Chinese General Practice

Update Focus Interpretation：CANMAT/ISBD 2018 Guidelines for the Management of Patients with Bipolar Disorders　

CHEN Jun，FANG Yiru，XU Yifeng

2019, 22(2): 123-127. DOI: 10.12114/j.issn.1007-9572.2018.00.408

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With the development of society and the increase of priority given to mental health，the impact on patients caused by bipolar disorders is brought into focus. How to make a correct diagnosis and treatment is a big challenge to every psychiatrist. In this review，key content and changes for the CANMAT/ISBD 2018 guidelines for the management of patients with bipolar disorders are addressed. The main contents include the general highlights of the guidelines，the basis of bipolar disorders management，drug treatment and the role and recommendation of psychosocial intervention，hoping to give a hand to clinicians to better understand the new guidelines.

Research Progress in Localized Group Therapy for Compulsory Isolation Drug Rehabilitation　

LI Ziyang，MA Zhiqiang，LIU Guorui，LIU Wei，CHENG Xiaoyu

2019, 22(2): 128-135. DOI: 10.12114/j.issn.1007-9572.2018.00.023

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Compulsory isolation is the main method of drug rehabilitation in China.Key to this method's success is not only physical rehabilitation but，more importantly，removing "addictedness".Compulsory isolation drug rehabilitation is associated with a high relapse rate，owing to the limitations of the work functions of the compulsory isolation agencies，the special role of police officers，and limitations in the practices of the related agencies，as well as the incompleteness of the follow-up care system.Our study explored a method of localized group therapy that integrates multiple techniques and modules.The high-dose，systematic group therapy was performed on a target population to improve efficacy and reduce relapse.Our study also provides evidence of the establishment of a scientific and effective drug rehabilitation model.

Group Exercise Therapy on Quality of Life and Emotions in Female New-type Drug Addicts　

LIANG Xueping，CHEN Chen，WANG Rui，ZHUANG Shumei

2019, 22(2): 136-141. DOI: 10.3969/j.issn.1007-9572.2018.00.189

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Background　Women addicted to new-type illegal drugs often suffer from physical and mental problems and undergo social dysfunctions.In China，the treatment of new-type drug addiction mainly focuses on compulsory rehabilitation and lacks effective treatments and rehabilitation methods for women.Objective　To explore the effects of group exercise therapy on the quality of life and emotions in female new-type drug addicts.Methods　A total of 73 female new-type drug addicts receiving detoxification treatment at Detoxification Center of Ankang Hospital of the Tianjin Public Security Bureau between January 2016 and June 2017 were enrolled in the study through cluster sampling.Thirty-seven female new-type drug addicts selected between January and September in 2016 were included in the control group，and 36 female new-type drug addicts enrolled between October 2016 and June 2017 were included in the test group.The control group received conventional detoxification treatment and nursing care，and the test group received 3 months of collective sports therapy based on conventional detoxification treatment and nursing care.Pre- and post-intervention，the Quality of Life Scale for Drug Addicts （QOL-DA V2.0），Self-Rating Depression Scale （SDS），and Self-Rating Anxiety Scale （SAS） were used to assess quality of life，and depression and anxiety in the new-type drug female addicts.Results　After the intervention，the scores of physical function，mental health，social functioning，withdrawal dimensions，and QOL-DA V2.0 of the drug addicts in the test group were higher than those in the control group （P<0.05）.The scores of physical function，mental health，social functioning，withdrawal dimensions，and QOL-DA V2.0 after intervention were higher than those before intervention in the control group （P<0.05）.The scores of physical function，mental health，social functioning，withdrawal dimension，and QOL-DA V2.0 after intervention were higher than those before the intervention in the test group （P<0.05）.After the intervention the SDS and SAS scores were lower in both the control and test groups （P<0.05）.Furthermore，after the intervention the SDS and SAS scores were lower in the test group than in the control group （P<0.05）.Conclusion　Group exercise therapy can improve the quality of life and effectively relieve negative emotions such as depression and anxiety in female new-type drug addicts.This treatment is recommended for further clinical use.

Prevalence of Alcohol Use Disorder in Patients with Mental Disorders　

YAN Baoping，LI Wei，ZHANG Xianfeng，HAN Zifei，BI Hao，WANG Sujuan，LI Bing

2019, 22(2): 142-146. DOI: 10.12114/j.issn.1007-9572.2018.00.069

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Background　Mental disorders are often comorbidities with alcohol use disorders. At present，there are few reports on the influencing factors of this phenomenon, and the conclusions are inconsistent. Clinicians pay more attention to the diagnosis of mental disorders and ignore the existence of comorbidity. Comorbidity are often missed. Objective　To investigate the prevalence of alcohol use disorder （AUD） and associated factors among inpatients with mental disorders.Methods　We enrolled 710 inpatients with mental disorders from Heibei Mental Health Center，from October 10 to October 17，2016.We employed the diagnostic and statistical manual of mental disorders-fifth edition （DSM-5） to assess the types of mental disorders，and according to the results，assigned 171 with AUD and 539 without to the comorbidity group and non-comorbidity group，respectively.We used a self-developed baseline questionnaire to collect their baseline data 〔including sex，age，marital status，education，living style，family relationship，occupation，pre illness personality，alcohol family history，diagnosis，risk assessment （such as impulsive，outward，self injury，suicide）〕.Results　The prevalence of AUD in inpatients with schizophrenia spectrum disorders，depressive disorders，bipolar and related disorders，and other types of mental disorders was 19.6% （59 cases），27.2% （44 cases），34.5% （51 cases），17.2% （17 cases），respectively.Inpatients with AUD and those without showed significant differences in the distribution of sex，status of family relations，occupation，family history of alcoholism，distribution of mental disorders and the proportion of impulsiveness （P<0.05）.Multivariate Logistic regression analysis showed that male 〔OR=7.57，95%CI （4.63，12.37）〕，inharmonious family relationship 〔OR=2.35，95%CI （1.36，4.08）〕，unemployed 〔OR=3.75，95%CI （1.98，7.10）〕，depressive disorders 〔OR=2.81，95%CI （1.40，5.63）〕and risk of impulse-control disorders 〔OR=1.72，95%CI （1.12，2.65）〕were the associated factors for the prevalence of AUD in inpatients with mental disorders （P<0.05）.Conclusion　The prevalence of AUD is high in inpatients with mental disorders.Male，inharmonious family relationship，unemployed，depressive disorders and risk of impulse-control disorders may be the factors associated with it.

Survey of the Correlation between Medication Adherence and Social Support among Locked Schizophrenia Patients after Receiving Unlocking Treatment　

ZHOU Mengdi，ZHANG Yunshu，WANG Qi，SUN Jianhua，LI Keqing

2019, 22(2): 147-150. DOI: 10.12114/j.issn.1007-9572.2018.00.243

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Background　In December 2004, the project “central subsidy for local management and treatment of severe mental illness” (also known as “686” project) was officially launched. Five hospitals in Hebei, including Hebei Mental Health Center have actively carried out the special work of “unlocking treatment” in Hebei Province, from which hundreds of patients with severe mental illness benefited. Objective　To explore the relationship between medication adherence and social support among locked schizophrenia patients after receiving unlocking treatment，providing a theoretical basis for improving the medication adherence of this population. Methods　This follow-up survey was conducted from October to November 2016. The participants were those locked schizophrenia patients in Hebei Province who received unlocking treatment，a therapy program by 5 hospitals （Hebei Mental Health Center，Huanghua Anding Hospital，Hengshui Jingda Mental Rehabilitation Hospital，Zhangjiakou Shalingzi Hospital and Hengshui Mental Hospital） between November 2006 and March 2012. The status of medication adherence and social support was surveyed by Data of Locked Schizophrenia Patients Receiving Unlocking Treatment Questionnaire，Social Support Rating Scale（SSRS），and Medication Adherence Rating Scale. Results　A total of 87 cases were included. The mean total scores of SSRS of them were much lower than those of the national norms 〔（24.0±4.8） vs （34.6±3.7）〕（t=-20.628，P<0.01）．　The medication adherence differed significantly by prevalence of receiving re-locking treatment（P<0.05），but not by sex，age，educational level，marital status，prevalence of somatic disease，prevalence of enjoying the minimum living guarantee，methods for paying the medical expenses（P>0.05）．The prevalence of having good medication adherence was （59±40） %. The medication adherence was positively correlated with the scores of subjective support and objective support and total scores of SSRS（rs=0.328，P=0.002；rs=0.351，P=0.001；rs=0.392，P<0.001），but showed no correlation with utilization of support（rs=0.204，P=0.058）． Conclusion　After receiving unlocking treatment，locked schizophrenia patients showed an significantly increased medication adherence，and social support is a contributing factor involved in the process.

Effect of Tolvaptan-induced Increase of Plasma Osmotic Pressure on the Prognosis of Patients with Chronic Heart Failure　

LIU Jing，LI Jiafu，ZHOU Lili

2019, 22(2): 151-156. DOI: 10.12114/j.issn.1007-9572.2018.00.210

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Background　Chronic heart failure （CHF） is the terminal stage of all cardiovascular diseases，and its incidence，hospitalization rate and mortality rate increased gradually.Compared with traditional diuretics，tolvaptan has less effect on electrolyte balance，which in turn can achieve better therapeutic effects，but there is also a risk of elevating plasma osmotic pressure.Objective　To investigate the predictive effect of elevated plasma osmotic pressure （POP） induced by tolvaptan on the prognosis of patients with CHF．Methods　We enrolled 83 patients with CHF from Department of Cardiology，the Affiliated Hospital of Southwest Medical University from January 2015 to January 2017.All of them received combination treatment with tolvaptan based on their own conditions and an outpatient follow-up of 12-months （started since the initiating of the standardized treatment）．We collected their clinical data，laboratory findings and echocardiographic results.Kaplan-Meier method was used to perform the survival analysis.Univariate and multivariate Cox proportional hazard models were adopted to investigate the factors affecting the prognosis of these patients and the values of them were examined by ROC analysis.Results　Except for 6 drop outs，other 77 completed the follow-up.Among them，25 with endpoint events and 52 without were found with poor prognosis，good prognosis，respectively.The 2-，4-，and 6-month survival rates for them were 93.8%，84.2%，77.0%，respectively.The analysis with multivariate Cox proportional hazard models identified that troponin T （cTnT）〔RR=1.373，95%CI（1.005，1.876）〕，left ventricular ejection fraction （LVEF）〔RR=1.463，95%CI（1.036，2.066）〕，N-terminal brain natriuretic peptide （NT-proBNP）〔RR=1.051，95%CI（1.015，1.166）〕，increased POP 〔RR=1.638，95%CI（1.206，2.224）〕were independent factors for the prognosis of CHF patients with tolvaptan treatment （P<0.05）．For predicting the prognosis of CHF treated by tolvaptan，the area under the ROC curve （AUC） of cTnT，LVEF，NT-proBNP，increased POP，NT-proBNP combined with increased POP was 0.74，0.67，0.80，0.83，0.87，respectively.NT-proBNP combined with POP had a larger AUC than NT-proBNP （Z=2.706，P=0.048） and POP （Z=3.124，P=0.032） alone.Conclusion　cTnT，LVEF，NT-proBNP and increased POP could independently predict the prognosis of patients with CHF treated by tolvaptan，in particular，NT-proBNP combined with increased POP has a higher predictive value.

Usage of Beta Blocker and Resting Heart Rate Control of Uyghur，Chinese Han Populations with Coronary Heart Disease in Xinjiang　

LIANG Jian，SU Xin，LIU Hongyang，XU Zhongcheng，LIU Wen，WANG Li

2019, 22(2): 157-161. DOI: 10.12114/j.issn.1007-9572.2018.00.184

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Background　Beta blockers can improve clinical symptoms of coronary heart disease（CHD），relieve the incidence of angina pectoris and reduce all-cause mortality in patients.Lesion degree and risk factors of CHD show differences in Uygur and Chinese Han patients.Between two ethnic groups，the difference in clinical medication should also be taken seriously.Objective　To investigate the usage of beta blockers and resting heart rate （RHR） controlling status in Uygur and Chinese Han patients with CHD in Xinjiang，and to explore its influencing factors.Methods　A total of 812 patients 〔140 Uyghur （17.24 %） and 672 Chinese Han （82.76 %）〕，diagnosed with CHD and hospitalized in the First Affiliated Hospital of the Medical College，Shihezi University from December 2016 to March 2017 were enrolled and followed up for six months.Data of general clinical information，coronary arteriography，revascularization，characteristics of coronary lesions，the usage，types and dosage of beta blockers，RHR at admission and discharge，controlling rate of RHR，and the rate of compliance and the causes of the drug withdrawal were collected and recorded.Factors influencing beta blockers-taking compliance and controlling rate of RHR were analyzed with multivariate Logistic regression analysis.Results　Compared to Chinese Han patients with CHD，Uygur patients are significantly younger and they displayed larger body mass index （BMI），lower controlling rate of RHR，higher low density lipoprotein level，higher rate of coronary arteriography and revascularization，combined with other diseases including hypertension，heart failure，myocardial infarction and multi-vessel lesion，with higher RHR at admission and discharge（P<0.05）．In addition，the results of multivariate Logistic regression analysis showed that age 〔OR=8.924，95%CI（5.483，14.525）〕，smoking 〔OR=2.014，95%CI（1.412，2.873）〕，hypertension 〔OR=1.697，95%CI（1.183，2.436）〕，myocardial infarction 〔OR=1.418，95%CI（0.994，2.022）〕，heart failure 〔OR=1.661，95%CI（1.155，2.388）〕，diabetes mellitus 〔OR=2.175，95%CI（1.497，3.160）〕，coronary angiography 〔OR=1.887，95%CI（1.320，2.696）〕，revascularization 〔OR=2.080，95%CI（1.376，3.145）〕，the number of involved coronary lesions 〔OR=0.159，95%CI（0.070，0.359）〕 were related to higher taking rate of beta blockers （P<0.05）．Factors influencing the controlling rate of RHR included age 〔OR=2.069，95%CI（1.173，3.649）〕，nationality 〔OR=0.292，95%CI（0.196，0.433）〕，myocardial infarction 〔OR=1.918，95%CI（1.357，2.710）〕.After a 6-month follow-up，the compliance rates were 89.29% （125/140） and 93.78% （618/659） among Uyghur and Chinese Han patients，respectively.Conclusion　Both Uygur and Chinese Han patients with CHD had low taking rate of beta blockers.Although Uygur patients had higher proportion of taking beta blockers than Chinese Han patients，they had faster RHR and lower controlling rate of RHR，which requires clinicians to improve the usage of beta blockers in Uygur patients with CHD.

Investigation of the Influences of Donor and Recipient Conditions on MELD Scores in Patients Undergoing Donor Liver Transplantation after Cardiac Death　

FANG Dazheng，HU Wei，ZHANG Bo

2019, 22(2): 162-166. DOI: 10.12114/j.issn.1007-9572.2018.00.024

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Background　In recent years，the score of model for end-stage liver disease （MELD） which explores high-risk factors of the incidence of complication and mortality after liver transplantation has attracted a lot of attention. Most studies focus on the effect of preoperative conditions on postoperative recovery at present.In this study，we investigated the effect of preoperative conditions on the changes of MELD score after liver transplantation and provided new ideas for the recovery of recipients after transplantation.Objective　To investigate the effects of the preoperative conditions of donors after cardiac death （DCD） on MELD scores after liver transplantation.Methods　A total of 25 DCD liver transplantation cases in the Institute of Organ Transplantation，Tongji Hospital，Tongji Medical College，Huazhong University of Science and Technology were retrospectively selected from September 2013 to September 2015.Data on donor sex，age，duration of ICU treatment，preoperative serum indices 〔alanine aminotransferase （ALT），aspartate aminotransferase （AST），direct bilirubin （DBiL），total bilirubin （TBiL），white blood cell count （WBC），and hemoglobin （Hb）〕，and the MELD scores of recipients before and after transplantation were collected and analyzed.Results　The decreases in the postoperative MELD scores of male （n=19） and female （n=6） donors were（2.80±1.32）% and （1.40±0.66）%，and the difference was significant（t=2.476，P=0.021）.There were 15 donors <45 years old and 10 donors ≥45 years old；the decreases in the postoperative MELD scores of the two groups were（2.73±1.26）% and （2.07±1.40）%，and were not significantly different between groups（t=-1.210，P=0.242）.Regarding the duration of ICU treatment，there were 3 cases <5 d，14 cases 5-10 d and 8 cases >10 d；the decreases in the postoperative MELD scores of the three groups were （2.30±1.38）%，（2.85±0.85）% and（2.94±1.76）%，and were not significantly different among groups （F=0.957，P=0.516）.There was no linear correlation between the decreases in the postoperative MELD scores of the recipients and the age，duration of ICU treatment，preoperative AST，DBiL，WBC and Hb of the donors，as well as the preoperative MELD scores of the recipients （r=-0.344，P=0.093；r=-0.294，P=0.154；r=-0.271，P=0.090；r=-0.181，P=0.386；r=-0.310，P=0.096；r=-0.205，P=0.325；r=-0.219，P=0.294）.The preoperative ALT and TBiL levels of the donors negatively correlated with the decreases in the postoperative MELD scores of the recipients （r=-0.301，P=0.044；r=-0.372，P=0.012）.Linear regression analysis showed that the preoperative levels of ALT，AST and TBiL of the donors correlated with the decreases in the postoperative MELD scores of the recipients （P<0.05）.Conclusion　The higher levels of ALT，AST and TBiL before transplantation，the lower decreases in the postoperative MELD scores of recipients，and the slower recovery of recipients.A high level of ALT，AST or TBiL is the main risk factor for complications in liver transplantation.

Protective Effect and Mechanism of Simvastatin on Cognitive Dysfunction in Type 2 Diabetes Mellitus　

ZHANG Hewei，FANG Hui，SUN Xueling，ZHANG Yazhong，TIAN Jinli

2019, 22(2): 167-173. DOI: 10.12114/j.issn.1007-9572.2018.00.128

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Background　Type 2 diabetes mellitus （T2DM） is a common endocrine and metabolic disorder　characterized by hyperglycemia. Long-term hyperglycemia can cause cognitive impairment，including memory and learning impairment, orientation impairment，executive impairment and so on. Compared with common complications of T2DM，there is less research on the complications of central nervous system. Objective　To observe the effect of simvastatin on learning and memory capacity in rats with T2DM and to determine the role of the mammalian target of rapamycin （mTOR）/p70 ribosomal protein S6 kinase （p70S6K） pathway in the improvement in cognitive function induced by simvastatin.Methods　In September 2016，120 healthy male Sprague-Dawley （SD） rats were divided into the control group，diabetic group and simvastatin group （n=40，respectively）．T2DM rat models were successfully established in the diabetic group （n=38） and the simvastatin group （n=37） by intraperitoneal injection of streptozotocin.Rats in the simvastatin group were given simvastatin intragastrically.Rats in the control group and diabetic group were administered an equal volume of 0.9% sodium chloride solution intragastrically.After 32 weeks of feeding，the rats were subjected to a Morris water maze test to evaluate memory capacity.Changes in the hippocampal formation in each group were observed under a microscope.Western blotting was performed to analyze the expression of mTOR，p70S6K，tau，malondialdehyde （MDA），and glutathione （GSH） protein.Results　Compared with the control group，rats in the diabetic group and simvastatin group were characterized by higher fasting blood glucose and lower body weight （P<0.01）．The escape latencies of rats in the diabetic and simvastatin groups were longer on the 2nd，3rd，4th，and 5th day than in the control group （P<0.05）；while the escape latencies on the 2nd，3rd，4th，and 5th days in the simvastatin group were shorter than those in the diabetic group （P<0.05）．Microscopic observations showed that hippocampal neurons in the diabetic group were reduced，showed disordered arrangement，membrane folds，missing nuclei，and reduced organelles；while the hippocampal neurons in the simvastatin group were approximately normal in structure and slightly reduced in number.The p-mTOR/mTOR，p-p70S6K/p70S6K，and p-tau/t-tau in the diabetic and simvastatin groups were significantly higher than those in the control group （P<0.01）；while these levels in the simvastatin group were lower than those in the diabetic group （P<0.01）．The MDA/β-actin and GSH/β-actin in the diabetic group and simvastatin group were significantly higher than those in the control group （P<0.01）；while these levels in the simvastatin group were lower than those in the diabetic group （P<0.01）．Conclusion　The improvement in cognitive function in T2DM rats administered simvastatin may be related to inhibition of the mTOR/p70S6K signaling pathway and reduced generation of oxidative stress.

Metabolic Parameters Measured by 18F-FDG PET/CT Imaging Predict the Prognosis of Small Cell Lung Cancer　

MENG Xin，GUO Hong，WANG Li，ZHOU Jian，ZHAO Wenjing，SUI Xuefeng，CUI Hongsheng，XU Jinzhi

2019, 22(2): 173-179. DOI: 10.12114/j.issn.1007-9572.2018.00.254

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Background　Clinical staging of small cell lung cancer （SCLC） is critical for its prognosis.18F-FDG PET/CT can show the shape，involvement range and metabolic status of the lesion.The purpose of this study is to explore the value of metabolic indicator，18F-FDG PET/CT in the diagnosis，clinical staging，efficacy evaluation and prognosis prediction of SCLC．Objective　To analyze the performance of metabolic parameters measured by 18F-FDG PET/CT imaging for predicting the prognosis of SCLC．Methods　Eighty-six cases of newly diagnosed SCLC who received 18F-FDG PET/CT imaging examination in the Third Affiliated Hospital of Qiqihar Medical University and the Fourth Affiliated Hospital of Harbin Medical University from 2007 to 2016 were enrolled，and divided into limited stage （LS） SCLC group （n=45） and extensive stage （ES） SCLC group （n=41） according to the examination results.The clinical data and metabolic parameters measured by 18F-FDG PET/CT imaging，including maximum standardized uptake value （SUVmax），mean standardized uptake value （SUVmean），peak standardized uptake value （SUVpeak），metabolic tumor volume （MTV） and total lesion glycolysis （TLG） with a fixed threshold of 40% SUVmax in LS SCLC group，and SUVmax，MTV，TLG of primary lesion，the biggest SUVmax of all lesions，the sum of metabolic volume （MTVsum） and TLG （TLGsum） in ES SCLC group were collected.Multivariate Cox proportional hazards analysis was performed to analyze the predictors of overall survival （OS） and progression free survival （PFS）．Results　Except the rate of receiving thoracic radiation therapy was higher in the LS SCLC group （P<0.05），two groups showed no significant differences in male-to-female ratio，mean age，prevalence of smoking history，mean ECOG score，prevalence of pleural effusion，TNM stage distribution，rate of receiving systemic chemotherapy，rate of receiving whole-brain radiation as a preventative therapy，prevalence of lactate dehydrogenase （LDH） ≥245 U/L，prevalence of carcinoembryonic antigen （CEA） ≥5 μg/L，prevalence of neuron-specific enolase （NSE） ≥15.2 μg/L （P>0.05）．The follow-up of 3-105 months showed that during this period，29 survived （including 24 LS SCLC patients and 5 ES SCLC patients） and 57 died （including 21 LS SCLC patients and 36 ES SCLC patients）；the mean OS and PFS were 21.3，30.6 months，respectively；the 1-，2-，3-year overall survival rates were 70.9%，51.2%，29.1%，respectively；the 1-，2-，3-year progression free survival rates were 61.6%，43.0%，32.6%，respectively.Multivariate Cox proportional hazard regression analysis showed that the ECOG score of 3 to 4 points 〔HR=3.118，95%CI（1.196，8.131）〕，TNM stage Ⅲ 〔HR=7.739，95%CI（2.017，29.691）〕，and TLG 〔HR=1.056，95%CI（1.004，1.111）〕 were independent influencing factors for OS in LS SCLC patients （P<0.05）；TLGsum 〔HR=3.898，95%CI（1.132，13.426）〕 was independent influencing factors for OS in ES SCLC patients （P<0.05）；LDH≥245 U/L 〔HR=4.957，95%CI（1.080，3.353）〕，MTV 〔HR=1.205，95%CI（1.008，1.440）〕 were independent influencing factors of PFS in LS SCLC patients （P<0.05）；ECOG score of 3-4 points〔HR=5.555，95%CI（1.697，18.183）〕，LDH≥245 U/L 〔HR=2.898，95%CI（1.326，6.335）〕，and TLGsum 〔HR=3.898，95%CI（1.355，11.211）〕 were independent influencing factors of PFS in ES SCLC patients（P<0.05）．Conclusion　The volume-based metabolic parameters measured by 18F-FDG PET/CT imaging can effectively predict the prognosis of SCLC patients.TLG and MTV are the independent factors associated with OS and PFS in LS SCLC patients，and TLGsum is an independent factor associated with OS and PFS in ES SCLC patients.But there is no significant correlation between SUVmax and prognosis.

Demand Analysis for Integrated Medical and Nursing Care among Community-dwelling Elderly People Based on Andersen's Behavioral Model　

LIU Xiaochu，YANG Liangqin，LUO Yuru，LUO Jing，JU Mei

2019, 22(2): 180-187. DOI: 10.12114/j.issn.1007-9572.2018.00.272

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Background　The development of integrated medical and nursing care in China frequently encounters bottlenecks，and numerous problems need to be urgently solved. Typically，the demand of a multi-stage，multi-layered and diversified medical and nursing care for the elderly is the source issue that affects institutional development and service implementation. Therefore，targeting and analyzing the demand can guarantee that integrated medical and nursing care will develop healthily，improve supply-demand balance，and optimize the allocation of resources.Objective　To investigate the awareness，demand and influencing factors of integrated medical and nursing care among community-dwelling elderly in Luzhou City，so as to provide evidence for the development of delivery modes of this kind of care.Methods　From February to May 2018，a cross-sectional survey was conducted in Luzhou City among a convenience sample of 650 community-dwelling elderly individuals who were eligible for the study.The Self-developed General Demographic Questionnaire and Integrated Medical and Nursing Care Questionnaire，Chinese version of the Comprehensive Frailty Assessment Instrument （CFAI），Chinese version of the Zung Self-Rating Depression Scale （SDS），and Social Support Rating Scale （SSRS） were adopted for the survey.Based on the framework of Andersen's behavioral model，3 Logistic regression models （named as model Ⅰ，model Ⅱ，model Ⅲ） incorporated with predisposing，enabling and need factors （obtained from the survey results），respectively，were established and their estimated probability and goodness of fit were assessed by Hosmer-Lemeshow test.Binary Logistic regression analysis was performed to investigate the influencing factors of community-dwelling elderly' needs for integrated medical and nursing care.Results　A total of 650 sets of questionnaires were distributed，and 627 responsive ones were collected，with a response rate of 96.5%.Among the 627 respondents，340 （54.2%） were aware of the integrated medical and nursing care，and 416 （66.3%） demanded for this kind of care.Compared with model Ⅰ，the -2 log likelihood （-2LL） values in models Ⅱ and Ⅲ were smaller，while Cox＆Snell R2 and Nagelkerke R2 were greater.Moreover，the -2LL of model Ⅲ was smaller，while Cox＆Snell R2 and Nagelkerke R2 were greater compared with model Ⅱ，suggesting that model Ⅲ displayed the best goodness of fit to the sample.Additionally，binary Logistic regression analysis indicated that，age〔OR=1.692，95%CI （1.118，2.560）〕，number of children 〔OR=0.571，95%CI （0.407，0.800）〕，convenience of seeking healthcare〔OR=2.931，95%CI （2.117，4.058）〕，social support degree 〔OR=0.455，95%CI （0.326，0.635）〕，chronic disease prevalence 〔OR=1.999，95%CI （1.343，2.975）〕，awareness level of integrated medical and nursing care 〔OR=1.719，95%CI （1.222，2.418）〕，frailty degree 〔OR=2.495，95%CI （1.666，3.736）〕，and depression degree 〔OR=1.914，95%CI （1.296，2.827）〕　were the influencing factors of demand for integrated medical and nursing care among the community-dwelling elderly （P<0.05）． Conclusion　Both the levels of awareness and needs of integrated medical and nursing care among the community-dwelling elderly people in Luzhou are relatively high.As the needs of such care are affected by multiple factors，it is recommended that the government，enterprises and subsequent researchers carry out classification analysis of these factors during the investigation.In addition，the delivery of integrated medical and nursing care should be gradually developed after pilot implementation.

Analysis and Strategy Research on the Mode of Medical Care Service for the Aged in Urban and Rural Areas of Guangzhou　

LIAO Shengwu，TAN Bihui，LI Wenyuan，CHEN Baoan

2019, 22(2): 188-193. DOI: 10.12114/j.issn.1007-9572.2018.00.232

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The nursing issue is under enormous pressure with a growing aging population in China.The aging level of Guangzhou is obviously higher than the national average level.There is a serious problem of medical care service for the elderly in urban and rural areas in Guangzhou.Facing this reality，we must have a in-depth analysis of the present situation of medical care service for the elderly in Guangzhou to study and discuss coping strategies，establish a basic mode of medical care，pay attention to the relationship of medical care services，and properly handle the relationship between the state and the private，the collective and the individual，the top and the grass-roots level.We need to realize the benign operation of medical care services for the aged in urban and rural areas of Guangzhou by integrating public resources，strengthening the infrastructure and management，formulating policies and regulations，and establishing and improving the operation mechanism of medical care services.

Development of Service Quality Indicators for Health Care Combined with Nursing Home　

DU Xiaofei，JING Liwei，WANG Qing，JIN Rong，XING Fengmei

2019, 22(2): 194-198. DOI: 10.12114/j.issn.1007-9572.2018.00.208

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Background　With an increasingly aging population in China，the model of integrated elderly care and medical services has become a trend.It will greatly alleviate the pressure of old-age care in China，but there is no clear and unified evaluation standard for the service quality of medical and nursing homes．Objective　To construct an evaluation index system of Service Quality Indicators for Health Care Combined with Nursing Home．Methods　Based on the “structure-process-result” framework，a quality evaluation index system framework was formulated through field research，related policies and literature and Delphi method to build a preliminary item pool of index system of Service Quality Indicators for Health Care Combined with Nursing Home from October 2017 to March 2018.The reliability of expert consultation was analyzed by using positive coefficient，authority coefficient （Cr） and harmony coefficient of experts.The importance mean score，coefficient of variation （CV） and full score was used to evaluate the entries，and the weight of each index was determined by the weight method of percentile．Results　The effective questionnaire recovery rates for two rounds of expert consultation were 91.6% and 100.0%，respectively，and authority coefficients were 0.83 and 0.84，respectively.Harmony coefficients （W） of level two and three indicators in the first round of expert consultation were 0.116 and 0.137，respectively，and in the second round 0.137 and 0.321，respectively （P<0.05）．The evaluation index system of Service Quality Indicators for Health Care Combined with Nursing Home was determined in the end，including 3 first-level indicators，14 second-level indicators，and 72 third-level indicators．Conclusion　Index system of Service Quality Indicators for Health Care Combined with Nursing Home is initially established，providing quantitative basis for service quality evaluation and continuous improvement for health care combined with nursing homes.

Development of the Evaluation Index System of the Supply Service Quality of the Community-home Care Center with Medical Care　

ZHU Liang，YANG Xiaojiao，ZHANG Qian，WANG Fenglan，ZHANG Xiaoli，XING Fengmei

2019, 22(2): 199-205. DOI: 10.12114/j.issn.1007-9572.2018.00.248

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Background　In order to cope with the aging，the government has given strong support to the medical care，so the number of community-home service institutions has increased. However，due to“old before rich”national conditions and the late start of pension undertakings in China，there are many problems，such as the non-standard medical service and the imperfection of the service quality system.Objective　To develop the Evaluation Index System of the Supply Service Quality of the Community-home Care Center with Medical Care.Methods　From June to August，2017，twenty community service centers and fifteen community day-care centers in Beijing，Tianjin and Hebei were chosen by purposive sampling，and the initial version of the service quality evaluation index system was established.From November 2017 to January 2018，three rounds of questionnaire consultations were delivered in person or by E-mail to 23 experts to make a judgment on the appropriateness，importance，familiarity and basis for determination.At the end of the questionnaire consultation，the expert positive coefficient，authority coefficient，coordination degree and index importance value，full score ratio and variation coefficient were calculated.Results　The three rounds of positive coefficients were 88.5%，100.0% and 100.0%，respectively；the authority coefficients were 0.905，0.909 and 0.922 respectively; the coefficients of variation were 0.06 to 0.24，0 to 0.17 and 0 to 0.22；and Kendall's W coefficient were 0.249，0.252 and 0.316.According to the index screeningcriteria and experts' opinions，twelve indicators were deleted，and sixteen indicators were increased in the first round and five indicators were deleted，only one indicator was revised and added in the second round.The indexs were not revised ，deleted or added in the third round.Finally，the service quality evaluation index system of the combination of medical care and pension in the home care center with 3 first-level indicators，15 second-level indicators，64 third-level indicators were established after three-round Delphi consultation.Conclusion　The expert opinion concentration degree of the system is high，and the result reliability is strong，which can provide a basis for the evaluation，construction and improvement of the Evaluation Index System of the Supply Service Quality of the Community-home Care Center with Medical Care.

Translation and Evaluation of Reliability and Validity of Multidimensional Fear of Death Scale　

SONG Zimin，LIU Weiwei

2019, 22(2): 206-209. DOI: 10.12114/j.issn.1007-9572.2018.00.155

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Objective　To translate the Multidimensional Fear of Death Scale（MFODS），and to filter items and construct structure of Chinese version of MFODS based on Chinese cultural background.Methods　A total of 15 community health service institutions in Beijing was selected to conduct a questionnaire survey on patients by a convenient sampling method from May to August 2017，and experts were organized to translate，back-translate the MFODS，then pre-investigation were conducted.The subjects were randomly divided into two groups，one group for filtering items and evaluating reliability and validity of MFODS，and the other group for verifying the reliability and validity of the scale.Results　In this study，1 100 questionnaires were distributed，and 1 031 questionnaires were effective，with a recovery rate of 93.7%.Through items filtering and multiple exploratory factor analysis，6 common factors were extracted，containing 33 items，and the cumulative variance contribution rate was 52.598%.The Cronbach'sαof the scale was 0.916，and of each dimension was 0.625-0.843.The retest reliability coefficient of the scale was 0.891，and of each dimension was 0.616-0.855.Six common factors were extracted in the other group，and cumulative variance contribution rate was 54.292%；the Cronbach'sαof total scale was 0.924，and of each dimension was 0.595-0.835.Conclusion　The Chinese version of MFODS constructed has a good reliability and validity，while it still needs to be further adjusted and improved in accordance with the Chinese culture.

Chinesization of the 10-item Identity-Consequence Fatigue Scale and Its Application in Patients after Gastrointestinal Tumor Surgery　

XU Xinyi，XU Qin

2019, 22(2): 210-214. DOI: 10.12114/j.issn.1007-9572.2018.00.250

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Background　Postoperative fatigue（POF）has a high incidence and a serious impact on prognosis and quality of life for patients after gastrointestinal tumor surgery.At present，there is no simple and targeted tool for gastrointestinal tumor patients to assess POF.In addition，the existing assessment scales have some limitations.Objective　To translate the 10-item Identity-Consequence Fatigue Scale（ICFS-10）into Chinese and test its reliability and validity and determine the optimal cut-off point in patients after gastrointestinal tumor surgery.Methods　We developed the Chinese version of ICFS-10 based on the translation，back translation，revision based upon expert consultations and cultural adaptation guideline recommended by American Academy of Orthopaedic Surgeons Evidence Based Medicine Committee.Then，using it and the Chinese version of PFS-R，and Chinese version of HADS，we conducted a survey among a convenience sample of 80 patients who underwent gastrointestinal tumor surgery in Jiangsu Province Hospital from November 2017 to January 2018.The reliability and validity of the Chinese version of ICFS-10 were analyzed，and its optimal cut-off point was defined by ROC analysis and threshold effect analysis.Results　According to the scale score of the Chinese version of ICFS-10，these patients were divided into high-score group（n=20）and low-score group（n=20）by the critical ratio.High-score group scored higher in each item of the Chinese version of ICFS-10 compared with the low-score group（P<0.05）．Item score increased with the scale score of the Chinese version of ICFS-10（P<0.05）．The Chinese version of ICFS-10 demonstrated scale-level content validity index（CVI）of 0.96，item-level CVI of 0.86 to 1.00.KMO value of Chinese version of ICFS-10 was 0.868，Bartlett's test of χ2 was 780.99，P<0.001，indicating that it was suitable for exploratory factor analysis.Exploratory factor analysis indicated that Chinese version of ICFS-10 consisted of 2 factors with igenvalues of 6.191，1.543（extracted on the basis of the extraction decision rule of eigenvalue ≥1.000）which explained 77.34% of the total variance，and factor loading of all 10 items ranged 0.588 to 0.918.The scale score of the Chinese version of ICFS-10 showed a positive correlation with that of the Chinese version of PFS-R（P<0.05）．The values of Cronbach's α for the scale and two common factors of the Chinese version of ICFS-10 were 0.928，0.907，0.877，respectively.For the diagnosis of POF，the AUC of the Chinese version of ICFS-10 was 0.833〔95%CI（0.729，0.910）〕，yielding a maximal Youden index of 0.595 with a sensitivity of 80.6%，specificity of 79.0%，and a cut-off point of 22.Threshold effect analysis revealed a change point（K）of 24〔95%CI（12，27）〕with a logarithmic likelihood ratio of 0.074.Therefore，the optimal cut-off point of the Chinese version of ICFS-10 was determined as 24 for the diagnosis of POF，and the evaluation of the physiology and psychology of such patients by this scale showed，49 cases（66.2% of the total）scored more than 24.Conclusion　The Chinese version of ICFS-10 has good reliability and validity and can be used to assess the POF.Its optimal cut-off point of 24 can be used as a warning sign of the adverse effects of POF on physiological and psychological health.

Efficacy and Safety of Linezolid Combined with Levofloxacin for Tuberculous Meningitis during the Intensive Phrase of Treatment　

ZHONG Jianfeng，SHEN Bin，QIU Jia，TONG Zhaowei，WANG Weihong

2019, 22(2): 215-219. DOI: 10.12114/j.issn.1007-9572.2018.00.218

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Background　As a serious global health problem, tuberculosis is the ninth cause of death. Tuberculous meningitis （TBM） is one of the most serious tuberculosis, and its current recommended treatment is 2HRZE/10HR. However. about half of patients with TBM were dead or disabled, with severe social harm. Linezolid （LZD） and levofloxacin （LFX） are second-line anti-tuberculosis drugs with strong anti-tuberculosis effect, and both have good blood-brain barrier permeability.Objective　To investigate the efficacy and side effects of LZD combined with LFX in the treatment of TBM during the intensive phrase of treatment.Methods 　We enrolled 49 cases who were diagnosed as definite，probable or possible TBM and received inpatient treatment from Huzhou Central Hospital from January 2014 to October 2017 and simply randomized them into the experimental group（n=24） and the control group（n=25），receiving the basic anti-TB treatment，basic anti-TB treatment combined with LZD and LFX，respectively.Examination of the cerebrospinal fluid （CSF） was performed at the baseline and end of the 1st，2nd，4th，8th weeks of treatment，white blood cell count （WBC），chloride and proteins，and glucose ratio （CSF/serum） were analyzed.The death，neurological sequelae and side effects associated with treatment were recorde between two groups at the end of the 8th week of treatment.Results　During the treatment period，the WBC and proteins decreased significantly but glucose ratio and chloride increased successively in the experimental group（P<0.05）．After the completion of 8-week treatment，the mortality rate and incidence of neurological sequelae were 8.0% （2/25），16.0% （4/24），respectively in the control group，and 4.2% （1/24），4.2% （1/24） respectively in the experimental group，indicating the two had similar rates of the death and neurological sequelae （χ2=1.203，P=0.273）．There was no significant difference in the incidence of adverse reactions between the two groups 〔56.0%（14/25） vs 66.7%（16/24），χ2=0.587，P=0.444）．Adverse reactionss associated with treatment occurred in both groups were not serious，and they were all relieved after the treatment was modified.Conclusion 　In the intensive phrase of treatment for TBM，basic anti-TB treatment combined with LZD and LFX can improve the outcome by promoting the recovery of CSF.

Effect of Botulinum Toxin Type-A in the Treatment of Bromhidrosis Using Two Dilutions　

TONG Tinghui，HUANG Wenbo，HOU Haixin，HUANG Lirong

2019, 22(2): 220-223. DOI: 10.12114/j.issn.1007-9572.2018.00.127

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Background　Botulinum toxin has been used to treat axillary osmidrosis for a long time with relatively good efficacy and less toxic side effects.However，no one can give a unified standard for botulinum toxin preparation，including manufacturers.Objective　To investigate the difference in efficacy of botulinum toxin type-A （BTX-A） at two different dilutions for the treatment of bromhidrosis.Methods　This study included 120 outpatients with bromhidrosis treated at Shenzhen Hospital of Southern Medical University from January 2014 to June 2017，who were randomly divided via a random number table into group A （n=59） and group B （n=61）．In group A，BTX-A was diluted with 0.9% sodium chloride solution to 50 U/1 ml，
and in group B，BTX-A was diluted with 0.9% sodium chloride solution to 50 U/2 ml，to form an intravenous injection-induced skin rash．The patients were followed-up for 2 weeks after injection，and the onset time and treatment effects were recorded.Results　During the follow-up period，some patients experienced symptom relief （onset） as early as the 3rd day after BTX-A injection，and on the 14th day，all patients experienced onset．The average onset time was （7.3±2.0） days in group A，and （6.5±2.0） days in group B．The difference was statistically significant （t=2.029，P=0.045）．In group A，therapy was ineffective in 8 patients，effective in 26 patients，and markedly effective in 25 patients.In group B，therapy was ineffective in 5 patients，effective in 29 patients，and markedly effective in 27 patients．There was no significant difference in the treatment effect between the two groups （u=-0.492，P=0.622）．Conclusion　Two different dilutions of BTX-A had similar effects on bromhidrosis，however，patients in the lower concentration group experienced faster symptom relief.

Clinical Analysis of 4 243 Patients with Fever of Unknown Origin　

LI Tong，WANG Rongying，HE Zhenyin，WANG Weijie，WANG Yayi，ZHANG Min

2019, 22(2): 224-227. DOI: 10.12114/j.issn.1007-9572.2018.00.025

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Objective　To analyze the etiological profile of fever of unknown origin（FUO），so as to improve the clinical level of early diagnosis of this disease.Methods　 We enrolled 4 243 cases of FUO from the Second Hospital of Hebei Medical University from 2009 to 2016，and analyzed their demographic data （sex and age） and clinical data （consultation department，diagnostic method，classification of etiology and outcome）.Results　The participants received treatment mainly from respiratory medicine department〔33.73%（1 431/4 243）〕，general practice department〔27.90%（1 184/4 243）〕，rheumatology and immunology department〔11.81% （501/4 243）〕，and infectious disease department〔9.50% （403/4 243）〕.The definite diagnosis was finally made in 3 823 with a rate of 90.10%.The etiologies were infectious diseases〔75.58%（3 207/4 243）〕，autoimmune diseases〔7.54% （320/4 243）〕，neoplasms〔2.74% （116/4 243）〕，miscellaneous causes〔4.24% （180/4 243）〕 and unidentified causes〔9.90% （420/4 243）〕，respectively.15 died during hospitalization，accounting for 0.35%.Conclusion　The causes of FUO are multitudinous.Nevertheless，most of the cases can obtain a definite diagnosis finally based on careful analysis and various examinations.

Clinical Characteristics of 12 Cases of Anti-gamma-aminobutyric Acid-B Receptor Encephalitis　

DAI Junjie，ZHANG Yinxi

2019, 22(2): 228-233. DOI: 10.12114/j.issn.1007-9572.2018.00.207

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Objective　To investigate the clinical，laboratory，imaging and electroencephalogram features，and treatment and follow-up outcome of anti-gamma-aminobutyric acid-B （GABAB） receptor encephalitis，raising clinicians' awareness of this disease.Methods　We collected the clinical data of 12 cases of anti-GABAB receptor encephalitis diagnosed in Department of Neurology of the Second Affiliated Hospital of Zhejiang University School of Medicine and Department of Neurology of Ningbo City Medical Treatment Center Lihuili Hospital from December 2012 to June 2017.We reviewed their clinical，laboratory，imaging and electroencephalogram features and evaluated the treatment effect and outcome by the modified Rankin Scale （mRS）．Results　Of the 12 patients，10 were male and the median age of onset was 56 years（range：47-71）．Seizures were the most common initial manifestations （9 cases）．All patients developed typical symptoms of seizures.Five had small cell lung cancer （SCLC），one had thymoma，and two had suspicion of a tumor.All of them received first-line immunotherapy but only 2 received antitumor treatment.Good outcomes were found in those who were identified with no tumor or those with a detected tumor and received targeted treatment，while poor outcomes were found in those with confirmed or suspected tumor but did not receive antitumor treatment.Conclusion　Anti-GABAB receptor encephalitis is a rare，special type of autoimmune disease，which frequently accompanies tumors.Middle-aged and elderly men with epilepsy，abnormal mental behavior，cognitive impairment and other symptoms of limbic encephalitis as the outstanding performance，should be considered to have this disease.Early identification of this potentially treatable disease can improve patient outcomes.

Diagnostic and Therapeutic Perspective Analysis of Two Cases of Hypertension Combined with Hypokalemia and Literature Review　

ZHANG Zijie，WANG Chuangchang，LI Rong

2019, 22(2): 234-237. DOI: 10.12114/j.issn.1007-9572.2018.00.134

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Hypertension combined with hypokalemia （HCH） is frequently seen in clinical practice.Due to complex underlying causes of HCH and difficult diagnosis，early onset，refractory and single gene hereditary hypertension are easy to appear，so early diagnosis and treatment are of great significance to the survival prognosis of the patients.Therefore，early diagnosis and treatment are of great prognostic significance.We reported one case of primary aldosteronism and one case of Liddle syndrome （LS） manifested by HCH，in particular，detailedly introduced the results of imaging examination，drug diagnostic test and genetic testing，and analyzed the features of HCH and the diagnostic value of aldosterone-to-renin ratio，imaging examination and genetic testing based on the review of related studies，and concluded that spironolactone in combination with other drugs are effective for refractory hypertension（RH），especially RH combined with low rennin，but ineffective for LS；amiloride and amitine are first-choice drugs for LS.

Adult Osteopetrosis：a Case Report and Literature Review　

XU Shaoce， WANG Shiyao， LI Kang， LUO Wei， WANG Yuliang

2019, 22(2): 238-242.

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Osteopetrosis is a rare hereditary disease whose clinical manifestations are diverse and complex.Specific imaging findings are the main evidence for diagnosis.The disease is caused by a decrease in the number of osteoclasts and by functional defects in osteoclasts， and it is regulated by multiple genes.Appropriate symptomatic treatments should be given according to clinical symptoms and signs.In this article， we report a case of adult osteopetrosis， review the related literature， and discuss the clinical classifications， characteristic X-ray findings， pathogenesis， diagnosis and differential diagnosis， treatment， and prognosis of the disease.

Research and Development of Community Intelligent Vaccination Cabinet and Its Initial Application Effects　

WANG Baoyan，HAN Zhengzheng，WANG Lingyun，YANG Jie，ZHANG Jinsheng，XIA Jingjing，ZHANG Xu

2019, 22(2): 243-246. DOI: 10.12114/j.issn.1007-9572.2018.00.143

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The continuous expansion of community vaccine varieties has resulted in greater risks due to the lack of vaccination personnel，limited space，and failure of the cold chain，etc.，thus threatening safe vaccination.With the aid of the interconnection and interoperability functions of the network information system and the intelligent computer system，an intelligent vaccine cabinet was developed to resolve the above-mentioned vaccination risks to fine-tune the vaccination process，assist nurses in ensuring vaccination safety and improve work efficiency.From July 2016 to June 2017，after the use of intelligent vaccine cabinets，1 721 more doses were inoculated compared with the previous year，the inoculation time was reduced by 4 h per day，the number of daily vaccinations by three nurses increased by 189%，and no adverse events occurred.Following use of the intelligent vaccine cabinet，the inoculation volume fluctuated between 32 and 35 doses on inoculation peak days，which was relatively balanced，and when using traditional refrigerators，the inoculation volume fluctuated between 2 and 53 doses，and the workload of the nurses at each time period was unbalanced.As a result，the use of intelligent vaccine cabinets and improvement of vaccination procedures can ensure vaccination safety，reduce manpower input，improve work efficiency，and reduce nurses' workload related to vaccination.

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