Chinese General Practice

Actions Speak Louder than Louds——but Words are a Start　Amanda Howe

Amanda Howe

2019, 22(4): 371-375. DOI: 10.12114/j.issn.1007-9572.2019.04.001

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The Seoul Declaration was launched at the 2018 Global Conference of the World Organization of Family Doctors （WONCA）． This editorial summarises its content，the reason for its launch，and evaluates the rationale for such advocacy statements，including a parallel review of the Astana Declaration launched by World Health Organization Member States，to mark the fortieth anniversary of Alma-Ata Declaration.

Global Experience in the Development of Primary Health Care and China's Health Workforce Development：a Commemoration of the 40th Anniversary of the Alma-Ata Declaration

XU Guoping，ZHENG Jialin，HAN Jianjun

2019, 22(4): 375-382. DOI: 10.12114/j.issn.1007-9572.2019.04.002

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The publication of the Alma-Ata Declaration at the International Primary Health Care Conference in 1978 is a milestone in global health history.The concept of primary health care（PHC） proposed at the meeting 40 years ago laid the foundation for the development of a modern，high-quality national health system.China has played a key role in the formation and development of the original concept of PHC by introducing its implementation experience of the barefoot doctor system and Rural Cooperative Medical Scheme.Since the adoption of the Alma-Ata Declaration，most developed countries and regions in the world，as well as Cuba，a developing country，have successfully established relatively mature PHC systems，but also witnessed failure of achievements in most developing countries.Since 2009，China has started a new round of health reform in Chinese mainland and has obtained many achievements，but its PHC system development is still in the initial phase.This paper reviews and analyzes the history，results and experience of the global development of PHC over the past 40 years，and puts forward that the unsatisfied development of a PHC system in China is due to the failure of strategic emphasis on contemporary high-quality health education and professional training，and lack of government requirements on the establishment of a vigorous high-quality health workforce for delivering high-quality health care services.On this basis，the concept of a dual-center construction （two-wheel drive） for the development of a national high-quality PHC system was proposed，that is，simultaneously building a people-centered basic health care system and a health workforce-centered health care system.It is hoped that this concept can provide a new way of thinking and strategic choice for the ongoing health reform and PHC system establishment in China.

A Brief Summary of the 22nd WONCA World Conference of Family Doctors　#br#

PEI Linxi，WEI Xinping

2019, 22(4): 383-386. DOI: 10.12114/j.issn.1007-9572.2019.04.003

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The 22nd WONCA World Conference of Family Doctors was held between October 17-21，2018，in Seoul，Korea，with the theme of Primary Care in the Future：Professional Excellence.This paper introduces the contents of Seoul Declaration launched at the conference and other reported key issues，including community-based integrated care services and the central role of general practitioners during the serving process，continuing medical education，infectious disease prevention and control for achieving universal health coverage，and so on.It is hoped that by advocating the contents of this conference，more colleagues can get to know the frontiers and progresses in general medicine，and the development of general medicine in China can be promoted.

Family Tragedy：Why Them? Why Now?

Leon Piterman，HUANG Wenjing，YANG Hui

2019, 22(4): 387-389. DOI: 10.12114/j.issn.1007-9572.2019.04.004

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A Case Study of Mental Health in Chinese Community——Illness Anxiety Disorder

HU Wen，GAN Xiaorong，ZHENG Yanan，LI Jianzhong

2019, 22(4): 390-394. DOI: 10.12114/j.issn.1007-9572.2019.04.005

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Illness anxiety disorder is characterized by persistent physical discomfort and lack of interpretable somatic lesions.In the Chinese Classification and Diagnosis of Mental Disorders （3rd Edition）（CCMD-3），the illness anxiety disorder is also called the somatoform autonomic nerve disorder.Cardiac neurosis with precordial pain as the chief complaint is a common type of illness anxiety disorder.This paper reports the psychotherapy process of a 29-year-old female patient with illness anxiety disorder in order to improve community doctors' ability in comprehensive psychotherapy and consultation.

Rate of Residents Intending to Sign a Health Service Contract with the Family Doctor in China：a Meta-analysis#br#

WANG Ronghua，LI Yuntao，TANG Zhongquan，OU Ting，CHEN Xianhua，XIN Wenjie，AN Jinhui，JI Guozhong

2019, 22(4): 395-401. DOI: 10.12114/j.issn.1007-9572.2019.04.006

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Background　In 2016，China began to promote the implementation of the contracted family doctor services by the member institutions of the regional medical consortium，aiming to improve the service delivery patterns and service capabilities of primary healthcare facilities.At present，the status of residents' intention of signing a health service contract with the family doctor is not unclear.And examining their intention and associated factors is favorable for the development of the contracted family doctor services.Objective　To systematically evaluate the rate of Chinese residents' intention of signing a health service contract with the family doctor and analyze the associated factors.Methods　Articles about residents' intention of signing a health service contract with the family doctor in China published during January 1，2009 to June 1，2018 were retrieved via searches of the electronic databases of CNKI，Wanfang Data Knowledge Service Platform，VIP，PubMed，EMbase，and The Cochrane Library.Two reviewers independently screened literature，extracted data and assessed the risk of bias of the included studies.Meta-analysis was performed by using Stata 12.0.Results　A total of 34 articles were included，involving 32 326 Chinese residents as the participants of surveys conducted during 2011 to 2017.The overall prevalence of signing a health service contract with the family doctor was 62.9%（20 344/32 326）〔95%CI（56.7%，68.6%）〕.To identify the associated factors for residents' intention of signing a health service contract with the family doctor，subgroup analyses on residential region，survey time，sex，minzu，age，educational level，occupation，awareness level of the family doctor services and health status were carried out and the results showed that minzu and awareness level of the family doctor services were associated with the intention of signing a health service contract with the family doctor （P<0.05）．For the following reasons，residents did not want to sign the contract：（1） Knowing little about family doctor services；（2） Distrusting the professional capabilities of general practitioners；（3） Worrying about the problem of limited access to healthcare possibly brought by receiving the contracted family doctor services；（4） Worrying about the problem of unsatisfactory treatment devices or limited drugs in community-based healthcare settings designated in the contract；（5） Being unclear about the benefits of the contracted family doctor services；（6） Worrying about not being able to afford the contracted family doctor services；（7） Worrying about being served by the contracted family doctor with bad attitude；（8） Having no need of such services.Conclusion　The rate of residents intending to sign a health service contract with the family doctor in China was 62.9%，which was influenced significantly by residents' minzu，and awareness level of the contracted family doctor services.

Community-based Diabetic Kidney Disease Management in China：Current Status and Progressive Development Exploration

NING Jie, WU Yanping, LI Yufeng

2019, 22(4): 402-406. DOI: 10.12114/j.issn.1007-9572.2019.04.007

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Diabetic kidney disease（DKD）, an important diabetes-induced microvascular complication, has become the leading cause of chronic kidney disease in China. DKD is associated with a significantly increased risk for cardiovascular disease, leading to an increased risk of mortality and bringing heavy financial burdens to the patient' family as well as the society. This paper reviews the status of community-based management of DKD in China, describes the patterns of management, and explores the ways for comprehensive management of DKD in the regional medical consortium. Moreover, it summarizes that community-based management of DKD in China is still in the initial phase；multiple interventions can significantly improve the risk factors of DKD；general practitioner team-based management and municipal-prefectural-community health institutions based management are two major management patterns for DKD；the implementation of community-based hierarchical and individualized management of DKD faces many challenges；optimized community-based comprehensive management for different stages of DKD is expected to be achieved by hierarchical diagnosis and treatment in combination with the Internet technologies and the support of government policies.

Guangdong Residents' Awareness and Satisfaction with China's National Essential Public Health Services：a Telephone-based Survey#br#

HAO Aihua，LI Cuicui，PAN Bo

2019, 22(4): 407-412. DOI: 10.12114/j.issn.1007-9572.2019.04.008

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Background　The implementation of China's national essential public health services is a free public welfare for Chinese residents，and an indispensible part of the strategies for building a "Healthy China".The governmental investment for the implementation of these services is increasing year by year，but the effect of the implementation in each province is unclear.Objective　To investigate the levels of awareness and satisfaction with the national essential public health services in Guangdong residents，providing a basis for improving the quality of such services and enhancing residents' sense of gain.Methods　In March 2018，by quota sampling，100 residents，including 38 priority adult individuals（consisting of 6 pregnant and puerperant women，18 parents of 0-6-year-old children，8 elderly people and 6 with chronic diseases） and 62 normal adult individuals，were selected from each of 21 prefecture-level cities of Guangdong Province（totaled 2 100）．All of them received a telephone-based survey with the questionnaire，Awareness of the China's National Essential Public Health Services，for collecting the approaches to know the knowledge about the 15 essential public health services（14 categories） and the awareness level of such services.Residents who knew at least 6 services were identified as having qualified awareness level.A total of 1 330 of the 2 100 residents who had received at least 1 category of such services also received a telephone survey with the questionnaire.Satisfaction with the China's National Essential Public Health Services，for collecting the level of satisfaction with convenience in accessing to such services，effect of such services on improving health，practical skills of healthcare providers and their attitude in delivering such services，and intention of continuing to receive such services.Spearman correlation analysis was used to investigate the correlation between residents' awareness level and overall satisfaction level of such services.Results　The overall awareness rate of the free national essential public health services in the residents was 13.52%（284/2 100）．Of the 15 services，immunization awareness rate〔39.90%（838/2 100）〕was the highest，while traditional Chinese medicine health management awareness rate〔8.19%（172/2 100）〕was the lowest.In terms of the approaches to know the essential public health services，reading the notices or posters on the community bulletin board was the most popular approach〔53.56%（143/267）〕，followed by WeChat/text messages 〔48.69%（130/267）〕.75.19%（25 001/33 250） of the Guangdong residents were satisfied with the national essential public health services.In terms of choosing the institutions for continuing to receive such services，the rate of the residents〔82.87%（5 511/6 650）〕intending to choose primary healthcare settings was the highest.However，in respect of the practical skills of healthcare providers，the rate of the residents〔70.17%（4 666/6 650）〕who were satisfied with primary care providers was the lowest.The overall levels of awareness and satisfaction with the national essential public health services showed a positive correlation（rs=0.189，P<0.001）．Conclusion　Guangdong residents have unsatisfactory levels of awareness and satisfaction with the national essential public health services.In order to promote the development of the national essential public health services，the publicity of such services should be strengthened and the qualities of primary care providers should be improved.

General Practitioner-patient Communications in Outpatient Clinic Settings in Beijing

ZHAO Tiefu，ZOU Xiaozhao，ZHOU Hongdan，MA Hanying

2019, 22(4): 413-416. DOI: 10.12114/j.issn.1007-9572.2019.04.009

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Background　General practitioners（GPs） are the main providers of community health services and gatekeepers of residents' health.For them，mastery of doctor-patient communication skills is particularly important.Objective　To evaluate the communication skills of GPs when they interact with patients in community health centers（CHCs） of Beijing.Methods　Using convenience sampling，60 out of 77 national and municipal community health demonstration centers recommended by Beijing Community Health Service Network were selected，from which 300 doctors in outpatient clinic settings were selected by accidental sampling（5 from each center）．The survey was conducted from January 2017 to March 2018.The assessors entered the clinic with the patients and their families.The doctor-patient communication skills were observed on-site and assessed by the SEGUE Framework.Results　The total SEGUE score of the GPs ranged 6-22，with an average score of （16.0±6.3）；the mean scores of 5 stages of set the stage，elicit information，give information，understand the patient's perspective and end the encounter were was （3.9±1.9）（6.4±2.1）（3.0±1.7）（2.7±1.5）（1.8±0.4），respectively.Compared with the physicians and specialists in outpatient clinic settings of tertiary grade A hospitals in Beijing who received the same assessment during this period，GPs in outpatient clinic settings of CHCs had much higher mean scores of set the stage（P<0.05）．Compared with the general physicians in outpatient clinic settings of tertiary grade A hospitals，GPs in outpatient clinic settings of CHCs obtained significantly higher mean scores in 3 stages of set the stage，elicit information，and end the encounter and higher mean total SEGUE score （P<0.05）．However，both these GPs from CHCs and the physicians from tertiary grade A hospitals achieved lower total SEGUE scores than the American general physicians（P<0.05）．Conclusion　In Beijing，only the score of set the stage of GPs in CHCs is higher than those of physicians in outpatient clinic settings of tertiary grade A hospitals，but are lower than those of international counterparts.GPs are suggested to improve their clinical communication skills further.

Association between Maternal Pre-pregnancy BMI and Neonatal Birth Weight：a Study Conducted in Women with Early Antenatal Registration and Their Infants Receiving Immunization Services in a Community Health Center

GUO Dongmei，FANG Yuhang，YANG Zhixi，QIN Fei，ZHOU Weijin，MAO Yanyan

2019, 22(4): 417-421. DOI: 10.12114/j.issn.1007-9572.2019.04.010

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Background　Neonatal birth weight influences the subsequent health of the infant and maternal postpartum health，which may be associated with maternal pre-pregnancy health and body mass index（BMI）．Objective　To investigate the status of maternal health and neonatal birth weight in community-based healthcare settings in Shanghai by reviewing early antenatal registration information and child's immunization information from a street community health center in Shanghai，and based on this，to examine the relationship between maternal pre-pregnancy BMI and neonatal birth weight.Methods　We conducted this study in women and their infants recruited from Huajing Community Health Center（located Xuhui District in Shanghai） during January to December 2016.All the women received antenatal care after establishing an antenatal record card during early pregnancy and their infants received immunization services after establishing an immunization record card.We collected the general data of the women，such as age，pre-pregnancy BMI，gravidity，and the general data of their infants，including sex，birth weight，gestational age at birth and so on.Neonatal birth weight was analyzed by maternal and infant characteristics.Pearson correlation coefficient and multiple linear regression model were applied to estimate the relationship between maternal pre-pregnancy BMI and neonatal birth weight.Results　The average pre-pregnancy BMI of the included 219 women was（21.8±2.3）kg/m2 and the average birth weight of their infants was （3 374.3±469.6） g.Neonatal birth weight differed significantly by sex and gestational age at birth （P<0.05），but did not by maternal age，place of hukou，gravidity，and pre-pregnancy BMI（P>0.05）．Pearson correlation analysis showed that maternal pre-pregnancy BMI was not correlated with neonatal birth weight（r=-0.072，P=0.290） among the 219 mother-newborn pairs，but was negatively correlated with neonatal birth weight limited in Shanghai residents （r=-0.273，P=0.007）．Gestational age at birth was positively correlated with neonatal birth weight （r=0.485，P<0.001）．Sex and gestational age at birth of the infants were associated with neonatal birth weight by the multiple linear regression model（P<0.05）．Conclusion　No association between maternal pre-pregnancy BMI and neonatal birth weight was found in this study，but maternal pre-pregnancy BMI was negatively correlated with neonatal birth weight limited in Shanghai residents.

Association of Hypoxia-related Indicators and Early Renal Injury in Obese Type 2 Diabetic Patients

WANG Xiaoqing，LI Qingjun，HAO Hairong，LIU Ziyu，WEN Surong，CHENG Liang，HU Wen，YU Weinan

2019, 22(4): 422-426. DOI: 10.12114/j.issn.1007-9572.2019.04.011

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Background　Previous studies have shown that type 2 diabetes is closely associated with obstructive sleep apnea hypopnea syndrome （OSAHS），a syndrome with a significantly elevated probability of being found in end-stage renal disease.However，there are few studies on the relationship between OSAHS and early renal damage in patients with type 2 diabetes.Objective　To explore the association between OSAHS-related parameters and early renal damage in obese patients with type 2 diabetes.Methods　Ninety-four obese type 2 diabetes inpatients were recruited from Endocrinology Department，the Affiliated Huaian Hospital of Xuzhou Medical University from November 2015 to November 2017.Their general personal data were collected by reviewing medical records，and biochemical and urine indicators were collected through laboratory tests.Respiratory parameters monitored with the portable polysomnography，and liver fact content（LFC） determined by quantitative hepatic fat ultrasonography were also collected.According to the urinary albumin/creatinine ratio （ACR），patients were divided into DN group （ACR>30 mg/g，n=34） and non-DN group （ACR≤30 mg/g，n=60）．Comparisons of the general personal data and laboratory indicators of both groups were performed.Correlation analysis was used to explore the correlation of ACR with OSAHS parameters and other clinical data.Multiple linear regression analysis was used to explore the influencing factors of ACR.Results　（1） There were significant differences in male ratio，hypertension history，serum creatinine （Scr），estimated glomerular filtration rate （eGFR），LFC，apnea-hypopnea index （AHI），oxygen desaturation index（ODI），mean oxygen saturation（MPO2） and cumulative time percentage with SPO2 <90% （CT<90%） between the two groups （P<0.05）．There were no significant differences in the average age，and duration of diabetes，rates of having smoking and drinking history，average BMI，waist circumference（WC），fasting plasma glucose（FPG），glycated hemoglobin （HbA1c），systolic blood pressure （SBP），diastolic blood pressure（DBP），total cholesterol （TC），triglyceride（TG），low-density lipoprotein cholesterol （LDL-C），high-density lipoprotein cholesterol （HDL-C），blood urea nitrogen（BUN），uric acid （UA），ACR，and lowest oxygen saturation （LSaO2） and the severity of OSAHS between the two groups （P>0.05）．（2） Correlation analysis showed that ACR was significantly associated with eGFR，AHI，ODI，LSaO2，MPO2 and LFC（P<0.05），but had no correlation with age，SBP，DBP，WC，FPG，HbA1c，TC，TG，HDL-C，LDL-C，UA and CT<90%（P>0.05）．（3） Multiple linear regression analysis showed that AHI，ODI，LSaO2，MPO2 and LFC were independent factors significantly associated with ACR（P<0.05）．Conclusion　ACR was positively correlated with AHI，ODI，and LFC，and negatively correlated with eGFR，LSaO2，and MPO2.Increased AHI and low ODI are independent risk factors for ACR，while elevated LSaO2 and MPO2 are its protective factors.Improving OSAHS status and reducing LFC may have certain clinical significance for the prevention and treatment of early diabetic nephropathy.

Effect of Comprehensive Self-management on Improving the Prognosis of Non-hospitalized Heart Failure Patients

CHI Cheng，ZHU Jihong，CHEN Hong

2019, 22(4): 427-432. DOI: 10.12114/j.issn.1007-9572.2019.04.012

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Background　Heart failure is one of the major diseases threatening human health.Despite the development of medicines and techniques for the treatment of heart failure，the prognosis is not satisfactory.One of the most important factors is lack of accurate monitoring and regular follow-ups outside the hospital for patients with chronic heart failure.Objective　To develop a comprehensive self-management pattern for non-hospitalized heart failure，and to evaluate its effectiveness of treatment and prognostic improvement effect in such patients.Methods　The study is designed as a two-group randomized controlled trial.Participants were recruited from Peking University People's Hospital during December 2016 to April 2017 and were equally and randomly assigned to the comprehensive management group（n=100） and control group（n=100）.Patients from the control group received regular clinical treatment and follow-ups.Those from comprehensive management group first received self-management training，then measured their heart rate，blood pressure，body weight，evaluated the level of edema，symptoms of short of breath and dyspnea and six-minute walk test （6MWT） results per day at home and recorded the data by themselves，and the regimen could be adjusted according to their self-reported data by health workers during the follow-ups.The effectiveness of the two intervention patterns was compared in terms of all-cause hospitalization rate，rate of hospitalization due to heart failure，incidence of adverse reactions，duration between the time of starting to receive interventions and first hospitalization，length of stay，cardiac functions and quality of life （evaluated by the Minnesota Living with Heart Failure Questionnaire） during the 9-month follow-up period.And the factors associated with re-hospitalization were analyzed.Results　Altogether，171 patients who competed the follow-up were included in the final analysis，including 87 from the control group and 84 from the comprehensive management group.Two groups showed no significant differences in the distribution of sex，and age，average heart rate，and causes of heart failure （P>0.05）．Comprehensive management group showed much lower all-cause hospitalization rate，rate of hospitalization due to heart failure and shorter average length of stay，and longer duration between the time of starting to receive interventions and first hospitalization during the follow-up period compared with the control group （P<0.05）．The average left ventricular ejection fraction（LVEF） levels at baseline，at the end of the 3rd，6th，and 9th months of intervention were similar in both groups （P>0.05）．The average BNP level was similar in both groups at baseline，but the median BNP decreased more significantly in the comprehensive management group instead of the control group at the end of the 3rd，6th，and 9th months of intervention （P>0.05）．By the end of the intervention，the average scores of activities of daily living score，medical cost and average total score of quality of life in the comprehensive management group were all much lower than those of the conventional group （P<0.05）．Stepwise Logistic regression analysis showed that changes in body weight，and prevalence of short of breath and dyspnea were associated with the rehospitalization （P<0.05）．Conclusion　The comprehensive self-management can reduce hospitalization rate，shorten the length of stay，decline the incidence of adverse reactions，and improve the quality of life in patients with heart failure.Changes in body weight and shortness of breath were associated with the rehospitalization in this population.

Serum Retinol-binding Protein 4 and Non-alcoholic Fatty Liver Disease in Postmenopausal Women

CAI Hong，ZHANG Zhifen，TONG Jinyi，CHEN Yun，ZHUO Guangchao，CHEN Yueming，LAI Lei，GE Cenhong

2019, 22(4): 433-437. DOI: 10.12114/j.issn.1007-9572.2019.04.013

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Background　Postmenopausal women are more prone to non-alcoholic fatty liver disease （NAFLD），a disease possibly leads to fatal cardiovascular disease and other metabolic disorders.However，the underlying pathogenesis of NAFLD after menopause is still unclear.Objective　To investigate the association of serum retinol-binding protein 4（RBP4） with NAFLD in postmenopausal women.Methods　A total of 181 women aged between 37 and 66 years old were recruited from the Health Checkup Department of Affiliated Hangzhou First People's Hospital，Zhejiang University School of Medicine from May to August 2017.They were divided into four groups according to the menopausal status and NAFLD diagnostic results，including premenopausal control group （n=42），premenopausal NAFLD group （n=42），postmenopausal control group （n=36） and postmenopausal NAFLD group （n=61）.Serum RBP4 was compared between the groups.Binary Logistic regression analysis was performed to explore the association between serum RBP4 and NAFLD.The diagnostic value of serum RBP4 for NAFLD was investigated by ROC curve and the area under the ROC curve （AUC） analyses.Results　The average serum RBP4 level in postmenopausal NAFLD group was significantly higher compared to premenopausal control group and postmenopausal control group（P<0.05）.After adjusting for confounding factors，Logistic regression analysis showed that elevated serum RBP4〔OR=1.155，95%CI （1.059，1.260），P<0.05〕 was an independent risk factor for NAFLD in postmenopausal period.The AUC of serum RBP4 for predicting NAFLD in postmenopausal women was 0.841〔95% CI （0.757，0.924）〕，the optimal cut-off value was 25.1 mg/L，with a sensitivity of 0.78 and a specificity of 0.79（P<0.001）.Conclusion　Elevated serum RBP4 level is positively associated with NAFLD in postmenopausal women.So serum RBP4 level has a good auxiliary diagnostic value for NAFLD in such a population.

Comparative Analysis of Lactose Intolerance Caused by Drinking Goat and Cow Milk Powder Solutions

HAO Shuping，LI Jing，LI Jingyun，TAN Sisi，LIU Ying，LIU Chunlong，WANG Dandan，LIU Lan

2019, 22(4): 438-441. DOI: 10.12114/j.issn.1007-9572.2019.04.014

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Background　The adults with partial lactose intolerance caused by drinking cow milk powder solution have reduced or disappeared symptoms after drinking goat milk powder solution.However，there is no available research evidence concerning whether it is an individual or a common phenomenon，and the proportion of such people in lactose intolerance group.Objective　To make a comparative analysis of lactose intolerance and gastrointestinal reactions caused by drinking goat and cow milk powder solutions in Chinese adults.Methods　This study was conducted from September to December 2017 following a self-controlled design.Participants first drank 300 ml cow milk powder solution （with 40 g cow milk powder dissolved） with empty stomach.Those with lactose malabsorption or intolerance drank the same amount of goat milk powder solution （with 40 g goat milk powder dissolved） with empty stomach after a 7-day washout period.Lactose intolerance was evaluated by the urinary galactose level measured by colorimetric assay at 2 hours after drinking the milk.Symptoms Checklist at 12 Hours after Drinking Cow or Goat Milk Powder Solution was used to assess the first onset time，duration and severity of abdominal distension and pain，and the increase in the number of bowel movements.Results　After drinking cow milk powder solution，the incidence of lactose malabsorption or intolerance was 93.3%（112/120） in participants，which was similar to that〔94.6%（106/112）〕after drinking goat milk powder solution （P>0.05）.Furthermore，the evaluation scores for lactose malabsorption or intolerance-related symptoms such as the first onset time，duration，and severity of abdominal distension and pain，and episode lengths of bowel movements caused by drinking cow and goat milk powder solutions were similar（P>0.05），but the scores for increased frequency of post-drinking bowel movements were significantly different（P<0.05）.Conclusion　After drinking goat milk powder solution，most adults with lactose malabsorption or intolerance caused by drinking cow milk powder solution also showed lactose intolerance.Moreover，they demonstrated similar increased bowel movements and abdominal pain and distention.These people had better have lactase solution or lactose-free dairy products before drinking cow or goat milk powder solution.

Low Dose of Methylprednisolone Combined with Intravenous Immunoglobulin for Kawasaki Disease Unresponsive to Intravenous Immunoglobulin

LI Dan，FENG Yuan，GENG Lingling，NAN Nan，ZHANG Cui，LI Xiaoqing

2019, 22(4): 442-446. DOI: 10.12114/j.issn.1007-9572.2019.04.015

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Background　Some children with Kawasaki disease（KD） unresponsive to intravenous immunoglobulin（IVIG） also show no response to standard therapy，resulting in a higher risk of developing coronary aneurysm. Biologic drug therapy or high-dose intravenous methylprednisolone pulse therapy（IMPT） is effective，but it is high-cost and induces severe side effects. Thus it is necessary to develop highly effective，yet inexpensive treatments. Objective　To investigate the clinical efficacy and safety of low-dose methylprednisolone combined with IVIG in the treatment of KD unresponsive to IVIG.
Methods　From January 2013 to January 2017，by use of the random number table method，114 cases of KD unresponsive to IVIG were evenly divided into the observation group and control group，receiving a second IVIG with low-dose methylprednisolone，a second IVIG，respectively. Serum C-reactive protein （CRP），interleukin-6 （IL-6），and tumor necrosis factor-alpha（TNF-α） levels before and at 72 hours after this round of treatment were measured for evaluating the treatment response. And the incidence of coronary artery injury before and at 1，3，6，12 months after this round of treatment as well as adverse drug reactions during the treatment were measured for evaluating the treatment safety. Results　The response rate of the observation group was much higher than that of the control group〔91.2% （52/57） vs 75.4% （43/57）〕（P<0.05）. Before the treatment，the serum CRP，IL-6，and TNF-α levels were similar in both groups （P>0.05），but they were much lower in the observation group than those of the control group at 72 hours after the treatment （P<0.05）. The incidence of coronary artery injury was similar in both groups before the treatment（P>0.05），but it decreased significantly in the observation group at 1，3 months after treatment（P<0.05），then became similar in both groups at 6，12 months after treatment（P>0.05）． Five cases had hypothermia and one case had sinus bradycardia in the observation group，but they recovered without treatment within 2 to 3 days after onset. Conclusion　For patients with KD unresponsive to IVIG，low-dose methylprednisolone combined with IVIG can significantly improve the clinical efficacy，reduce inflammatory response，and promote the recovery of injured coronary artery with high safety.

Construction of Clinical Skills Database for General Practitioners in Primary Healthcare Facilities：a Pilot Study

GUO Wang，LEI Yi，MO Dongyang，GONG Jiaxin，LUO Minghui，LIAO Xiaoyang

2019, 22(4): 447-450. DOI: 10.12114/j.issn.1007-9572.2019.04.016

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Background　Literature retrieval results show that there is no unified standardized clinical skills training and assessment system for newly graduated general practitioners （GPs），and in China，there are quite a lot of studies about standardized comprehensive abilities training and assessment for GPs.Therefore，it is of great significance to establish a GP clinical skills database to screen the core clinical skills of GPs.Objective　To establish a GP clinical skills database，providing a basis for the screening of the core clinical skills of GPs and offering a reference for clinical skills training for GPs in primary care facilities.Methods　GP clinical skills were pooled by literature review at first.During the review process，the skills of GPs in articles at home and abroad were compared to the clinical skills included in the 8th National Medical College Students' Clinical Skills Competition Scope（reference group）.Skills that were found to be the same as those in the reference group for twice or more times were kept as items in the database.Then the other skills were discussed and selected by voting by our research team members and were tested by a survey in a stratified cluster sample of 3 600 clinical professionals from 30 primary healthcare institutions in 5 areas of Sichuan Province（Liangshan Yi Autonomous Prefecture，Aba Tibetan and Qiang Autonomous Prefecture，Ganzi Tibetan Autonomous Prefecture，Chengdu City，and Nanchong City） during April to October 2017 with a self-developed questionnaire named Essential Clinical Skills of General Practitioners consisting of personal characteristics and the choice of clinical skills should be mastered by GPs.Altogether，3 231 cases returned responsive questionnaires，gaining a response rate of 89.75%.Results　Of the 137 clinical skills collected though literature review and choice voting，54 were found to be identical with 54 skills in the reference group for twice or more times，other 83 were tested by the questionnaire survey.According to the survey results，37 were included in the database，32 were excluded，and other 14 were indeterminate.Finally，a total of 105 skills were included in the database.Conclusion　Our GP clinical skills database has a wide coverage，good scientificity and practicability，which can be used as a reference tool for the standardized clinical skill training for GPs in primary care facilities.

Implication of Continuing Education Programs for General Practice in Australia to General Practice Development in Shenzhen，China

LI Zhanzong，JIANG Lili，YANG Hui

2019, 22(4): 451-456. DOI: 10.12114/j.issn.1007-9572.2019.04.017

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To ensure that residents have qualified healthcare "gatekeepers"，it is necessary to train excellent general practitioners（GPs）．And continuing medical education for GPs is an important measure for promoting the sustainable development of general practice workforce.After years of exploration，Australia has developed a relative mature system and an effective mode for general practice education.The studying of the advanced experience of Australia is conducive to the improvement of general practice education in China.We discussed the development of continuing education for general practice in Australia from the aspects of essentials of general practice education system，model of continuing medical education for GPs，and practices for continuing medical education programs for GPs in the country.Then，to solve the problems and overcome the barriers in general practice development in Shenzhen，we put forward some reasonable and feasible suggestions with referring to the advanced experience of Australia.

Grading Care Model Study for the Elderly in Geriatric Nursing Facilities Based on Health Management Framework

XU Guihua

2019, 22(4): 457-461. DOI: 10.12114/j.issn.1007-9572.2019.04.018

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In China，the irreversible trend of population aging and huge supply-demand gap in elderly care services，make it necessary to develop a scientific，normative and sustainable elderly care system for providing precise elderly care.Grading care for the elderly based on the objective assessment tool has become an important component of the elderly care system in developed countries.However，the elderly care service system in our country is imperfect.Therefore，it is of great significance to create a grading nursing system based on the assessment of the ability and health demands of elderly people to provide precise services for them based on their own conditions.This study，guided by the theoretical framework of health management，on the basis of analyzing the problems and impact factors of elderly care system in our country comprehensively，sets up a grading nursing theoretical framework and radicates an assessment tool for the grading of elderly care.In addition，this study establishes grading criterion and determines the corresponding service contents，and develops a grading elderly care model fitting for geriatric nursing facilities in China.Furthermore，the study builds a network platform for grading care for the elderly，which makes the ability assessment automatic，care grading intelligent and data management normative.Thus，the study can provide a reference for the reform of grading elderly care system，and sophisticated management of elderly care in geriatric nursing facilities，and can offer a scientific basis for the establishment of the third-party evaluation，government's accurate grant of pension subsidies，purchase of elderly services and rational allocation of human resource for long-term care for the elderly.

A Systematic Review of Recent Developments in Comprehensive Geriatric Assessment Instruments in Long-term Care Facilities

ZHANG Qin，GUI Qian，WANG Yanjun，CHEN Yujing，XU Guihua

2019, 22(4): 462-467. DOI: 10.12114/j.issn.1007-9572.2019.04.019

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Background　There are many comprehensive geriatric assessment（CGA） tools at home and abroad，but there are no unified CGA tools for older people in long-term care facilities （LTCF） delivering different qualities of care in China.Objective　To review systematically the psychometric properties of CGA tools in LTCF and choose the appropriate ones for LTCF in China.Methods　From January to June 2018，we performed an analysis of the data for CGA in LTCF published from 2008 to 2018 that were retrieved from eight databases：CNKI，Wanfang，Scopus，PubMed，Usearch，CINAHL，PsycINFO and Medline.The COSMIN checklist was used to assess the methodological quality of the eligible studies.Results　Altogether，21 papers were included.Of the papers，there were 9 kinds of CGA instruments，but only 5 instruments' psychometric properties were reported.By use of the COSMIN checklist，the internal consistency of interRAI-LTCF was rated as fair，and its retest reliability was rated as poor，fair，and fair in 3 studies，respectively.The internal consistency and retest reliability of Nottingham Health Profile was evaluated as poor.Both the validity and reliability of BGA used in Chongqing's hospitals，elderly care facilities and community-based healthcare institutions were assessed as poor.The internal consistency of Ability Assessment for Older Adults was assessed as fair.The internal consistency，content validity and construct validity of Elderly Comprehensive Health Assessment Scale were assessed as poor.Conclusion　Both the interRAI-LTCF and the Ability Assessment for Older Adults are worth promoting in LTCF in China，but their psychometric properties and feasibilities need to be tested by more high-quality studies.

Ability Levels and Influcening Factors in Eldlerly People in Geriatric Nursing Facilities

WANG Yanjun，GUI Qian，ZHANG Qin，CHEN Yujing，LI Weitong，DING Huan，CHEN Lihong，DING Yayuan，SONG Jiamu，XU Guihua

2019, 22(4): 468-472. DOI: 10.12114/j.issn.1007-9572.2019.04.020

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Background　The number of disabled elderly people in China was over 40 million in 2015.The great amount of disabled elderly people pose great challenges to medical care and long-term care.However，studies about this population in China is still in its infancy.Objective　To investigate the ability levels and infuencing factors of elderly people in geriatric nursing facilities.Methods　We conducted this questionaire survey from October 2017 to June 2018.Participants were 547 elderly people aged ≥60 years old who were selected from 3 demonstrative geriatric nursing facilities in Nanjing，China.A set of questionaires were used in the survey for collecting the data concerning general demograpchic characteristics，living habits and health-related problems，ability level（assessed by Ability Assessment for Older Adults），status of sleep，nutrition，and depression.Sequential multinomial Logistic regression analysis was conducted to determine the influencing factors of the ability.Results　 A total of 516 cases returned responsive questionnaires，obtaining a response rate of 94.3%.Among the respondents，the prevalence of disability was 83.7%（432/516）．Specifically，the prevalence of mild，moderate and severe disability was 41.5%（214/516），14.9%（77/516） and 27.3% （141/516），respectively.Sequential multinomial Logistic regression analysis revealed that age，educational level，physical exercise status，chronic pain，dementia，number of chronic diseases，self-rated health，nutrition status，and depression were influencing factors for the ability level in respondents with disability（P<0.05）．Conclusion　The prevalence of disability is high in elderly people in geriatric nursing facilities.Older age，low educational level，lack of physical exercise，accompanying chronic pain，prevalence of dementia，prevalence of 4 or more chronic diseases，poor self-rated health，malnutrition and depression are risk factors for disability in this group.In view of this，priority should be given to these risk factors and corresponding management should be strengthened.

interRAI-LTCF-assessed Care Needs Study in Elderly People with Different Levels of Ability in Geriatric Nursing Facilities

GUI Qian，WANG Yanjun，ZHANG Qin，CHEN Yujing，XIE Haiyan，DING Yayuan，CHEN Lihong，JING Dongmei，XU Guihua

2019, 22(4): 473-477. DOI: 10.12114/j.issn.1007-9572.2019.04.021

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Background　The inconsistent criteria and basis for grading the level of nursing care in heath institutions in different regions of China，and the financial and other factors of the elderly，have affected the integrity and objectivity of the contents of nursing care of different levels，possibly leading to the failure of services in meeting elderly people's disability and needs in actual practice.Objective　To explore the long-term care needs of elderly people with different ability levels in geriatric nursing facilities，providing a basis for the delivery of targeted care for the elderly.Methods　From April to July，2018，a questionnaire survey was conducted in a convenience sample of 575 elderly people aged ≥60 years old in 2 geriatric nursing facilities in 2 cities of China，Nanjing and Changzhou.The questionnaire used includes two parts：Ability Assessment for Older Adults and interRAI-LTCF，the former was used to assess the ability level of the elderly，and the latter was adopted to evaluate the health problems and needs.Comprehensive assessment results were analyzed and health problems were recorded with the interRAI CAPs.Correspondence analysis was performed to investigate health problems and ability level in the elderly.Results　The survey achieved a response rate of 92.5%.Of the 532 respondents，the prevalence of normal ability，mild，moderate and severe disability was 10.3%（55 cases），49.6%（264 cases），13.4%（71 cases），and 26.7%（142 cases），respectively.By use of CAPs，health problems of the elderly were divided into 4 categories and 21 aspects.The median number of health problems of the elderly was 4（3）．Correspondence analysis results showed that：the major health problem of those with normal ability was bad living habits，and health education was required.Those with mild disability mainly had mental and social problems and insufficient physical activities，showing high demand for spiritual comfort and health promotion services.Those with moderate or severe disability had ADL limitation and clinical health problems.They were a high-demand group for daily care and medical care.Conclusion　The corresponding analysis of health problems and care needs found that care needs differed significantly by ability level in elderly people.This provides a basis for carrying out appropriate health services for improving the quality of life in the elderly in geriatric nursing facilities.

Development of Scale of Patients' Presupposed Distrust

ZHENG Xuejian，ZHAO Jingbo，CHEN Jianbin，CHEN Zhuangyou，LIANG Shunwei，Chen Rongning

2019, 22(4): 478-483. DOI: 10.12114/j.issn.1007-9572.2019.04.022

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Background　Some patients' mistrust of doctors before taking medical treatment is an important cause of bad doctor-patient relationship. At present, there are still few tools for assessing patients' presupposed distrust.Objective　To compile Patients' Presupposition Distrust Scale and test its reliability and validity.Methods　Literature review，clinical practice，research group discussion and other methods were used to develop Patients' Presupposition Distrust Scale.A total of 52 patients and 384 patients were selected by convenient sampling method for pre-investigation and formal investigation from January to February 2018 and February to March 2018.The structure of the scale was optimized preliminarily by pre-investigation，and the items were screened and validated based on exploratory factor analysis，correlation analysis，criterion validity and Cronbach's alpha coefficient.Results　The final Patients' Presupposition Distrust Scale consisted of 22 items.Eight common factors were extracted by exploratory factor analysis，including doctor-patient communication，patients' personal experience，doctor's characterization，medical system，doctor's medical ethics，other factors，doctor's skills and patients' judgment.Exploratory factor analysis showed that the cumulative variance contribution rate of the 8 common factors was 58.794%.Pearson correlation analysis showed that the score of each item was positively correlated with the total score，the score of each item and the corresponding common factor score （P<0.05）．Wake Forest Physician Trust Scale was used as a criterion for Scale of Patients' Presupposed Distrust.Pearson correlation analysis showed that the total scores of the two scales were negatively correlated （P<0.05）．The Cronbach's alpha coefficient of the preset distrust scale was 0.708 and the split half reliability coefficient was 0.729.Conclusion　The developed patient presupposition distrust scale has good discrimination，good validity and reliability，and can be used as a suitable tool for measuring the degree of patients' presupposition distrust to doctors in China.

Development of an Evaluation Instrument for Warning Signs of Individual Psychological Crisis

YANG Xueling，HU Quanxi，ZHAO Jingbo，ZHAO Jiubo，ZHANG Xiaoyuan

2019, 22(4): 484-489. DOI: 10.12114/j.issn.1007-9572.2019.04.023

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Background　Identification of the warning signs of psychological crisis by observing behaviors is favorable for early detection and management of the potential psychological crisis.However，in China，there is still no psychological crisis warning instrument available.Objective　To develop an individual psychological crisis warning instrument for dynamic early warning of psychological crisis.Methods　Items were screened using Delphi expert consultation method to form the Psychological Crisis Signs Checklist （PCSC）．By two rounds of survey，the reliability and validity of PCSC were examined，and the PCSC was then modified on the basis of an expert discussion according to item analysis including inter-rater reliability，sensitivity and specificity indicators.The Yoden Index was used to calculate the warning threshold.Results　The items were screened by a two-round Delphi study，resulting in a 35-item PCSC.During a formal survey 〔the number of respondents in the formal survey was 183，consisting of the crisis group （n=82），and non-crisis group （n=101）〕，the PCSC demonstrated excellent internal consistency （Cronbach's α=0.85） and inter-rater reliability （rs=0.84），scores of PCSC could effectively distinguish between crisis and non-crisis group.The Spearman' rho between PCSC and Triage Assessment Form （TAF） was 0.90，indicating good criterion validity.The PCSC was then modified on the basis of an expert discussion according to item analysis including inter-rater reliability，sensitivity and specificity indicators.The modified PCSC includes 30 items.Based on the threshold corresponding to the maximum Youden index，it was determined that when the total PCSC score is ≥9，yellow crisis alarms；when the total cutoff score is ≥14，red crisis alarms.Conclusion　The PCSC could effectively screen individuals at high risk for psychological crisis，which is conducive to early identification of warning signs and dynamic monitoring of psychological crisis.

Effect of Comprehensive Care and Support Interventions on the Psychological Status and Quality of Life of Family Caregivers of Community-dwelling Schizophrenic Patients

LI Shiming，YANG Queping，ZHANG Zijuan，FENG Wei,DONG Xiaohui，CHEN Jia

2019, 22(4): 490-494. DOI: 10.12114/j.issn.1007-9572.2019.04.024

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Background　Family caregivers of schizophrenia often experience psychological stress during long-term care，and the quality of life decreases.Effective interventions may improve the mental condition and quality of life of caregivers.Objective　To explore the effect of comprehensive care and support interventions on the psychological status and quality of life of family caregivers of community-dwelling schizophrenic patients.Methods　Using stratified and random cluster sampling，from 5 districts of Wuxi City，we selected 200 schizophrenic patients（40，42，36，38，44 from Liangxi District，Binhu District，Xinwu District，Xishan District and Huishan District，respectively） who were provided with community-based management/treatment on the basis of obtaining their informed consent from March to May 2016，then，we sampled one key family caregiver of each patient as the participants.The totaled 200 caregivers were equally randomized into the control group and observation group，receiving one-year conventional follow-up management，one-year comprehensive care and support interventions，respectively.Psychological status and quality of life of both groups were assessed by the Zung Self-Rating Anxiety Scale （SAS），the Zung Self-Rating Depression Scale （SDS） and WHO Quality of Life-BREF （WHOQOL-BREF） before and after intervention.Results　（1） After intervention，the mean scores of SAS and SDS changed insignificantly in the control group （P>0.05），but decreased obviously in the observation group （P<0.05）．Moreover，both scores were much lower in the observation group than those of the control group （P<0.05） although they were similar in both groups before the intervention（P>0.05）．（2） After intervention，the mean scores of the WHOQOL-BREF and its 4 domains（physical health，psychological health，social relationships，and environment） were all increased significantly in the observation group，but only the mean scores of physical health increased significantly in the control group（P<0.05）．Moreover，the mean scores of the WHOQOL-BREF and its 4 domains were all higher in the observation group than those of the control group（P<0.05） although they were similar in both groups before the intervention（P>0.05）．Conclusion　Appropriate comprehensive care and support interventions can alleviate the levels of anxiety and depression，and improve the quality of life of family caregivers of community-dwelling schizophrenic patients.

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