Objective To investigate the relationship between the expression of Toll-like receptor 4 (TLR4) on mononuclear cells in peripheral blood and changes of serum vitamin D level in children with bronchiolitis.Methods The children who were diagnosed as bronchiolitis and received treatment in the Second Affiliated Hospital of Harbin Medical University from October 2013 to January 2014 were chosen as the pre-treatment group,and then divided them into moderate group and severe group according to the clinical symptoms,20 cases for each group.Then the cases in pre-treatment group who recovered after treatment were recruited as the after-treatment group,and the children who were healthy and medical examination in the Second Affiliated Hospital of Harbin Medical University in the same period were recruited as the healthy control group.The expressions of TLR4 on CD14 labeled mononuclear cells in the periphera were measured by flow cytometry.The level of 25 (OH) D in serum was detected by enzyme linked immunosorbent assay (ELISA).Results (1) The expression level in children with bronchiolitis of TLR4:the mode-rate group [(18.98 ±2.29)％] and severe group [(30.13 ±2.13)％] increased significantly (P ＜0.05) compared with control group [(1.17 ± 0.57) ％].And the expression level of moderate group [(2.02 ± 0.48) ％] and severe group [(11.43 ± 1.52) ％] decreased significantly after treatment (P ＜0.05).(2) Serum vitamin D level in children with bronchiolitis of the moderate group[(17.16 ± 3.34) μg/L] and severe group [(6.56 ± 2.28) μg/L] were lower than healthy control group [(53.69 ± 20.18) μg/L] before treatment (P ＜ 0.05),especially the severe group [(6.56 ±2.28) μg/L].The level of moderate group [(9.59 ± 2.31) μg/L] and severe group [(4.70 ± 0.67) μg/L] became lower after treatment (P ＜ 0.05).(3) Both severe group (r =-0.491,P ＜ 0.05) before treatment and moderate group (r =-0.436,P ＜ 0.05) after treatment showed negative correlation between TLR4 on mononuclear cells in peripheral blood and serum 25 (OH)D level in children with bronchiolitis.And no correlation was found among healthy control group,moderate group before treatment and severe group after treatment (P ＞ 0.05).Conclusions The conditions of children with bronchiolitis was positively correlated with the expression level of TLR4,and negatively correlated with the vitamin D level.The serum 25 (OH) D decreased steadily during the treatment.The expression of TLR4 in monocytes has a certain correlation with the level of vitamin D in children with bronchiolitis.

Reform of public hospitals is key to the healthcare system reform.This article introduced how Hangzhou implemented such a reform of " Hangzhou characteristics" by referring to the hospital reform framework of the World Bank, and the theoretical achievements and practical experiences of domestic public hospitals′reform.Led by the service concept of " Medicine has its limitations but we have the courage to overcome, service is boundaryless and we must pursue excellence" , Hangzhou has established a public hospital value system of " reorientation to public welfare".The smart healthcare system serves as a focus, to support the delicacy management of the hospitals. The construction of hierarchical medical care system functions as the pillar, to support the coordinated development of hospitals, primary health institutions and public health institutions.This way a public hospital comprehensive reform mode is established featuring " one value system, 2 levels of organization structure, 6 mechanisms, and 19 supporting measures ". Its experiences may serve as reference to streamline hospital internal operation and external cooperation mechanism.

Based on a sufficient analysis of the theoretical framework of " transformation learning collaboration" ( TLC ) and " people-centered and integrated health care " ( PCIC ) mode, this article introduced the main practices and achievements of " Hangzhou characteristics" countywide medical alliances, centering on TLC mode.Hangzhou takes the countywide medical alliance construction as a pilot, refers to the TLC model, and takes growth-oriented collaboration as the guidance, to promote responsibility sharing, benefit sharing, service integration and management collaboration.Guided by the PCIC model proposed by the World Health Organization, the city has established an integrated service model of hierarchical medical system-prevention-rehabilitation-aging care.The countywide medical alliance system framework features " 5 fields, unified leadership, unified culture, 6 supports, 3 tasks and TLC teams " , which may provide references for the coordinated and integrated development of such alliances.

Digital healthcare empowers optimization of medical services.This article introduced the practices and achievements of Hangzhou in the following aspects: the construction of a hierarchical medical system guided by " people-oriented integrated service" ; development of the five digital platforms, namely regional health information platform, integrated medical care platform, remote consultation platform, intelligent supervision platform and doctor-patient remote interaction platform; development of " Smart Medicine" to promote institutional cooperation, service integration, management coordination, quality improvement and doctor-patient interaction.The paper also analyzed the supporting role of digital healthcare construction in promoting the hierarchical medical system, and put forward corresponding countermeasures and suggestions.

Higher service efficiency and better medical experience are main goals of the healthcare system reform.The article explained the logical framework, main actions, initial results of the " one visit for all" reform, which aims at promoting the efficiency of medical services and management in Hangzhou.Policy suggestions are raised, namely involving more people into the governance mechanism, collaboratively optimizing the working process of medical staff, improving the information security mechanism, and perfecting the effectiveness evaluation system.These measures are designed to accelerate the construction of modern hospital management system, and to build a scientific and orderly hierarchical medical system.

Objective:To establish the normal values of water-perfused high resolution esophageal manometry (HREM)(GAP-36A) at resting period, water swallowing, semisolid swallowing and solid swallowing in Chinese population.Methods:From September 1, 2019 to June 30, 2020, 91 healthy volunteers receiving water-perfused HREM (GAP-36A) at resting period, water swallowing, semisolid swallowing and solid swallowing were selected from 9 hospitals (Union Hospital, Tongji Medical College, Huazhong University of Science and Technology; the First Affiliated Hospital of Dalian Medical University; the Second Hospital of Hebei Medical University; the Second Affiliated Hospital, Naval Medical University; the First Affiliated Hospital, Sun Yat-sen University; the First Affiliated Hospital, University of Science and Technology of China; Aviation General Hospital of China Medical University; the Affiliated Hospital of Medical School of Nanjing University and the First People′s Hospital of Yichang). Parameters included the position of the upper and lower edges of the upper esophageal sphincter (UES) and lower esophageal sphincter (LES), the length of the LES and UES, the position of the pressure inversion point (PIP), the resting pressure of UES and LES and swallow-related parameters such as the distal contraction integral (DCI), 4 s integrated relaxation pressure (IRP), distal latency (DL) and UES residual pressure. One-way analysis of variance, post-hoc test and sum rank test were used for statistical analysis.Results:A total of 87 healthy volunteers were enrolled, including 40 males and 47 females, aged (38.5±14.2) years old (ranged from 19 to 65 years old). The position of the upper and lower edges of the LES was (42.7±2.8) and (45.6±2.8) cm, respectively, the length of the LES was (2.9±0.4) cm, and the position of PIP was (43.3±2.8) cm. The position of the upper and lower edges of the UES was (18.1±3.0) and (22.6±2.0) cm, respectively, and the length of the UES was (4.8±1.0) cm. The resting pressure of LES and UES was (17.4±10.7) and (84.1±61.1) mmHg (1 mmHg=0.133 kPa), respectively. The DCI value at solid swallowing was higher than those at water swallowing and semisolid swallowing ((2 512.4±1 448.0) mmHg·s·cm vs. (2 183.2±1 441.2) and (2 150.8±1 244.8) mmHg·s·cm), and the differences were statistically significant ( t=-4.30 and -3.74, both P<0.001). The values of 4 s IRP at semisolid swallowing and solid swallowing were lower than that at water swallowing ((4.6±4.1) and (4.9±3.9) mmHg vs. (5.4±3.9) mmHg), and the differences were statistically significant ( t=3.38 and 2.09, P=0.001 and 0.037). The DL at water swallowing was shorter than those at semisolid swallowing and solid swallowing ((8.5±1.8) s vs. (9.8±2.2) and (10.6±2.8) s), and the DL at semisolid swallowing was shorter than that at solid swallowing, and the differences were statistically significant ( t=-10.21, -13.91 and -4.68, all P<0.001). The UES residual pressure at water swallowing was higher than those at semisolid swallowing and solid swallowing (9.5 mmHg, 6.5 to 12.3 mmHg vs. 8.0 mmHg, 4.5 to 11.7 mmHg and 5.5 mmHg, 2.0 to 9.3 mmHg), and the UES residual pressure at semisolid swallowing was higher than that at solid swallowing, and the differences were statistically significant ( t=3.48, 10.30 and 6.35, all P<0.001). Conclusions:The normal values of water-perfused HREM (GAP-36A) in Chinese population at resting period, water swallowing, semisolid swallowing and solid swallowing can provide a reference basis for clinical diagnosis and treatment for patients receiving water-perfused HREM examination.