后疼痛率和椅旁总操作时间,分析影响根管治疗疗效的因素.方法 选择2015年9月～2018年12月接受初次根管治疗的176例患者的202颗患牙,随机分配进行一次或多次治疗,记录医生椅旁总操作时间.术后随访记录疼痛情况,依据临床检查和X线片评判治疗效果.结果 一次法和多次法根管治疗的成功率分别为83.9％和85.3％,术后一周疼痛率分别为24％和14％,差异无统计学意义(P>0.05).经logistic回归分析显示牙髓状态及根尖周有无病变是与根管治疗效果有显著相关性的因素.一次法和多次法根管治疗的椅旁总操作时间分别为72.33 min和86.98 min,经多元方差分析结果显示,一次法根管治疗和单根管减少了椅旁操作时间.结论 牙髓状态和根尖周情况对初次根管治疗的成功率有着较明显的影响.一次法与多次法根管治疗效果无明显差异,但一次法根管治疗可明显缩短椅旁操作时间,值得在临床推广使用.

近10年来,虽然我国的公共医疗支出大幅增长,但看病难现象却趋于严重,这是为什么?是医疗市场的供需失衡?要满足需求就需要增加供给,将更多的资源投入到供给方.如此,医疗供需失衡就转化为卫生资源配置强度问题.但据了解,中国医疗卫生资源配置总量并未出现严重偏低情形,因此,治理看病难问题不能仅从增加投入上着手.经研究发现,我国医疗资源总量的投入是偏向大楼、床位和设备等资本积累的,而忽视向人力资源的投资.这种有偏的资源配置是理解我国看病难现象的重要突破口.

目的:探讨我国医疗市场拥堵的形成机理、效应及其主要的改革政策取向.方法:基于国际比较、制度演化和信息经济学范式进行研究.结果:我国医疗卫生资源配置总量并未偏低,拥堵是市场内部结构失衡的直接结果.在价格管制条件下,既往的医疗卫生体制改革诱导产生趋向资本密集而忽视人力资本的投资动机,“柠檬市场”式市场失灵驱动医疗从业人员和患者流向高等级医院.既有的激励结构会引致产生成本提升效应、人力资本“双退化”效应和特定要素效应.结论:不合理激励结构的解构端赖于价格体系重构和医疗人员执业自由等市场机制的运用.

OBJECTIVE To explore the causes of incision infections in patients undergoing periodontal surgery and put forward the response countermeasures so as to provide guidance for prevention of the infections .METHODS A total of 416 patients who underwent the periodontal surgery from Jan 2010 to Dec 2012 were enrolled in the study , then the clinical data were collected from the patients ,the related factors for the incision infections were analyzed , the response countermeasures were put forward ,the statistical analysis was performed with the use of SPSS16 .0 software ,and the count data were analyzed by means of the chi-square test .RESULTS The incision infections oc-curred in 35 of the 416 patients undergoing the periodontal surgery with the incidence rate of 8 .41% .The age ,op-eration duration ,complications ,visitors of surgery ,and perioperative use of antibiotics were the related factors for the incision infections in the patients undergoing the periodontal surgery (P<0 .005) .CONCLUSION There are a variety of related factors for the incision infections in the patients undergoing the periodontal surgery .It is necessa-ry to take targeted prevention measures according to the factors so as to reduce the incidence of incision infections and improve the therapeutic effect .

BACKGROUND:Osteogenesis is closely integrated with angiogenesis in bone formation and repair process, and hypoxia-inducible factor 1 alpha (HIF-1α) is considered to be the most important core transcription factor promoting angiogenesis gene regulation, which may promote the formation of blood vessels at hypoxia portion, and thus contribute to bone formation. <br> OBJECTIVE:To construct the Lenti-HIF-1α-IRES-EGFP (wild type) and Lenti-HIF-1α-IRES-EGFP (point mutant type) lentiviral eukaryotic expression vectors and to detect their impact on the osteogenic gene expression of rabbit bone marrow mesenchymal stem cells. <br> METHODS:The Lenti-HIF-1α-IRES-EGFP (wild type) and Lenti-HIF-1α-IRES-EGFP (point mutant type) lentiviral eukaryotic expression vectors were constructed according to the wild type human HIF-1αgene sequence and the determined restriction sites of human HIF-1αpoint mutant sequence. Rabbit bone marrow mesenchymal stem cells were transfected with the prepared Lenti-HIF-1α-IRES-EGFP (wild type) and Lenti-HIF-1α-IRES-EGFP (point mutant type) virus solution. <br> RESULTS AND CONCLUSION:Immunofluorescence microscopy observations indicated that the cells of Lenti-HIF-1α-IRES-EGFP (wild type) group and Lenti-HIF-1α-IRES-EGFP (point mutant type) group showed no obvious fluorescence on transfected 7 days, and two groups of cells showed a more obvious green fluorescent after transfection 14 days. Quantitative PCR analysis results showed that there were obvious HIF-1αand bonemorphogenetic protein 2 gene expressions on days 7 after transfection and the two genes stil showed highly expression levels after transfection 14 days. The two lentiviral eukaryotic expression vectors of Lenti-HIF-1α-IRES-EGFP (wild type) and Lenti-HIF-1α-IRES-EGFP (point mutant type) could be constructed according to the wild type human HIF-1αgene sequence and the determined restriction sites of human HIF-1αpoint mutant sequence;HIF-1αgene can promote the osteogenic gene expression of lentivirus-transfected rabbit bone marrow mesenchymal stem cells.

目的:探索一定浓度的低氧诱导因子-1α对兔骨髓间充质干细胞体外成骨分化的影响。方法:全血培养法培养兔BMSCs,根据不同浓度HIF-1α分为四组:1基础培养2基础培养+50ng/ml 3基础培养+100ng/ml 4基础培养+200ng/ml,三天更换一次培养基,第1天至第7天,用MTT法分析细胞增殖情况,绘制细胞生长曲线。在第7天和第14天进行碱性磷酸酶(ALP)染色及半定量检测。结果:原代兔BMSCs培养10天可见细胞克隆,放射状生长,传代后细胞生长旺盛,长梭形,铺满皿底。MTT检测显示基础培养+100ng/ml组相对其它各组细胞增殖旺盛,第14天时,碱性磷酸酶染色及半定量检测显示基础培养+100ng/ml组促进其表达。讨论:骨替代材料由于没有骨诱导性,成骨能力受到限制,细胞因子可以刺激和诱导细胞增殖、分化,近年研究发现HIF-1α可以促进VEGF的表达,进而影响BMSCs成骨分化,ALP是细胞成骨分化的标志,100ng/ml的HIF-1α组ALP活性增强。结论:100ng/ml的HIF-1α可以促进BMSCs体外分化成骨,为骨缺损修复提供了理论依据。

Biomimetic, macroporous composites of polycaprolactone (PCL) and calcium phosphate cement (CPC) were fabricated and successfully applied as bioscaffolds for in vitro culture of bone marrow stromal cells (BMSCs). These spongy composites could be obtained by simple mixing of PCL and CPC and then removal of sodium chloride particle. The properties of the composites such as morphology, porosity and mechanical modulus were characterized by scanning electron microscopy, Archimedes method and dynamic mechanical analysis. It was found that the incorporation of PCL into CPC could markedly improve the modulus of resulting PCL/CPC composites, yielding an optimal modulus at a PCL/CPC mass ratio of 70/30. These composites were examined by in vitro culture of rat BMSCs into the composites and evaluation of the cellular attachment profile, proliferation and differentiation into osteoblastic phenotypes. Further, osteoconductivity of the composites were investigated in vivo by determining the osteogenesis in nude mouse and rat. The PCL/CPC scaffold at a mass ratio of 70/30 could allow BMSCs for active attachment, proliferation, and osteogenesis in full-thickness, critical-size mandibular in a rat model. Because of improved mechanical modulus and good biocompatibility in vivo, the PCL/CPC 70/30 composite system has high potential for bone implantation.

目的:探讨Hif-1α基因转染骨髓间充质干细胞（Bone marrow mesenchymal stem cells,BMSCs）对犬种植体"骨结合"的影响。方法首先采用携带Hif-1α基因的慢病毒转染犬BMSCs,通过骨组织工程方法将转染细胞与支架材料构建组织工程化骨后植入预先制备的犬下颌骨种植体周围骨缺损,通过大体标本观察、X线片、Micro-CT等方法分析种植体"骨结合"的情况。结果:三个月后,转染细胞组的种植体周围骨缺损愈合明显好于未转染组和空白对照组,X线显示种植体周围与骨组织之间无明显低密度阴影,表明种植体与周围骨组织发生良好的骨结合,未转染组种植体周围仍存在较明显的阴影线,表明该处组织密度较低,而空白对照组骨缺损尚未完全愈合。讨论:种植体成功的首要条件须形成良好的骨结合,Hif-1α基因转染BMSCs利于成骨、成血管基因的表达,促进骨组织再生进而利于种植体"骨结合"的产生。结论:Hif-1α基因修饰BMSCs可以促进种植体/骨组织发生良好的"骨结合"。

目的:构建Hif-1α基因（野生型、点突变型）慢病毒真核表达载体,并研究其对兔BMSCs（骨髓间充质干细胞）成骨基因表达的影响。方法:根据野生型人源Hif-1α基因序列和确定酶切位点的点突变型序列及质粒抽提、PCR等制备Hif-1α基因（野生型、点突变型）慢病毒液;转染兔BMSCs后通过免疫荧光显微镜及qPCR定量分析等检测被转染细胞目的基因Hif-1α和BMP-2的表达。结果:免疫荧光显微镜下可见,转染7d后野生型组和点突变组细胞均未见明显荧光,转染14d后两组细胞均呈现较明显的绿色荧光;qPCR定量结果显示,转染7d后即有Hif-1α和BMP-2基因的显著表达并在转染14d后仍然显示较高表达水平。讨论:免疫荧光显微镜和qPCR定量分别从定性和定量两个方面确定了转染细胞目的基因表达。结论:通过野生型人源Hif-1α基因序列信息和确定酶切位点的点突变型序列信息可以构建野生型和点突变型Hif-1α基因慢病毒真核表达载体;Hif-1α基因慢病毒转染可以促进目的细胞成骨基因表达。

探讨新型聚己内酯（PCL）/磷酸钙（CPC）复合材料支架的制备方法及对骨髓基质细胞（BMSCs）的生物相容性。采用溶液共混法,利用可溶盐晶体做造孔剂,制备PCL/CPC复合材料支架,以单纯PCL和CPC支架为对照组,Q800型动态力学分析仪进行动态力学性能试验（DMA）,采用排水法测量孔隙率;灭菌后通过与犬BMSCs体外共同培养后细胞形态、生长曲线、碱性磷酸酶（ALP）染色和半定量及骨钙素（OC）半定量等方法检测细胞在支架材料上的黏附、增殖及成骨分化情况,动物体内异位成骨检测其成骨情况。结果显示,复合材料的储能模量在PCL/CPC比例为7:3时达到最大,制得的材料孔径为250～350μm,多孔支架的孔隙率为70%～80%;BMSCs在新型PCL/CPC组、CPC组支架表面分布均匀,生长增殖明显较PCL组活跃（P＜0.05）;PCL/CPC组、CPC组BMSCs成骨行为与PCL组之间有显著差异（P＜0.05）。动物体内异位成骨检测提示,4周时PCL/CPC组为13.78%±1.60%、CPC组BMSCs为15.29%±1.20%,成骨显著强于PCL组BMSCs的7.56%±2.20%（P＜0.05）,表明PCL和CPC的复合明显改善了两种材料的缺陷,获得的PCL/CPC支架具有良好的生物相容性,可与BMSCs共同构建具有成骨能力的三维立体组织工程化骨。

Objective To construct two lentiviral eukaryotic expression vectors of pEGFP-N1-HIF-1α and pEGFP-N1-muHIF-1α and identificate the gene sequences.Methods Primers were designed according to wild-type human HIF-1 α gene sequence information and determined restriction sites of human HIF-1α point mutant sequence,taking human HIF-1α and constructed HIF-1α gene mutant clone as a template for polymerase chain reaction(PCR) amplification.Then,the target gene PCR product and purpose vector were digested.Adapter-ligated fragments of the target fragment with purpose vector were transformed into DH-5α competent cells using the recombinant PCR methods.Finally,the positive clones were selected and sequenced to verify whether the sequence of insert fragments in recombinant clones was consistent with oligo sequences designed or not.Results Through recombinant clone colony PCR,enzyme digestion of the recombinant clones and plasmid cloning and sequencing,the fragment sequences inserted in recombinant clones were consistent with the designed oligo sequences.Conclusions The two lentiviral eukaryotic expression vectors of pEGFP-N1-HIF-1α and pEGFP-NI-muHIF-1α were successfully constructed and applicable for follow-up experiments on transfection of bone marrow mesenchymal stem cells.

OBJECTIVE:To investigate the effect of novel porous calcium phosphate cement (CPC) scaffoldings on attachment, proliferation and differentiation of bone marrow mesenchymal stem cells (BMSCs). METHODS:BMSCs of Beagle dogs were implanted and cultured with CPC scaffoldings in vitro, tricalcium phosphate (TCP) and poly (lactide-coglycolide) (PLGA) scaffoldings as controls. The attachment, proliferation and differentiation of BMSCs were detected through morphological characters, growth curve and the semi-quantitative detection of alkaline phosphatase (ALP) and osteocalcin (OC) activity. RESULTS:Cell morphology and growth curve illustrated that BMSCs attached to and grown better on the surface of novel porous CPC scaffoldings than that of PLGA group (P < 0.05). Semi-quantitative analysis of ALP showed that ALP expression level in BMSCs on the CPC and TCP group were significantly higher than that of the PLGA group (P < 0.05), the CPC group was slightly higher than the TCP group, but no significant difference was found between the two groups (P > 0.05). The staining and semi-quantitative analysis results of OC demonstrated that calcium deposition of the PLGA group was significantly less than the CPC and TCP group on both observation point (P < 0.05), but no significant difference between the CPC and TCP group (P > 0.05). CONCLUSION:The novel porous CPC material used in this study has good biocompatibility similar to TCP but much better than PLGA which is favorable of BMSCs adhesion, proliferation and osteogenic differentiation. The novel porous CPC material is a suitable scaffolding for BMSCs to fabricate tissue-engineered bone in vitro.

Objective To analyze the influence factors on deciduous teeth caries of preschool children and provide first-hand data for children oral hygiene.Methods Study samples were chosen from all deciduous teeth children aged 4 to 6 from Hangzhou by random cluster sampling method.The deciduous teeth caries were examined according to the survey standard of WHO and the Third National Oral Health Investigation.Data was collected by questionnaire from their parents.The data were analyzed by using of ANOVA(F-test) of Excel 2003 software package and Logistic regression of SPSS 16.0 software package.Results The deciduous teeth caries prevalence rate of 1136 children was 68.05%,mean dmft and mean dmfs was 3.61 and 5.34 respectively.The prevalence rate of deciduous teeth caries was significantly different among different groups of age,feeding pattern,sweet food intake,teeth brushing habits,regular oral examination,family income,parents'caries,parents'oral knowledge and parents'education level(P0.05),and there was no significant difference between different groups of genders and residence(urban or rural)(P0.05).Conclusion Various factors take part in the development of deciduous dental caries in preschool children,so comprehensive prevention and control measures must be adopted.

胚胎干细胞（embryonic stem cell,简称ES细胞）和成体干细胞（adult stem cell,简称AS细胞）是干细胞研究的两个主要领域。相比而言,ES细胞是全能干细胞,但存在免疫排斥和伦理学争论;而AS细

目的探讨牙龈岀血的主要病因和治疗方法。方法收集急性牙龈出血病例169例,进行检查、诊断和治疗。自行设计问卷对患者进行问卷调查和统计分析。结果由局部因素引起的急性牙龈出血113例,占66.86%,应急止血加洁治并去除局部因素后彻底止血109例,有效率为96.46%,辅助应用抗生素后所有患者急性牙龈出血症状均消失;由全身因素引起的急性牙龈出血56例,占33.14%,应急止血后彻底止血27例,有效率仅为48.21%,辅助全身因素治疗和止血药物后,共50例牙龈出血明显减轻,有效率为89.29%,但仍有6例无明显疗效,占10.71%。结论口腔局部因素是引起急性牙龈出血的主要原因,可应急止血后去除局部因素达到根治目的 ;全身因素引起的急性牙龈岀血应在口腔局部处理的基础上对因治疗,预防再次牙龈出血。

The processes of angiogenesis and bone formation are coupled both temporally and spatially during bone repair. Bone marrow-derived mesenchymal stem cells (BMSCs) have been effectively used to heal critical-size bone defects. Enhancing their ability to undergo angiogenic and osteogenic differentiation will enhance their potential use in bone regeneration. Hypoxia-inducible factor-1α (HIF-1α) has recently been identified as a major regulator of angiogenic-osteogenic coupling. In this study, we tested the hypothesis that HIF-1α gene therapy could be used to promote the repair of critical-sized bone defects. Using lentivirus-mediated delivery of wild-type (HIF) or constitutively active HIF-1α (cHIF), we found that in cultured BMSCs in vitro, HIF and cHIF significantly enhanced osteogenic and angiogenic mRNA and protein expression when compared with the LacZ group. We found that HIF-1α-overexpressing BMSCs dramatically improved the repair of critical-sized calvarial defects, including increased bone volume, bone mineral density, blood vessel number, and blood vessel area in vivo. These data confirm the essential role of HIF-1α modified BMSCs in angiogenesis and osteogenesis in vitro and in vivo.