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Table of Content

    05 August 2018, Volume 21 Issue 22
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    Monographic Research
    Content Analysis of China's Policies for the Delivery of Contracted Family Doctor Services
    XU Hang，CAO Zhi-hui，WU Shuang
    2018, 21(22):  2647-2654.  DOI: 10.12114/j.issn.1007-9572.2018.22.001
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    Objective　To analyze and compare the supportive policies for the delivery of contracted family doctor services（CFDSs） across the provinces（autonomous regions/municipalities） in Chinese mainland，providing a reference for the development of such services.Methods　Using typical sampling，we selected 45 sample cities〔consisting of 4 municipalities，and 41 prefecture-level cities selected from 27 provinces （autonomous regions） with the ratio of 1-2∶1〕.Using the terms "family doctor"/"general practitioner" + "singing a contract" as the title or key words，we searched the official municipal government websites or the same level commissions of health and family planning of these cities，CNKI and Wanfang Data Knowledge Service Platform for policy documents and studies about CFDSs delivered in these cities as of September 30，2017.Content analysis of the extracted data was performed.Results　Totaled 57 consisting of 52 policy documents（from the government websites） and 5 articles（from CNKI and Wanfang Data Knowledge Service Platform） were included.CFDSs were delivered experimentally in public hospitals in 7 cities in the first round，11 cities in the second round，9 cities in the third round，13 cities in the fourth round，and in private hospitals in 5 cities．The policy documents in various cities mainly included coverage goal，receivers and providers，contents and charging mechanism of CFDSs，incentive mechanism of family doctors and so on.For more detail，the similarities of all the cities in delivering CFDSs are as follows：（1）The rates of general and priority populations enjoying CFDSs needed to be achieved as of 2017 were determined.（2）The service populations of CFDSs included the general population，those aged over 65，those with diabetes as well as those with hypertension.（3）CFDSs were offered by the general practitioner（GP） from grassroots medical institutions，either by a sole GP （in 2 cities） or a group of general practitioners （in 43 cities）．（4）Clinical-based and home-based CFDSs were offered.Moreover，differences in delivering CFDSs existed between these cities，which are demonstrated by the following：（1）Contents of CFDSs：4，15，3 cities delivered first-level service package，second-level service package，third-level service package，respectively，6 cities delivered population-specific service package，and 17 cities did not offer classified CFDSs.（2）Criteria for charging for CFDSs：28 cities clearly stipulated the charging criteria for CFDSs while other 17 did not.（3）Specific incentives for family doctors：income allocation，staffing，employment，title promotion，in-service training，awarding，and excellence appraisal for family doctors was defined explicitly in 36，18，5，21，30，28 cities，respectively.Conclusion　The policies for the delivery of CFDSs attached importance to provide services for priority populations，and positively innovated the contracted service package and service forms，but the providers of CFDSs were not multiple and the incentives for family doctors were not satisfactory.In view of this，it is recommended to pay attention to improve the quality of CFDSs，strengthen the technical support for CFDSs，promote signing a contract with multiple-provider coordination team（for enjoying better CFDSs） and improve the incentive mechanism for family doctors.
    Implementation of Supportive Policies for Family Doctor Services Based on Smith's Policy Implementation Process Model
    WU Qian-qian，YIN Wen-qiang，MA He，LIN Jing-wei，SONG Chun-yan，ZHU Li-li，TANG Chang-hai，SONG Jun-wei，FENG Zhi-qiang，WEN Qing-zhu，CHEN Zhong-ming
    2018, 21(22):  2655-2659.  DOI: 10.12114/j.issn.1007-9572.2018.22.002
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    In the current situation，the promotion of family doctor services in China is an important initiative for improving the primary care，care delivery model，and the implementation of hierarchical medial system.Moreover，it plays a key role in safeguarding the people's health.We analyzed the implementation status of supportive policies for family doctor services based on the framework of Smith's policy implementation process model，detailedly discussed the policies，implementors，target group and environmental factors，and concluded that the promotion of family doctor services have increased the awareness and perception rates of these polices，and most residents enjoying the contracted family doctor services are satisfied with such polices，although the implementation results have not matched the expected outcome，it could be improved by detecting and overcoming the implementation-related barriers via multiple perspectives.With the fundamental support of policies，family doctor services can be better extended in an all-round way.
    Models for Training General Practitioners in the UK，U.S. and China：a Comparative Study
    ZHAO Xin-xin，SUN Xiao-ting，PAN Zhi-gang，ZHENG Jia-lin
    2018, 21(22):  2660-2663.  DOI: 10.12114/j.issn.1007-9572.2018.22.003
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    Talent training plays a key role in the development of general medicine in China.Although China has obtained some achievements in educating and training general practitioners（GPs），qualified GPs are badly needed and the training system for GPs is to be improved.In contrast，in the UK and U.S.，the training for GPs started earlier，and rather mature training systems for GPs have been developed.We introduced the English "5+2+3" model and American "4+4+3" model for training GPs，and compared them with China's "5+3" model.The implications for improving domestic training of GPs include defining training goals，focusing on the improvement of comprehensive qualities and work-related competencies of GPs，and setting up standardized general practice residency training programs that consist of training syllabus，qualified trainers and training sites，and program evaluation.
    GPs with Special Interests Training in China and Relevant Recommendations
    LIU Ying，CHEN Shao-hua，QIU Yan，REN Wen，REN Jing-jing
    2018, 21(22):  2664-2667.  DOI: 10.12114/j.issn.1007-9572.2018.22.004
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    In recent years，general practice develops rapidly in China.A relatively complete system of general practitioner training has been established，which includes college education and further education after graduation.However，there are lack of efficient ways to deliver continuing medical education for general practitioners（GPs） after receiving standardized training.GP with special interests（GPwSI） play a role in connecting primary and secondary care，ensuring the continuous supply of care.Nowadays，GPwSI training has been explored in some places of China.In this article，we analyzed the achievements and limitations of GPwSI training in China and suggested that further GPwSI training should be competency-based，with a reasonable definition of GPwSI's role in delivering care，as well as strict enrollment and eligibility criteria，in addition，good financial support for the training should be ensured.
    SWOT Analysis and Strategic Choices for the Development of China's Community Health Services in the Big Data Era　#br#
    LIU Zhi-han，ZHAO Xu-hong
    2018, 21(22):  2668-2671.  DOI: 10.12114/j.issn.1007-9572.2018.22.005
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    With the development of big data technologies，the growing number of big data healthcare studies and the thriving mobile healthcare industry bring favorable opportunities for the development of China's community health services characterized by wide coverage and high availability.However，severe challenges to its development are also brought by entering the era of big data due to lack of adequate human and material resources，lack of advanced technologies，sound laws and regulations for the management of big data，increasingly prominent information security risks with the application of big data and other unfavorable internal and external factors.We used the SWOT analysis to systematically analyze the internal strengths and weaknesses and external opportunities and threats for the development of China's community health services in the era of big data，and based on this，proposed targeted development strategies.
    Assessment of the Implementation of Hierarchical Medical System in Shanghai from a Multi-stakeholder Perspective：a Systematic Review　
    YANG Sen，WANG Zhao-xin，JIN Hua，GE Xu-hua，ZHANG Han-zhi，ZHANG Bin，LU Yuan，MA Le，YU De-hua
    2018, 21(22):  2672-2678.  DOI: 10.12114/j.issn.1007-9572.2018.22.006
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    Objective　To assess the achievements and challenges of the implementation of hierarchical medical system （HMS） in Shanghai from a multi-stakeholder perspective based on a systematic review.Methods　The search was done in January 2018.We searched the databases of CBM，VIP，Wanfang Data Knowledge Service Platform，CNKI，PubMed，ScienceDirect and Ovid via Google Scholar，Baidu Scholar and other search engines to identify the articles about descriptive introduction and assessment of the implementation of HMS in Shanghai from their inception to January 10，2018.The data were synthesized with a thematic analysis approach with EPPI-Reviewer 3.0 software.Results　32 articles were included.Three themes emerged from the analysis：the level of satisfaction with the implementation of HMS，achievements of the implementation of HMS and challenges of the implementation of HMS.In terms of level of satisfaction with the implementation of HMS，healthcare providers（medical institutions，healthcare professionals and healthcare enterprises） showed high level of satisfaction while the healthcare receivers （residents/patients） and the organizer（the government） showed fair level of satisfaction with the implementation of HMS.With regard to the achievements of the implementation of HMS，medical institutions and healthcare professionals thought the rate of initial consultation in primary care and rate of signing a contract with the family doctor among residents were increasing，and healthcare cost and visits in primary care increased significantly，healthcare enterprises thought its implementation is conducive to the application and development of information technology；residents/patients considered that the implementation of HMS was beneficial to the delivery of convenient and inexpensive healthcare；the government put forward that the implementation of HMS played a role in diverting patients（although the effect of diverting was not obvious），and improved the equity and accessibility of healthcare and the efficiency of healthcare delivery.In respect of the challenges for the implementation of HMS，medical institutions and healthcare professionals pointed out that sharply increased visits overwhelmed the capabilities of primary care，residents thought the categories of drugs were inadequate in primary medical institutions，and they did not trust the service capabilities of primary care practices，and still preferred to go to large-scale hospitals when seeking healthcare，the government put forward that the supporting measures for the implementation of HMS were inadequate.Conclusion　The implementation of HMS in Shanghai needs to be improved further，which could be achieved by bettering and popularizing the HMS，raising the level of primary care quality，and improving the proportion of residents seeking healthcare in primary care.All these provide a reference for policy-making related to the development of HMS.
    Cause and Solution Analysis of the Letters and Calls of Community Health Services in Beijing's Chaoyang District from 2014 to 2016　#br#
    NI Na-na，LIU Bao-hua，BAI Jiang-liang，ZHANG Sha，HU Sheng-xing，BAI Xu，RAO Fu-yang，LYU Chun-hua，ZUO Yang-ping，ZHU Lei
    2018, 21(22):  2679-2685.  DOI: 10.12114/j.issn.1007-9572.2018.22.007
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    Objective　To analyze the letters and calls concerning community health services in Beijing's Chaoyang District，and based on this，to put forward solutions.Methods　We collected three types of letters and calls（complaints，tip-offs and suggestions） concerning community health services delivered by 38 community health centers（CHCs） in Chaoyang District，from the Information Management Platform for Letters and Calls of Health Services，Center for Letters and Calls on Health Service in Chaoyang District，during 2014 to 2016，and analyzed the correlations of the total annual amount of letters and calls with the total annual workload，annual workload per capita，and annual healthcare cost per capita.Results　Totaled 1 539 letters and calls were included，including 380 in 2014，553 in 2015 and 606 in 2016，with an annual growth rate of 26.28%.They were mostly concerned with drug issues 〔21.77%（335/1 539）〕，hospital management 〔20.08%（309/1 539）〕，and preventive healthcare 〔17.93%（267/1 539）〕.Both total annual workload and annual workload per capita were positively correlated with total annual amount of letters and calls，annual amount of letters and calls concerning hospital management，service attitude，healthcare quality，and medical ethics，respectively （P<0.05）.Conclusion　During 2014 to 2016，the amount of letters and calls for community health services in Chaoyang District increased year by year.Drug issues，hospital management and preventive healthcare were the top three concerns.In view of this，we propose the following suggestions：the CHCs should improve their levels of self-management；the government should appropriately increase the number of workforce of the CHCs，develop and improve health policies，laws and regulations，better the performance appraisal mechanism and establish a risk prevention mechanism for letters and calls.
    Features of Elderly Outpatients Seeking Primary Care in the General Hospital
    QIU Yan，LIU Ying，REN Wen，LIU Juan-juan，ZHU Lu，REN Jing-jing
    2018, 21(22):  2686-2689.  DOI: 10.12114/j.issn.1007-9572.2018.00.049
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    Objective　To explore the characteristics of elderly outpatients seeking primary care in the general hospital.Methods　Data （including sex，age，consultation time，diagnosis，type of disease，and concomitant diseases） were collected from the electronic medical record system of The First Affiliated Hospital，Zhejiang University，involving 1 174 eligible elderly patients seeking primary care between February 2016 and February 2017.Results　Among the elderly outpatients，73.3%（860/1 174） were diagnosed with two or more types of disease.The three diseases owning the highest prevalence were hypertension〔28.1%（330/1 174）〕，diabetes〔14.0% （164/1 174）〕 and chronic gastritis〔11.2% （132/1 174）〕．The multimorbidity diseases owning the highest prevalence were hypertension+ diabetes+chronic nephropathy〔2.4%（15/613）〕，hypertension+hyperlipidemia+osteoporosis〔2.3% （14/613）〕，hypertension+ hyperlipidemia+benign prostatic hyperplasia〔2.1% （13/613）〕．The prevalence of hypertension，diabetes，chronic gastritis and sleep disorder varied significantly by age and diagnosis（P<0.05），but not by sex and quarter（P>0.05）.The prevalence of hyperlipidemia differed obviously by sex, age and diagnosis（P<0.05），but not by quarter（P>0.05）.Conclusion　The prevalence of multimorbidity was high in elderly patients seeking primary care in the general hospital.Moreover，hypertension，diabetes and chronic gastritis were found to have the highest prevalence.
    Influence of Transformational Leadership and Psychological Empowerment on Organizational Innovation Climate of General Practitioners in Community Health Service Centers
    XU Qi，YAO Zhi-zhen
    2018, 21(22):  2690-2695.  DOI: 10.12114/j.issn.1007-9572.2018.22.009
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    Objective　To investigate the organizational innovation climate of general practitioners in community health service centers and to analyze the influence of transformational leadership and psychological empowerment on organizational innovation climate of general practitioners.Methods　According to the proportion of urban，suburban and urban-rural areas in ratio of approximately 1∶1∶1，multistage sampling method was applied to select randomly 10 community health service centers from 45 community health service centers in Pudong New Area of Shanghai from September to October in 2016，and then the whole group of all registered general practitioners in the selected community health service centers was included.A total of 380 registered general practitioners were investigated by the self-designed demographic data questionnaire，Organizational Innovation Climate Scale，Transformational Leadership Scale，and Psychology Empowerment Scale.A total of 380 questionnaires were distributed，and 355 valid questionnaires were collected.The effective recovery rate was 93.4%.Results　Among 355 general practitioners，the score of Organizational Innovation Climate Scale was （3.82±0.57），in which the scores of team cooperation （4.13±0.66） and superior support （4.00±0.74） were high，while the scores of resource guarantee（3.14±0.88） and incentive mechanism（2.89±0.60） were low.The score of Transformational Leadership Scale was （5.61±0.89），and the score of the Psychological Empowerment Scale was （3.92±0.69）.The score of Transformational Leadership Scale and the score of Psychological Empowerment Scale were positively related to the score of Organizational Innovation Climate Scale linearly（P<0.01）.Apart from the score of resource guarantee，the scores of other dimensions in Transformational Leadership Scale and Psychological Empowerment Scale were positively related to the scores of all dimensions in Organizational Innovation Climate Scale（team cooperation，superior support，leadership，organizational promotion，self-employment，and incentive mechanism） linearly（P<0.01）.The multivariate stepwise regression analysis showed that the scores of dimensions in Transformational Leadership Scale and Psychological Empowerment Scale were the influencing factors of the scores of dimensions in Organizational Innovation Climate Scale（P<0.01）.Conclusion　The organizational innovation climate in community health service centers was at a moderate level，and it is positively related to transformational leadership and psychological empowerment.Managers should strengthen transformational leadership and psychological empowerment as the breakthrough point，give full play to the role of transformational leadership，enhance the level of psychological empowerment among general practitioners，and create the new organizational innovation climate so as to promote community health services effectively and efficiently.
    Effect of Intensive Diabetes Management on the Incidence of Diabetic Retinopathy and Diabetic Nephropathy in Sanlitun Community-dwelling Type 2 Diabetic Patients：a 9-year Cross-sectional Study　
    ZHAO Chen-mei，CUI Xue-li，WAN Gang，LU Yu-zhe，NIU Yu-qin，SU Cheng-yu，CAO Shuo，LIANG Guan-xiu，CHEN Hong-wei，LI Jing，LU Xia，DENG Zhi-yun，YU Xue-hui，YANG Wen-xia，LI Jian-hua，FAN Hua，YANG Mao-xia
    2018, 21(22):  2696-2701.  DOI: 10.12114/j.issn.1007-9572.2018.22.010
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    Objective　To study the effect of a 9-year intensive diabetes management conducted by Beijing Sanlitun Community Health Center on the incidence rate of diabetic microvascular complications （DMCs） in patients with type 2 diabetes mellitus （T2DM） and to explore the relationship of meeting the control targets of fasting plasma glucose （FPG），blood pressure and blood lipids for 3 times or more with the incidence rate of DMCs in this population.Methods　The participants were 224 T2DM patients enrolled from Sanlitun Community in 2008.They were randomized into the intensive management group （n=113） and standard management group （n=111），receiving intensive management and follow-up，standard management and follow-up，respectively，for consecutive 9 years.Comparisons were made between two groups in terms of systolic blood pressure （SBP），diastolic blood pressure （DBP），glycosylated hemoglobin （HbA1c） and low-density lipoprotein cholesterol （LDL-C） at baseline and at the end of management，and in regard to outcome events （diabetic retinopathy and diabetic nephropathy）．To investigate the relationship of management method and meeting the control targets of FPG，blood pressure and blood lipids for 3 times or more with the incidence of DMCs.Results　There were no significant differences in the distribution of sex，age，duration of T2DM，BMI，prevalence of smoking，mean SBP，DBP，FPG，2 h PG，LDL-C ，HbA1c and urinary albumin excretion rate （UAER） at baseline between the two groups （P>0.05）．At the end of management，mean FPG，2 h PG，HbA1c，LDL-C and UAER were much lower in the intensive management group （P<0.05） except the distribution of BMI，mean SBP and DBP were still similar in both groups （P>0.05）；the intensive management group showed lower incidence and exacerbation rates of diabetic retinopathy 〔0.9%（1/113） vs 5.4%（6/111）〕 and lower incidence and exacerbation rates of diabetic nephropathy 〔4.4%（5/113） vs 11.7%（13/111）〕（P<0.05）．A much lower rate of DMCs was found in those meeting the target objective for HbA1c as well as those meeting the control targets of FPG，blood pressure and blood lipids for 3 times or more in both groups（P<0.05）．Conclusion　The incidence rate of DMCs in T2DM patients can be effectively reduced by community-based intensive diabetes management.Moreover，it will be lower and improved quality of life will be achieved if the HbA1c reaching the target objective or FPG，blood pressure and blood lipids meeting the control targets for 3 times or more.
    Value of Serum Homocysteine Level for the Prediction of Progression from Prehypertension to Hypertension　#br#
    HOU Hui-li，CHEN Ying，WU Ping，XU Wei，GU Hai-li
    2018, 21(22):  2702-2706.  DOI: 10.12114/j.issn.1007-9572.2018.00.093
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    June 2013 and June 2014，we recruited 421 individuals with prehypertension who received health examination in Jiading District Nanxiang Town Community Health Center，Shanghai.Baseline data including laboratory testing results were collected.Enzymatic cycling assay was used to determine the serum Hcy level.Based on the level of serum Hcy，they were classified into Q1 group （quartile 1：Hcy<11.2 μmol/L，n=105），Q2 group （quartile 2：Hcy 11.2-13.7 μmol/L，n=105），Q3 group （quartile 3：Hcy 13.8-16.4 μmol/L，n=105） and Q4 group （quartile 4：Hcy>16.4 μmol/L，n=106）.During the follow-up period，all the participants underwent physical examination once a year，in particular，the incidence of hypertension was evaluated，and 128 were found with hypertension and 293 without were assigned to hypertension group，non-hypertension group，respectively.Comparisons were made between hypertension and non-hypertension groups in terms of serum Hcy level and between Hcy groups in respect to the incidence of hypertension.Moreover，the associated factors for the progression of prehypertension to hypertension were explored.Results　The mean follow-up duration was （2.6±0.9） years，during which the incidence of hypertension was 30.4%.Compared with the non-hypertension group，hypertension group had higher mean age，mean BMI，mean systolic blood pressure（SBP），mean diastolic blood pressure（DBP），mean fasting blood glucose（FBG） and mean Hcy levels，and a higher proportion of men，but a lower proportion of patients who had regular physical activity at baseline （P<0.05）.The incidence of hypertension in Q1，Q2，Q3 and Q4 groups was 16.2% （17/105），23.8% （25/105），33.3% （35/105） and 48.1% （51/106），respectively，indicating that it increased along with the elevation of Hcy levels （χ2trend =28.320，P<0.001）.Multivariate Logistic analysis revealed that age，regular physical activity，BMI，SBP and Hcy level were the associated factors of the progression to hypertension for prehypertension patients （P<0.05）.Conclusion　Elevated serum Hcy level is an independent risk factor for progression of prehypertension to hypertension，suggesting that measurement of Hcy may be helpful for the risk stratification and early management of these patients.
    Value of Serum Uric Acid in Predicting Metabolic Syndrome in Obese Male Children　
    XU Xiao-hua，DONG Guan-ping，WU Wei，HUANG Ke，JIN Wei，YAO Qi-hong，WANG Ling，FU Jun-fen
    2018, 21(22):  2707-2711.  DOI: 10.12114/j.issn.1007-9572.2018.00.012
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    Objective　To evaluate the value of serum uric acid （SUA） in predicting metabolic syndrome （MS） in obese male children.Methods　We enrolled 256 obese male children from Department of Endocrinology，The Children's Hospital，Zhejiang University School of Medicine，Department of Pediatrics，The First Affiliated Hospital of Huzhou University，Department of Pediatrics，Huzhou Maternal & Child Care Hospital between June 2008 and October 2015，including 118 with MS and 138 without.We collected and compared their data about physical examination and laboratory findings.Performance analysis of different combinations of markers for the prediction of MS was conducted using area under the ROC curve （AUC），sensitivity，specificity and Cohen's Kappa coefficient（κ）．Results　For the prediction of MS，the AUC of SUA 〔0.631，95%CI（0.562，0.970）〕was significantly different from that of triglycerol（TG）〔0.878，95%CI（0.833，0.932），Z=5.898，P<0.001〕and high-density lipoprotein cholesterol （HDL-C）〔0.787，95%CI（0.730，0.844），Z=3.432，P<0.001〕，but similar to that of systolic blood pressure （SBP）〔0.688，95%CI（0.621，0.754），Z= 1.168，P= 0.243〕，diastolic blood pressure （DBP）〔0.592，95%CI（0.251，0.667），Z=0.777，P=0.437〕，low-density lipoprotein cholesterol（LDL-C）〔0.664，95%CI（0.598，0.731），Z=0.676，P= 0.449〕，fasting plasma glucose（FPG） 〔0.642，95%CI（0.571，0.713），Z=0.219，P=0.827〕，2 h-postprandial plasma glucose（2 h PG）〔0.647，95%CI（0.576，0.718），Z=0.319，P=0.750〕.The sensitivity of TG in serial combination with SUA was significantly different from that of TG in serial combination with FPG or 2 h PG，TG in serial combination with HDL-C or LDL-C and TG in serial combination with hypertension（P<0.001）；TG in serial combination with SUA showed obviously different specificity compared with TG in serial combination with FPG or 2 h PG（P=0.001） as well as TG in serial combination with hypertension（P<0.001），but was similar to that of TG in serial combination with HDL-C or LDL-C（P=0.324）．The κ of TG in serial combination with SUA did not significantly differ from that of TG in serial combination with FPG or 2 h PG，TG in serial combination with HDL-C or LDL-C，TG in serial combination with hypertension（Z=1.913，0.389，1.057；P=0.056，0.697，0.291）．The κ for measuring the extent of agreement was 0.357 between TG in serial combination with SUA and TG in serial combination with FPG or 2 h PG，0.554 between TG in serial combination with SUA and TG in serial combination with HDL-C or LDL-C，0.459 between TG in serial combination with SUA and TG in serial combination with hypertension.Conclusion　SUA can be used as a predictor of MS，and the prediction effect will be better if it is used in combination with TG.
    Clinical Analysis of Bone Loss in Middle-aged and Elderly Women with Rheumatoid Arthritis　
    GUO Jia，HUANG Ji-yuan，ZHENG Hong-yin
    2018, 21(22):  2712-2715.  DOI: 10.12114/j.issn.1007-9572.2018.00.039
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    Objective　To explore the clinical features of bone loss in middle-aged and elderly women with rheumatoid arthritis（RA）.Methods　 All the participants were enrolled from Sichuan Provincial People's Hospital between August 2008 and June 2016，including 543 female patients aged ≥40 years receiving a definite diagnosis of RA（RA group） from Rheumatology and Immunology Clinic，and 1 742 age-matched healthy female controls undergoing physical examination（control group）. BMD of the lumbar spine （L1-4） in the frontal position，left femoral neck，Ward's triangle of the left hip，great trochanter of the left femur，shaft of left femur and total hip bone，and prevalence of osteoporosis（OP） at lumbar spine and femur were compared between the groups by age group. Results　 RA was associated with much lower mean BMD of L1 to L4 vertebrae in age groups of 40-49 and 50-59（P<0.05），but showed no association with the mean BMD of L1 to L4 vertebrae in age groups of 60-69，70-79 and ≥80 （P>0.05）. Moreover，RA was found to be associated with obviously lower mean BMD of left femoral neck，great trochanter of the left femur，Ward's triangle of the left hip，shaft of left femur and total hip bone in age groups of 40-49，50-59，60-69（P<0.05），but demonstrated no association with the mean BMD of the above 5 regions in age group of ≥80（P>0.05）. RA was correlated with higher prevalence of OP at the lumbar spine and femur in age group of 40-49 and 50-59，and higher prevalence of OP at the femur in age groups of 60-69（P<0.05），while showed no correlation with the prevalence of OP at the lumbar spine in age groups of 60-69 as well as the prevalence of OP at the lumbar spine and femur in age groups of 70-79 and ≥80（P>0.05）.Conclusion　 RA could increase the risk of having bone loss and OP. Moreover，its impact varied differently by age and anatomic region. Furthermore，focused attention should be paid to the prevention and treatment of OP in middle-aged and elderly women.
    Clinical Study of Gastrointestinal Malignancies with VTE as the Initial Manifestation　#br#
    HAN Hong-chao，XU Jie，WANG Ai-kun，XU Yue-chao
    2018, 21(22):  2716-2719.  DOI: 10.12114/j.issn.1007-9572.2018.22.014
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    Objective　To explore the clinical features of gastrointestinal malignancies with venous thromboembolism （VTE） as the initial manifestation，so as to improve the diagnosis and treatment of these diseases to enhance the patients' prognosis.Methods　The 42 participants with a definite diagnosis of gastrointestinal malignancies with VTE were enrolled from Yancheng Third People's Hospital from January 2012 to January 2017，including 25 （59.5%） who had VTE after surgery or during the hospitalization （control group） and 17 （40.5%） who sought medical care due to VTE，but were diagnosed with gastrointestinal malignancies after admission and did not receive surgical treatment（study group）．Through reviewing the medical records，we collected their clinical data，including sex，age，BMI，prevalence of underlying diseases，site of VTE，site of cancer，histological type of cancer，degree of cancer invasion，admission laboratory results and so on.Results　Compared with the control group，the proportion of males，the incidence of VTE in both lower limbs and the percent of gastric carcinoma were higher in the study group （P<0.05）．Moreover，the average levels of D-dimer，platelet count and fibrinogen were higher，but the average level of hemoglobin was lower in the study group （P<0.05）．However，both groups showed no significant differences in the distribution of age，BMI，site of VTE （except both lower limbs），tumor histological type and the degree of cancer invasion as well as the incidence of complications（P>0.05）．Conclusion　Gastrointestinal malignancy with VTE as the initial manifestation is more common in males，frequently manifested by DVT in both lower limbs，and gastric cancer is in the majority.Therefore，patients，especially males having VTE in both lower limbs due to unknown reasons，may be considered with gastric cancer possibly.
     
    Levels of Oxidative Stress Biomarkers and the Severity of Parkinson's Disease　
    ZHAO Zhen-hua，WANG Xiao-song，WEI Zhen，HE Ying-chao，CHENG Qiong，WANG Yin-zhou
    2018, 21(22):  2720-2723.  DOI: 10.12114/j.issn.1007-9572.2018.00.050
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    Objective　To investigate the level of oxidative stress biomarkers in plasma and the severity of Parkinson's disease（PD）.Methods　The participants enrolled were all from Fujian Provincial Hospital between December 2016 and June 2017，including 40 outpatients and inpatients with idiopathic PD from Department of Neurology〔23 with mild PD （mild PD subgroup） and 17 with moderate-to-severe PD（moderate-to-severe PD subgroup）classified by Hoehn and Yahr Scale〕，and 40 health individuals without biological relatives with PD undergoing physical examination （control group）.The levels of malondialdehyd（MDA），8-hydroxy-2-deoxyguanosine（8-OHdG）and DJ-1 protein were compared between the mild，moderate-to-severe PD patients and controls.Results　（1）The average levels of MDA and 8-OHdG differed significantly between mild，moderate-to-severe PD patients and controls（P<0.05）.To be specific，compared with the controls，mild and moderate-to-severe PD patients demonstrated much higher average MDA levels，and mild PD patients presented significantly higher average 8-OHdG levels（P<0.05）.（2）The average DJ-1 protein levels were similar in the controls and the PD patients（P>0.05）.Conclusion　Elevated MDA can be found in PD patients.Moreover，increased 8-OHdG can also be found in mild PD patients.
    Hypertension Control Status and Influencing Factors in Representative Areas of Western China during the Comprehensive Reform of Primary Care System　#br#
    YUAN Guang-lei，QIN Jiang-mei，LIU Jun，LIN Chun-mei，ZHANG Li-fang，ZHANG Yan-chun
    2018, 21(22):  2724-2728.  DOI: 10.12114/j.issn.1007-9572.2018.22.016
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    Objective　To explore the hypertension control status and influencing factors in representative areas of western China during the comprehensive reform of primary care system.Methods　The data were obtained from the Inhabitants' Family Health Survey，which was carried out by the National Health and Family Planning Commission of the People's Republic of China and Ministry of Finance of the People's Republic of China in 34 key representative areas across 17 provinces from 2014 to 2016 during the comprehensive reform of primary care system.2 269 hypertensive patients from 8 of these areas in western China（Chengbei District and Huangzhong County of Xining City，Hongshan District and Hexigten Banner of Chifeng City，Wuhou District and Xinjin County of Chengdu City，Wudang District and Kaiyang County of Guiyang City） were enrolled.Information regarding sociodemographic characteristics，availability and utilization of medical care，awareness of hypertension management，health behaviors and hypertension control status of the participants was analyzed.And the influencing factors of hypertension control were investigated by multiple Logistic regression analysis.Results　The overall hypertension control rate was 75.23%（1 707/2 269）．Urban areas owned a higher hypertension control rate than rural areas〔84.60%（961/1 136） vs 65.84%（746/1 133）〕（P<0.05）．The hypertension control rate was 60.72%（286/471），71.48%（579/810），93.58%（525/561），74.24%（317/427） for Xining City，Chifeng City，Chengdu City，and Guiyang City，respectively，with significant differences（P<0.05）．Multiple Logistic regression analysis showed that administrative city，urban-rural location，level of household income，awareness level of hypertension，lifestyle，status of hypertension management and medication use were the influencing factors of hypertension control（P<0.05）．Conclusion　The hypertension control in the representative areas of western China was satisfactory，which was associated with administrative city，urban-rural location，level of household income，awareness level of hypertension，lifestyle，status of hypertension management and medication use.It could be further improved by narrowing the income gap between urban and rural areas and between the administrative cities，targeted hypertension education，developing a healthy lifestyle with guidance and enhancing the medication adherence.
    Application of Antihypertensive Drugs and Blood Pressure Control among Hypertension Population in Jiangxi Province　
    ZHOU Wei，HUANG Xiao，YOU Chun-jiao，ZHAN Bi-ming，YANG Ren-qiang，DONG Yi-fei，LI Ju-xiang，LI Ping，HONG Kui，WU Yan-qing，WU Qing-hua，SU Hai，BAO Hui-hui，CHENG Xiao-shu
    2018, 21(22):  2729-2735.  DOI: 10.3969/j.issn.1007-9572.2017.00.260
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    Objective　To investigate the prevalence of hypertension，its awareness rate，medication taking rate and control rate in Jiangxi Province，and to understand the current situation of the application of antihypertensive drugs and the blood pressure control among hypertension patients.Methods　Using the simple random sampling（SRS） method，four cities in urban areas and four counties in rural areas were randomly selected，in which two districts or two townships were selected.Then，three communities or villages were selected within each district and township respectively.In these areas，a total of 15 364 participants who were 15 years or older and lived in Jiangxi Province for at least 6 months were selected from November 2013 to August 2014.Current situation of hypertension and its medication taking were recorded by questionnaires to calculate the prevalence rate of hypertension，its awareness rate，medication taking rate，overall control rate，and blood pressure control rate after taking medicine.And a physical examination including blood pressure measurement was carried out.Results　The prevalence rate of hypertension among 15 years or older population in Jiangxi Province was 29.0%（4 436/15 296） and standardized rate was 14.1%（China's population standardized rate in 2010）．The awareness rate，medication taking rate，and overall control rate of hypertension patients were 64.8%（2 875/4 436），27.6%（1 223/4 436），and 12.6%（561/4 436） respectively.Moreover，the control rate after taking medicine in patients who took the medicine was 45.9%（561/1 223）．The prevalence rate of hypertension，its awareness rate，medication taking rate，and overall control rate of participants in urban areas were higher than those in rural areas，while the control rate after taking medicine in urban areas was lower than that in rural areas（P<0.05）．The systolic blood pressure（SBP），diastolic blood pressure（DBP） and pulse pressure（PP） of patients who took the medicine were significantly lower than those who did not take the medicine（P<0.05）．Among patients with hypertension，75.1%（918
    /1 223）of patients were single drug users and 12.7%（155/1 223） of patients used two-drug combinations.There is no significant difference in the control rate after taking medicine in hypertensive patients with different ways of taking medicine（χ2=2.692，P=0.611）．The control rate after taking medicine of patients using two-drug combinations in rural areas was higher than that in urban areas（χ2=4.262，P=0.039）．Among single drug users，76.1%（699/918） of patients took calcium channel blockers（CCB），and 18.6%（171/918） of patients took angiotension-converting enzyme inhibitors（ACEI）．No significant difference was observed in the control rate after taking medicine among patients using different single drugs（χ2=6.779，P=0.148）．Among patients who took CCB，39.9%（279/699）of patients took Nitrendipine and 24.7%（173/699） of patients took Amlodipine Benzenesulfonate.There was no statistical difference in the control rate after taking medicine among patients using different CCB（χ2=3.995，P=0.407）．Likewise，among patients who took ACEI，76.6%（131/171） of patients took Captopril and 12.9%（22/171）of patients took Enalapril.There was no statistical difference in the control rate after taking medicine among patients using different ACEI（χ2=2.241，P=0.524）．Conclusion　Patients with hypertension are mainly treated with short-acting antihypertensive drugs，and the medicine taking rate is low as well as the overall control rate in Jiangxi Province.Hypertension patients in both rural and urban areas need to improve their medical awareness and the government needs to increase investment to meet the demands of medicine taking.
     
    Analysis of Hypertension Control among Community Residents in Tongzhou District of Beijing　
    HU Kang，SUN Kai-ge，WU Shi-yan，ZHANG Xu-xi，JIA Wei-lan，SHAO Chun-xin，WU Qin，XUAN Xiao-wei，LIU Yong-chang，LIU Si-jia，SUN Xin-ying
    2018, 21(22):  2736-2740.  DOI: 10.3969/j.issn.1007-9572.2017.00.275
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    Objective　To investigate the prevalence，control situation and influencing factors of hypertension among community residents in Tongzhou District of Beijing，and to analyze the relationship between the control of blood pressure and the utilization of community health services among patients with hypertension.Methods　A total of 7 008 residents aged 18 and older were selected within the service area of community health service centers in Tongzhou District of Beijing from July to September in 2015.Questionnaire on Health Status and Health Service Demand among Community Residents in Tongzhou District was adopted to conduct questionnaire survey，and physical examinations were conducted to examine height，weight，waistline and blood pressure.Multiple Logistic regression was used to analyze factors affecting blood pressure control among patients with hypertension.Results　The prevalence of hypertension in the investigated population was 30.66%（2 149/7 008）．The prevalence of hypertension in male was 34.01%（1 191/3 502），which was higher than 27.32%（958/3 506） in female（χ2=36.820，P<0.001）．The awareness rate of hypertension was 61.47%（1 321/2 149）．The awareness rate of hypertension in male was 54.58%（650/1 191），which was lower than 70.04%（671/958） in female（χ2=53.620，P<0.001）．And the blood pressure control rate of patients with hypertension was 43.38%（573/1 321）．There was a significant difference in the control rate among hypertension patients with different medical insurance（χ2=60.195，P<0.05），having the health examination or not in half a year（χ2=4.319，P<0.05），and having blood pressure measurements provided by primary care doctors or not in a year（χ2=11.014，P<0.05）．Multiple Logistic regression analysis showed that the total monthly household income〔OR=1.087，95%CI（1.022，1.157） 〕，new rural cooperative medical scheme〔OR=1.775，95%CI（1.185，2.659）〕 and having blood pressure measured by primary care doctors in a year〔OR=1.383，95%CI（1.095，1.745）〕 were protective factors of blood pressure control（P<0.05），while urban employees basic medical insurance〔OR=0.654，95%CI（0.431，0.993）〕 was the risk factor（P<0.05）．Conclusion　The prevalence of hypertension in residents aged 18 and older of Tongzhou District is high and the control of blood pressure in patients with hypertension is not good.Comprehensive measures should be taken to strengthen the control of blood pressure，such as providing regular blood pressure measurements and physical examination，and improving residents' economic condition.For patients with socialized medicine and urban employees basic medical insurance，more attention and further studies should be given to deal with the control of their blood pressure.
    Transcutaneous Acupoint Electrical Stimulation for Diabetes-related Constipation　
    WU Yuan-rong
    2018, 21(22):  2741-2745.  DOI: 10.3969/j.issn.1007-9572.2018.00.253
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    Objective　To observe the effectiveness of transcutaneous acupoint electrical stimulation（TAES） in the treatment of diabetes-related constipation.Methods　 Totals of 74 cases of diabetic inpatients with constipation from Endocrine Department of a grade A tertiary hospital in China from September 2016 to October 2017 were enrolled and equally divided into the control group and experimental group based on a random number table.Both groups received basic treatment for diabetes and constipation and health education about diabetes，the experimental group additionally received 2 courses of treatment with TAES〔delivered at half an hour after breakfast for 30 minutes，once daily，for consecutive 14 days（7-day treatment is a course）〕．The effectiveness of treatment was evaluated by the initial defecation time，constipation symptom scores in 6 aspects （defecation interval，speed of defecation，fecal properties，difficulty in defecation，defecation urge，and other accompanying symptoms） after receiving interventions.Results　69 cases（34 in the experimental group and 35 in the control group） who completed the treatment were included in the final analysis.After treatment，the constipation symptom scores in the aforementioned 6 aspects decreased significantly in both groups （P<0.05）.Better effectiveness of treatment was achieved in the experimental group（P<0.05），which was indicated by the following two aspects：（1） Initial defecation after treatment occurred in the experimental group earlier（P<0.05）.（2） Although baseline constipation symptom scores in all the 6 aspects were similar in both groups（P>0.05），after treatment，the experimental group showed significantly lower constipation symptom scores in defecation interval，speed of defecation，fecal properties，difficulty in defecation than the control group（P<0.05）.Conclusion　 TAES can enhance the clinical symptoms of diabetes-related constipation.
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    ZHENG Guo-hua，ZHENG Xin，LI Jun-zhe，DUAN Ting-jin，LING Kun
    2018, 21(22):  2745-2749.  DOI: 10.12114/j.issn.1007-9572.2018.22.020
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    Objective　To explore influence of Tai Chi training on carotid artery function in community-dwelling populations at high risk of ischemic stroke.Methods　From October 2014 to March 2015，we recruited 170 eligible individuals at high risk of ischemic stroke from 3 communities located on Huada Street，Fuzhou's Gulou District and equally randomized them into the control group and Tai Chi training group.The participants in the Tai Chi training group received a 12-week Tai Chi training（five times per week，60 minutes each time），while those in the control group maintained their lifestyle without additional physical activities.The outcome indicators including carotid intima-media thickness（CIMT），blood flow velocity of carotid sinus，resistance index of carotid artery and carotid plaque measured by transcranial Doppler were compared at baseline，at the end of 12-week intervention period，and end of additional 12-week follow-up period.Results　Mixed linear model analysis showed the following：the main effects produced by intervention content were significant on left CIMT（P<0.05），but were insignificant and similar on right CIMT，blood flow velocities of left and right carotid sinus，resistance indices in the left and right internal carotid arteries（P>0.05）．The main effects exerted by intervention duration were obvious on left and right CIMT，resistance indices in the left and right internal carotid arteries（P<0.05），but were insignificant and similar on blood flow velocities of left and right carotid sinus（P>0.05）．Intervention content and duration had no interactive effects on all the outcome indicators（P>0.05）．Furthermore, left CIMT became similar in both groups after intervention and after follow-up（P>0.10） although it was greater in the Tai Chi training group before intervention found by the t-test run with an α level of 0.10（P=0.06）; the resistance index in the left internal carotid artery was significantly decreased in the Tai Chi training group after intervention（P<0.05） although it was similar in both groups before intervention and after follow-up（P>0.05）. The analysis with generalized estimating equation found that the mean prevalence of carotid plaque was lower in Tai Chi training group rather than control group（P<0.05）；the prevalence of carotid plaque in both groups did not receive any significant main effects produced by intervention duration as well as significant interactive effects between intervention content and duration（P>0.05）．Conclusion　A 12-week Tai Chi training was beneficial to block the increase of CIMT，reduce the resistance index of carotid artery and formation of carotid plaque in community-dwelling populations at high risk for ischemic stroke.It may be an effective exercise intervention to prevent ischemic stroke.
    Identification and Treatment of Psychological Disorder in Patients with Cardiovascular Diseases　
    YU Guo-long，DENG Yun-long
    2018, 21(22):  2750-2754.  DOI: 10.12114/j.issn.1007-9572.2018.22.021
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    Cardiovascular disease combined with psychological disorder （psycho-cardiology disease） is very common clinically，but doctors in general and primary hospitals in China have not been able to identify it in time.To solve this outstanding problem，this paper，combined with the recent progress in this area at home and abroad，elaborates the epidemiology，status quo of diagnosis and treatment，and clinical common types of cardiovascular disease combined with psychological disorder.It also focuses on the identification，diagnosis methods and main treatment measures of cardiovascular disease combined with psychological disorder，so as to improve the understanding and diagnosis of psycho-cardiology disease among doctors in general hospitals，especially general practitioners in primary hospitals.

    Pathogenesis of Cyberchondria and Its Impact on Individuals：a Qualitative Study　
    XU Dan-yang，DING Jia-li，YANG Zhi-hui
    2018, 21(22):  2755-2759.  DOI: 10.12114/j.issn.1007-9572.2018.22.022
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    Objective　To explore the pathogenesis of cyberchondria and its impact on individuals.Methods　Study design was qualitative.In January 2016，one-to-one semi-structured interviews were carried out in a random sample of 6 persons who scored high on Chinese version of Cyberchondria Severity Scale（≥36.50）and Chinese version of Short Health Anxiety Inventory（≥44.52） for collecting the data about the frequencies of searching the information concerning health/illness，source of information，reactions after searching，and impact of searching on oneself.Data obtained were organized and analyzed using NVivo 11 and grounded theory.Results　Participants demonstrated a good understanding of the strengths and limitations of online health/illness-related information.Reactions after searching mainly include the following 3 aspects——cognitive reactions：spending time on searching for such information online was thought to be helpful，worthwhile and necessary；emotional reactions：being scared/confused of and worried/anxious about their own conditions；behavioral reactions：self-diagnosis and self-treatment/medication were attempted to be conducted，or seeking healthcare in hospitals or continuing to search the relevant information.Causes for long-term prevalence of cyberchondria cover the following 4 aspects：insufficient explanations related to treatment given by professional physicians，self-perceived poor health status，poor tolerance of uncertainty and perfectionism.Conclusion　Contradictory emotional and cognitive reactions can be found in individuals with cyberchondria after searching health/illness-related information online，which，together with the causes of cyberchondria，can be used as the basis for monitoring such information and delivering clinical interventions.
    Comprehensive Geriatric Assessment Tools in China and Abroad　
    ZHU Kai-yi，TAO Hong*
    2018, 21(22):  2760-2767.  DOI: 10.12114/j.issn.1007-9572.2018.22.023
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    Comprehensive geriatric assessment （CGA） is both the foundation and the key to health management and is important for achieving healthy aging.This article reviews the research progress of CGA tools and their application at home and abroad.The results show that related research abroad is relatively mature，and there are several complete assessment scales with a wide range of application.However，the research of CGA in China is still in its infancy with a lack of assessment scales and limited suitable objects.Therefore，CGA in China has more room for development and it is necessary to develop CGA tools suitable for China's national conditions and cultural background based on related research of CGA tools abroad.
    Recent Developments in Common Nutritional Risk Screening Tools for the Elderly　
    ZHAO Xiao-fang，JIANG Chun-yan
    2018, 21(22):  2768-2772.  DOI: 10.12114/j.issn.1007-9572.2018.22.024
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    With the accelerated development of population aging in China，the number of elderly people with nutritional risk is increasing.Nutritional risk is an important factor leading to the deterioration of clinical outcomes.Therefore，its screening should be regarded as a routine clinical task.Up to the present，there are a variety of nutritional risk screening tools.We introduced the current nutritional status of the elderly，analyzed and compared the contents，evaluation methods，scopes of application and limitations of several commonly used nutritional risk screening tools suitable for older people.It would be helpful for clinical medical care providers to choose an appropriate nutritional risk screening tool in different situations.
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