Table of Content

05 March 2019, Volume 22 Issue 7

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Commentary

Interpretation of Australian and New Zealand Society for Geriatric Medicine Position Statement of Prescribing in Older People　

FANG Lizheng，XU Zhijie

2019, 22(7):  747-752.  DOI: 10.12114/j.issn.1007-9572.2019.07.001

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The elderly has higher demand of health care than other populations，but prescribing in older people is rather complex.As they have ageing organs and declined functions with pharmacokinetic and pharmacodynamic changes and tend to be multimorbid，polypharmacy is very common among the aged.Therefore，how to promote the rational drug use in the context of growing global ageing is a urgent problem to be solved.In August 2018，the Australia and New Zealand Society of Geriatric Medicine（ANZSGM） issued a position statement of prescribing in older people，which indicated many aspects of challenges of prescribing in older people and the adverse outcome of irrational prescription，explained the medical ethics involved and put forward the strategies of improving prescription quality.In light of the important reference value of the position statement to the problem of rational drug use in China，this article illustrates some ideas to improve the prescription in older people combined with domestic situation based on the conclusion of key points from the original text.


Monographic Research

Influence of Commonly Used Antihypertensive Drugs on Sleep：a Review of Community-based Studies　

LIU Yanjiao，CHEN Tieguang，LIU Zhengyu，CAI Xia

2019, 22(7):  753-756.  DOI: 10.12114/j.issn.1007-9572.2019.07.002

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Hypertension and sleep disorders are common chronic diseases in community health care institutions.The prevalence of both the two has increased in recent years.Hypertensive patients often suffer from sleep disorders，and sleep disorders can also cause abnormal blood pressure.Based on the feedback from doctors in community health centers and relevant literature reports，this paper explores the influence of common antihypertensive drugs on sleep in community health centers（stations），and then advocates the rational and appropriate use of antihypertensive drugs in community health care to reduce the adverse effects of such drugs on sleep by suggesting that community doctors should pay attention to obesity，sleep disorders and other individualized characteristics of hypertensive patients when prescribing.


Enlightenment of Extraterritorial Legislation for General Practitioners to China　

LI Jingyun，LIU Lanqiu

2019, 22(7):  757-760.  DOI: 10.12114/j.issn.1007-9572.2019.07.003

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A sound legislative system for general practitioners（GPs） is essential to ensure the development of GPs.Determination of the role，responsibilities，rights and interests of GPs in the healthcare system by legislation，and regulation of the occupation and practice of GPs by laws，are active responses to the national initiatives for the development of hierarchical medical system and initial consultation in primary care，and the construction of general practice workforce，and are also contributive to the implementation of hierarchical medical system.We combed the health legislation concerning GPs in the U.K.，Canada，Hungary，Sweden，and Portugal，and summarized that in these 5 countries，a tiered national healthcare system，and the role，requirements for eligibility，practice scope，rights，interests and obligations of GPs are determined by health laws.On the basis of the above advanced experience，we put forward specific and feasible suggestions for legal protection of GPs in China.


How Building Trust Fell on Deaf Ears

Leon Piterman，LIANG Yan e，YANG Hui

2019, 22(7):  761-763.  DOI: 10.12114/j.issn.1007-9572.2019.07.004

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Prevalence and Influencing Factors for Job Burnout among General Practitioners in China　

ZHENG Yanling，YU Fang，CHEN Yanli，YU Minyi，LIU Ling，GAN Yong，LI Liqing，YANG Yudi，LU Zuxun

2019, 22(7):  764-769.  DOI: 10.12114/j.issn.1007-9572.2019.07.005

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Background　At present，general practitioners（GPs） in China are facing many problems，such as heavy work tasks，low social recognition，and imperfect salary incentive mechanism，which make them prone to job burnout.Analyzing the factors associated with job burnout in GPs can provide a basis for stabilizing the workforce of GPs，and improving the quality of care at primary care level.Objective　To investigate the prevalence of job burnout of GPs in China and explore its influencing factors.Methods　Multistage stratified random sampling was used to conduct a questionnaire survey in 3 244 GPs with at least one year of full-time work experience in community health centers from the eastern，central，and western China between October，2017 and February，2018.The questionnaire is consisted of two parts：the first part is the sociodemographic information and the second part is the job burnout scale.Burnout was measured using the revised version of the Chinesized 22-item Maslach Burnout Inventory-Human Services Survey，including emotional exhaustion（EE），depersonalization（DP） and low personal accomplishment（PA）．Associated factors with burnout and its subscales among GPs were estimated using a stepwise binary Logistic regression model.Results　A total of 3 236（99.75%） of the GPs returned responsive questionnaires.The survey results showed that the prevalence of high EE，high DP and low PA among the respondents was 43.17%（1 397/3 236），22.93%（742/3 236） and 41.19%（1 333/3 236），respectively.Stepwise binary Logistic regression analysis revealed that location，educational level，working hours per day，and overtime were associated with high EE（P<0.05）．Location，sex，years of working as a GP，and income level were associated with high DP（P<0.05）．Location，age，and working hours per day were associated with low PA （P<0.05）．Conclusion　The prevalence of burnout among Chinese GPs is high，which is more often manifested as EE and low PA.The associated factors for burnout are complex and various.Actions such as optimizing the working hours，reducing the work intensity，increasing the wages，and attaching importance to the career prospect are needed to relieve the burnout of GPs.


Challenges and Countermeasures for the Delivery of Internet-based Integrated Medical and Nursing Care for Community-dwelling Elderly People with Chronic Diseases　

LIAO Shengwu，ZHU Hong，TAN Bihui

2019, 22(7):  770-776.  DOI: 10.12114/j.issn.1007-9572.2018.00.391

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In China，the aggravated population aging has boosted the demands of the elderly for health，medical and nursing services，and the popularization of the internet and smart tech products is increasing.To promote the development of elderly and medical care industries to satisfy the health needs of older people，integrating the internet technologies into integrated medical and nursing care and community-based care，is a good way yet a big problem that needs to be discussed and solved urgently.In this paper，we discussed the implementation of internet-based integrated medical and nursing for health management of community-dwelling elderly people with chronic diseases，and analyzed the opportunities and challenges during the implementation.Moreover，corresponding countermeasures were put forward as follows：further increasing the government support，improving the offline service capabilities and realizing a closed loop management with the integrated medical and nursing care，training high-quality professional care providers，strengthening the supporting role of information technology，building an age-friendly society，integrating resources by attracting more companies engaged in elderly care industry and more investments into the industry，and developing an internet-based elderly care pattern suitable for domestic conditions with joint efforts of multidisciplinary teams. In addition，in an explorative way，we developed a comprehensive health management system of internet-based integrated medical and nursing，which includes the basic database subsystem，end-user subsystem，service subsystem，and supervision and evaluation subsystem.



Implementation Status and Residents' Needs Analysis of Contracted Family Doctor Services in Chongqing City　

LIU Weiwei，HOU Ying，FENG Jie，WANG Haozhuo，HU Bin

2019, 22(7):  777-782.  DOI: 10.12114/j.issn.1007-9572.2018.00.387

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Background　The contracting service of family doctors in Chongqing has been fully implemented since 2011 and fully lunched in 2016. The government has improved the system，guaranteed funds and personnel, standardized service forms and contents to promote the orderly， standardized and high-quality contracting service of family doctors. However， there is still a lack of research on the demand and status of contracting service of family doctors in Chongqing.Objective　To investigate the implementation status and residents' needs of contracted family doctor services in Chongqing，putting forward evidence-based suggestions for policy-making institutions.Methods　From March to May 2018，we conducted a survey in a convenient sample of 2 400 residents who received healthcare from primary healthcare institutions selected from 12 districts/counties（Beibei，Pengshui，Banan，Yongchuan，Liangping，Hechuan，Shapingba，Xiushan，Qianjiang，Dianjiang，Dazu，Kaizhou） of Chongqing City by use of multistage sampling with a self-designed questionnaire consisting of basic demographic characteristics，needs of contracted family doctor services，and status of signing a contract with the family doctors.Of the 2 400 questionnaires distributed，2 342 returned were responsive，achieving a response rate of 97.58%．Results　Of the 2 342 respondents，2 153 （91.93%） had needs for contracted family doctor services，including 1 358 （57.98%） who had signed a contract with the family doctors，and 984 （42.02%） who had not.The status of needs for contracted family doctor services differed significantly by age and occupation （P<0.05），but not by sex，living area，educational level and average monthly household income （P<0.05）．The top five items in the list of "badly needed" family doctor services were prompt diagnosis and treatment of common diseases and frequently-occurring diseases （43.42%，1 017/2 342），physical examination and health assessment of pregnant women/children/the elderly （34.93%，818/2 342），regular physical examination/health assessment （33.69%，789/2 342），visits of family doctors paid to patients （32.96%，772/2 342） and management of chronic diseases （32.45%，260/2 342）．The rate of signing a contract with the family doctors varied obviously by health status，awareness and status of needs of contracted family doctor services，medical treatment history/history of signing a contract with the family doctors （P<0.05）．Conclusion　The contracted family doctor services are needed by a large majority of Chongqing residents，in particular，prompt diagnosis and treatment of common diseases and frequently-occurring diseases are mostly needed.Residents' health status，awareness level of contracted family doctor services，and past healthcare-seeking habits，as well as healthcare quality are associated factors for the status of signing a contract with the family doctors.Therefore，the family doctor system should be publicized more intensively to increase its popularity，and targeted service packages should be developed for key populations in order to promote the implementation of contracted family doctor services in an orderly way.


Intention and Influencing Factors of Signing a Health Service Contract with the Family Doctor among Community-dwelling Residents in Yunnan Province　

DAI Jing，ZHU Xiangyu，LI Wei

2019, 22(7):  783-788.  DOI: 10.12114/j.issn.1007-9572.2019.07.008

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Background　The implementation of the contracted services of family doctors in Yunnan Province started late.Understanding the intention and influencing factors of signing a health service contract with the family doctor in community-dwelling residents in this province，is conducive to further improving the utilization and effectiveness of such services，and enhancing the medical service coverage in a tangible way.Objective　To explore the intention and influencing factors of signing a health service contract with the family doctor in community-dwelling residents in Yunnan Province，and based on this，to put forward suggestions for promoting the residents' contract signing rate.Methods　By geographical and economic stratification，two districts and one county from 13 districts （counties） in Kunming City，Yunnan Province were selected.Then by typical sampling，Hongyun Community，Qianwei Community and Gucheng County were selected from Wuhua District，Xishan District，Jinning District，respectively.Then，by convenience sampling，the family members of 90 households were selected from each of the communities and participated in a survey conducted between July and September 2017.A self-designed questionnaire was used in the survey，which mainly included basic personal characteristics，health seeking behavior，and the intention of signing a health service contract with the family doctor.Of the 1 412 residents，1 318 returned responsive questionnaires，achieving a response rate of 93.3%.Results　Of the 1 318 respondents，1 187 （90.1%） intended to sign a health contract with the family doctor.The intention of signing a health contract with the family doctor differed significantly among the respondents by age，educational level，type of medial insurance，annual income，living environment（urban or rural area），chronic illness，initially consulted institution，waiting time for consultation in a community health center，and time needed to get to the nearby community health center（P<0.05）．Multivariate Logistic regression analysis showed that the type of medical insurance，living area（urban or rural），chronic diseases，waiting time for consultation in a community health center，time needed to get to the nearby community health center were significantly associated with respondents' intention of signing a health service contract with the family doctor（P<0.05）．Conclusion　The prevalence of intention to sign a health service contact with the family doctor is high among community-dwelling residents in Yunnan Province.Having medical insurance, living in urban areas, suffering from at least one chronic illness, access to consultation after waiting for no more than half an hour, and getting to the nearby community health center within half an hour are associated with higher level of intention of signing a health service contract with the family doctor.


Intention of Renewing the Health Service Contract with the Family Doctor and Associated Factors among Contracted Residents in Lanzhou New Area　

ZHANG Qianqian，ZHENG Yajun，LI Hongli，XU Shanwen，CHEN Yongcong

2019, 22(7):  789-793.  DOI: 10.12114/j.issn.1007-9572.2019.07.009

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Background　Family doctor services are a kind of contractual services provided by the contracted general practitioner（GP） for the contracted residents.GP is the first person who is liable for providing contracted residents with safe，effective，easy access and inexpensive essential health care services，guiding them to use health resources in a reasonable way，and safeguarding their health，realizing the goal of universal health coverage eventually.Objective　To examine the implementation status of contracted family doctor services，contracted residents' intention of renewing the contract and associated factors in Lanzhou New Area.Methods　This survey was implemented from March to June 2018.By use of stratified random sampling，650 contracted residents were selected from administrative villages of 3 towns in Lanzhou New Area.Contracted Residents' Needs of Family Doctor Services，a questionnaire designed by our research team，was used in the survey，which included sociodemographic characteristics，awareness，use and needs of contracted family doctor services，and the intention to renew the contract.Logistic regression analysis was adopted to explore the factors associated with contracted residents' intention of renewing the contract.Results　The survey obtained a response rate of 95.7%（622/650）.The prevalence of intending to renew the contract was 82.0%（510/622）.Logistic regression analysis demonstrated that，building health records，intention of continuing to receive community-based rehabilitation therapy，and needs of home-based health services had great impact on contracted residents' intention to renew the contract（P<0.05）.Conclusion　Building health records had significant effect on the intention of renewing the contract among the contracted residents.Higher level of intention to renew the contact was found in those who were willing to continue to receive community-based rehabilitation therapy，and those who needed home-based services.In view of this，allocation of health resources to primary health care institutions should be promoted reasonably，personalized targeted services should be delivered，coverage gap of different medical insurance schemes should be narrowed，and the referral pathways should be barrier-free.


Tianjin Residents' Intention of Choosing the Contracted Family Doctor as a First Contact and Its Influencing Factors　

ZHANG Lingling，SUN Huajun，WANG Yanshang，ZOU Jiachen，DU Zhuo，CHEN Xin

2019, 22(7):  794-798.  DOI: 10.12114/j.issn.1007-9572.2019.07.010

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Background　Changing the delivery patterns of primary care and implementation of the contracted family doctor services are important tasks during the deepening the reform of the pharmaceutical and healthcare system，and are necessary approaches to the achievement of initial consultation in primary healthcare institutions and the development of hierarchical medical system.Residents are the demand side of health services.Their intention of choosing the contracted family doctor as a first contact for health problems is closely related to the successful achievement of initial consultation in primary healthcare institutions.Objective　To investigate the intention and influencing factors of choosing the contracted family doctor as a first contact for health problems among community-dwelling residents in Tianjin.Methods　From January to February 2018，by use of convenience sampling，3 （Heping District，Beichen District and Hebei District） of 16 administrative divisions of Tianjin were selected，from which 760 contracted community-dwelling residents with experience of seeking healthcare in primary healthcare institutions were sampled.A survey was conducted in them using a questionnaire composing of the general personal data，residents' satisfaction with the contracted family doctor，and their intention of choosing the contracted family doctor as a first contact for health problems.Logistic stepwise regression was used to analyze the factors associated with their intention.Results　A total of 754 cases handed in responsive questionnaires，with a response rate of 99.2%.The survey results revealed that 90.3% （681/754） of the respondents were willing to choose a contracted family doctor as their first contact for heath problems.The intention associated with initial consultation in primary healthcare institutions changed significantly by age，annual household income，type of medical insurance，waiting time for consultation，level of satisfaction with the contracted family doctor services，level of trust in the contracted family doctor，level of understanding of health problems，level of ability to cope with health problems，and level of ability to maintain health status among the respondents （P<0.05），but not by sex，educational level，employment status and prevalence of chronic diseases （P>0.05）．Logistic regression analysis showed that respondents' age，annual household income，waiting time for consultation，level of trust in the contracted family doctor，and level of ability to cope with health problems were the influencing factors of their intention of choosing the contracted family doctor as a first contact for health problems （P<0.05）．Conclusion　The prevalence of intending to choose the contracted family doctor as the first contact for health problems is high in community-dwelling residents in Tianjin，which is significantly associated with residents' age，annual household income，waiting time for consultation，level of trust in the contracted family doctor，and level of ability to cope with health problems.


Correlation between Residents' Decisions to Contract for Family Doctor Services and Influencing Factors　

ZHU Huirong，ZHU Chun，MI Yikai，SHEN Ao，ZHANG Xingna，LI Donghua，CHEN Li

2019, 22(7):  799-805.  DOI: 10.12114/j.issn.1007-9572.2019.07.011

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Background　Promoting the contracted family doctor services plays a key role in the development of hierarchical medical system and is an important measure for deepening the reform of the pharmaceutical and healthcare system.However，despite incentive effects of various policies，and the vigorous promotion and delivery of the contracted family doctor services by community health centers，residents' rate of signing a health service contract with the family doctor is less than 30%，and the utilization rate of family doctor services is still quite low.Identifying the determinants for community residents' decisions to contract for such services is of great significance in improving the contracting rate，and enhancing the quality level of such services.Objective　To examine the correlations of community residents' decisions to contract for family doctor services with influencing factors，to provide recommendations for improving the contracted family doctor services.Methods　This questionnaire survey was carried out in a convenience sample of 201 contracted and uncontracted residents from the service areas of Pudong New Area Tangqiao Community Health Center（PNATCHC），Shanghai，from May 4th to May 25th 2018.The questionnaire used included sociodemographic characteristics，comprehensive evaluation of PNATCHC，intention to contract and the utilization of contracted services.We did the analyses with the level of intention to contract and utilization of the contracted services among the residents with different sociodemographic characteristics and evaluation scores of PNATCHC.Wilcoxon rank-sum test or Kruskal-Wallis H test was used to compare the unordered categorical independent variables，and Spearman's correlation analyses were performed with ordered categorical or quantitative independent variables.Results　The retirees showed higher rates of contracting and utilizing the contracted services compared with others （P<0.05）.Those with an experience of contracting were more prone to contract，and they showed higher rates of contracting and utilizing the contracted services compared with those without （P<0.05）.Spearman's correlation analysis revealed that the level of intention to contract increased with the evaluation scores for PNATCHC（P<0.05）.And the utilization of the contracted services increased with the resident's age and the evaluation scores for PNATCHC，but decreased with personal monthly income（P<0.05）.Conclusion　In order to improve the quality of contracted family doctor services，and enrich the contents of health management，priorities should be given to enhance the capabilities and maintain a good image of community family doctors，and publicize the contracted family doctor services and the role of family doctors in delivering such services.Moreover，it is suggested that the service coverage should be enlarged in young，employed and high-income groups.


A Prospective Cohort Study on Total Cholesterol Levels and Risk of Acute Pancreatitis 　

ZHU Guoling，ZHANG Bing，JI Ruigeng，ZHANG Yanmin，WANG Haitao，WANG Shan，TONG Bo，ZHANG Hailing，WANG Qian，ZHANG Jie，JIANG Xiaozhong，DUAN Heli，CHEN Shuohua，MEN Xiuli，WU Shouling

2019, 22(7):  806-811.  DOI: 10.12114/j.issn.1007-9572.2019.07.012

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Background　It is generally believed that hypertriglyceridemia （HTG） increases the risk of developing acute pancreatitis （AP）． However，the relationship between hypercholesterol and AP has not yet been confirmed.Objective　To investigate the effects of serum total cholesterol （TC） on the risk for new-onset AP.Methods　 A prospective cohort study design was applied.Study cohort consisted of 125 210 current employees and retired employees from Kailuan Group who participated in the health check-ups between 2006 and 2009 launched by the group，the starting point of follow-up was when the subjects completed the health examination, and the end point was new AP events，deaths or the end of follow-up （2014-12-31）.and had complete data on serum TC with no AP history at baseline.Participants were divided into normal blood lipid group（TC<5.2 mmol/L），borderline high blood lipid group （TC 5.2-<6.2 mmol/L） and high blood lipid group （TC≥6.2 mmol/L） according to the baseline fasting serum TC levels.Baseline data and incidence of new-onset AP data were collected.The survival curve was plotted by Kaplan-Meier method.The cumulative incidence was determined by Log-Rank method.Multivariate Cox proportional hazards regression model was used to explore the effect of baseline fasting serum TC level on new-onset AP.Results　The sex ratio，average age，BMI，systolic blood pressure，fasting blood glucose，high-density lipoprotein cholesterol （HDL-C），triglyceride，and length of education，rates of smoking，drinking，physical exercising，history of hypertension，and diabetes history differed significantly between the groups （P<0.05）． All of them received an average follow-up period of （7.4±1.2） years，during which 195 cases were found with AP.The density rates of AP were 1.99/10 000，1.81/10 000，and 3.64/10 000 persons-years，in normal，borderline high and high blood lipid groups，respectively.The cumulative incidence in normal，borderline high and high blood lipid groups，was 0.16%，0.14%，0.27%，respectively，showing a significant inter-group difference by Log-Rank test （χ2=12.37，P=0.002）． After adjusting for age，gender，BMI，HDL-C，TG，smoking，drinking，length of education，physical exercising，history of hypertension and history of diabetes，Cox regression analysis showed that compared with the normal blood lipid group，borderline high blood lipid group 〔HR=0.84，95%CI（0.59，1.19）〕 and high blood lipid group 〔HR=1.56，95%CI （1.06，2.31）〕 had a higher risk for AP.Conclusion　Baseline fasting serum TC level greater than or equal to 6.2 mmol/L increases the risk of developing AP.


Incidence and Influencing Factors of Microvascular Complications in Patients with Nephrotic Syndrome　

YUAN Liying，HE Hong，BAN Zunpu，ZHANG Fangshun，LUO Guohong，CHEN Tong，LUO Yadan，ZHAO Jin

2019, 22(7):  812-816.  DOI: 10.12114/j.issn.1007-9572.2019.07.013

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Background　Patients with nephrotic syndrome have symptoms such as disorders of lipid metabolism，hypoproteinemia，massive proteinuria，and increased risk of arteriosclerosis.The discussion of related influencing factors is one of the key starting points for the diagnosis and treatment of this disease.Objective　To investigate the incidence and influencing factors of microvascular complications in patients with nephrotic syndrome.Methods　The 82 participants were recruited from The First People's Hospital of Zunyi from January to June 2017，including 42 cases of nephrotic syndrome（observation group） from Department of Nephrology，and 40 health examinees（control group）．The glycemic markers，lipid metabolism markers，and atherosclerosis score index（ASI） were compared between the observation group and control group.Multivariate Logistic regression analysis was performed to explore the influencing factors of microvascular complications in nephrotic syndrome.Pearson correlation analysis was performed to explore the correlation between ASI and lipid metabolism markers.Results　Compared with the control group，the observation group demonstrated much higher average levels of hypersensitivity C-reactive protein（hs-CRP），α-lipoprotein（LP-α），low-density lipoprotein cholesterol（LDL-C），fasting blood glucose（FBG），triacylglycerol（TG），total cholesterol（TC），white blood cell count（WBC），24-hour urine protein（24 hUpro） and homeostatic model assessment of insulin resistance index（HOMA-IR），but much lower average levels of serum high-density lipoprotein cholesterol（HDL-C），albumin（ALB），total protein（TP）（P<0.05）．The incidence of microvascular complications in nephrotic syndrome patients was 64.3%（27/42）．Multivariate Logistic regression analysis found that elevated hs-CRP，LDL-C，LP-α and FBG were risk factors and elevated HDL-C was a protective factor for microvascular complications in nephrotic syndrome（P<0.05）．At the end of 18 months follow-up，the average ASI of the observation group was found to be obviously higher than the baseline level，and was significantly higher than that of the control group（P<0.05）．Pearson correlation analysis revealed that ASI had a positive linear correlation with LP-α and TC（P<0.05）．Conclusion　The incidence of microvascular complications in nephrotic syndrome is relatively high.Its occurrence and development are influenced by serum hs-CRP，LDL-C，LP-α，FBG and HDL-C levels.


24-hour Ambulatory Blood Pressure Monitoring，Follow-up Blood Pressure and Office Blood Pressure Measurements in Patients with Hypertension：a Comparative Study　

YANG Danhong，WU Jing，GE Ying，LI Hengna

2019, 22(7):  817-821.  DOI: 10.12114/j.issn.1007-9572.2019.07.014

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Background　Blood pressure monitoring is a method that helps hypertensive patients to know their blood pressure level and control effects，and also an important way for early identification of hypertension-associated abnormalities.Community-based blood pressure measurement methods include office and follow-up blood pressure measurements and 24-hour ambulatory blood pressure monitoring（ABPM）.Objective　To compare the consistencies and differences of 24-hour ABPM，office and follow-up blood pressure measurements for hypertensive patients，offering a reference for the promotion of 24-hour ABPM.Methods　This study was carried out in a convenience sample of 169 cases of hypertension who received the management（including 24-hour ABPM） of Jinshan Industrial Area Community Health Center，Shanghai，from March 2017 to May 2018.By reviewing the electronic medical records，the results of 24-hour ABPM（daytime，night-time and average 24-hour blood pressure），and those of office and follow-up blood pressure measurements were collected.Consistencies and differences of these three measurements were compared.Results　Significant differences were observed when comparing daytime，night-time and average 24-hour blood pressure，office blood pressure and follow-up blood pressure by difference analysis（P<0.05）.Daytime，night-time，average 24-hour blood pressure，and follow-up blood pressure had poor consistency in the measurement of blood pressure with office blood pressure by consistency analysis（Kappa<0.400）.Conclusion　Combination of 24-hour ABPM，office and follow-up blood pressure measurements can improve the accuracy of community-based blood pressure monitoring for hypertensive patients.Attention should be paid to guide the patients using the appropriate monitoring way and inform them the matters that should be noted during the monitoring.


Influencing Factors of Time to Peak Insulin Level after Glucose Load in Type 2 Diabetic Patients 　

LIAO Shibo，WU Min，HUANG Shuyu，ZOU Yi，YAN Yimin，ZHU Zhao，HUANG Gao，LI Ling，XIANG Cheng，ZHU Wei

2019, 22(7):  822-829.  DOI: 10.12114/j.issn.1007-9572.2019.07.015

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Background　Delayed timing of peak insulin level after glucose load is common in patients with type 2 diabetes mellitus （T2DM），which may be an important cause of postprandial hyperglycemia in this population.However，there are no studies concerning the influencing factors of delayed timing of post-load peak insulin level in T2DM patients.Objective　To investigate the influencing factors of time to peak insulin level after glucose load in T2DM patients.Methods　We selected 490 hospitalized patients with T2DM from Department of Endocrinology，Xiaogan Hospital Affiliated to Wuhan University of Science and Technology from January 2016 to June 2018.We collected their clinical data，serum HbA1c and ketone bodies levels，routine blood test and biochemistry analysis results，FPG，blood glucose levels measured again 30，60，120，180 minutes（G30 min，G60 min，G120 min，G180 min levels） after having glucose solution in a 3-hour 75 g oral glucose tolerance test （OGTT） and fasting insulin （FINS） and INS levels measured again 30，60，120，180 minutes（I30 min，I60 min，I120 min and I180 min levels） after having glucose solution in a 3-hour insulin response test，and recorded peak INS level after glucose load （Imax） and the time during which INS was at its peak （tmax）．According to tmax，we divided them into short tmax group （tmax≤90 min，n=159），medium tmax group （90 min<tmax≤135 min，n=169），and long tmax group （135 min<tmax≤180 min，n=162）．The general data，laboratory indicators，OGTT and IRN indicators of the three groups were compared.Logistic regression was used to analyze the influencing factors of tmax in patients with T2DM.Results　There were significant differences in the distribution of sex，and average course of T2DM，erythrocyte count，HbA1c concentration，G0 min，G120 min，G180 min，I60 min，I120 min and I180 min among the three groups （P<0.05）．The ratios of male to female in medium and long tmax groups were all less than that in short tmax group （P<0.016 7）．The average number of erythrocytes and HbA1c concentration in long tmax group were all less compared with those in short tmax group （P<0.05）．The average course of T2DM was shorter and average HbA1c concentration was lower in medium tmax group than those in short tmax group （P<0.05）．Long tmax group showed higher average G120 min and G180 min levels than short tmax group，and demonstrated higher average G0 min，G120 min and G180 min levels than medium tmax group （P<0.05）．Long tmax group presented lower average I60 min level but higher average I120 min and I180 min levels compared with short tmax group，and showed lower average I60 min level compared with medium tmax group （P<0.05）．Medium tmax group had higher average I120 min，and I180 min levels than short tmax group （P<0.05）．Logistic regression analysis showed that elevated G120min was a risk factor for tmax in patients with T2DM，and decreased G0 min and shorter course of T2DM were protective factors for tmax （P<0.05）．Conclusion　Elevated G120 min is an independent risk factor for delayed timing of peak insulin level after glucose load in patients with T2DM.


Three Treatments for Cesarean Scar Pregnancy　

LI Fan，YUAN Lihong，ZHOU Ping

2019, 22(7):  830-833.  DOI: 10.12114/j.issn.1007-9572.2019.07.016

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Background　Cesarean scar pregnancy（CSP） is a serious complication in the early pregnancy.With the implementation of the universal two-child policy，cesarean section rate remains high and the incidence of CSP is increasing. Objective　To evaluate the clinical value and safety of three treatments in the termination of CSP.Methods　The medical records of 44 patients with CSP hospitalized in the First Affiliated Hospital of Anhui University of Science & Technology/Huainan First People's Hospital，from April 2013 to December 2017 were retrospectively analyzed.According to the treatment，they were divided into group A（n=16），group B（n=14） and group C（n=14），receiving uterine artery embolization with B-mode ultrasound-guided uterine curettage，transvaginal removal of ectopic pregnancy tissue with repair of uterine scar，B-mode ultrasound-guided uterine curettage following killing the embryo by methotrexate and mifepristone，respectively.Age，gravidity，number of cesarean sections，duration of menstruation cessation，baseline serum human chorionic gonadotropin（HCG）， intraoperative blood loss，duration of operation，postoperative vaginal bleeding time，duration of antibiotic use，length of stay，time taken for postoperative HCG to fall to the pre-pregnancy level，and occurrence of complications were compared between the three groups.Results　Three groups showed no significant differences in average age，gravidity，number of cesarean sections， duration of menstruation cessation，and baseline HCG level（P>0.05）.The average intraoperative blood loss，duration of operation，postoperative vaginal bleeding time，duration of antibiotic use and length of stay differed significantly across the groups（P<0.05）.The average time taken for postoperative HCG to fall to the pre-pregnancy level in three groups demonstrated no significant differences（P>0.05）.To be specific，pairwise comparisons showed that the average intraoperative blood loss increased successively in groups A，C，and B（P<0.05）.Group B had shorter average duration of operation than other two groups（P<0.05）.The average postoperative vaginal bleeding time of group A was shorter than that of group C（P<0.05）.The average duration of antibiotic use of group A was shorter than that of group B（P<0.05）.Group C had longer length of stay compared with other two groups（P<0.05）.No uterine perforation，abortion-related syndrome，massive hemorrhage，bladder injury and hysterectomy occurred during the operation，and no drug-induced liver and kidney injuries and leukopenia occurred after the operation.Conclusion　Uterine artery embolization with B-mode ultrasound-guided uterine curettage is minimally invasive and safe，but should be selected cautiously for those with fertility needs.Transvaginal removal of ectopic pregnancy tissue with repair of uterine scar has good eradication effect but with higher risks. B-mode ultrasound-guided uterine curettage following killing the embryo by methotrexate and mifepristone is minimally invasive and safe，but need longer length of stay. Therefore，for the termination of CSP，an individualized treatment plan should be formulated according to the patient's condition and fertility need.


Prevalence of Glaucoma in First-degree Relatives of Patients over 40 Years Old with Primary Open Angle Glaucoma　

HAN Yucan，TAN Rong，WANG Ping，GONG Jin，YANG Qingguo

2019, 22(7):  834-838.  DOI: 10.12114/j.issn.1007-9572.2019.07.017

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Background　Primary open angle glaucoma（POAG） is the most common type of glaucoma.Epidemiological data show that genetic factors play an important role in the pathogenesis of POAG.The incidence of POAG has an obvious tendency of familial aggregation due to genetic factors.Objective　To study the prevalence of primary glaucoma in first-degree relatives over 40 years of age of POAG patients，to identify the role of family history in the pathogenesis of POAG，providing a reference for early prevention and treatment of glaucoma.Methods　This study was carried out following a case-control design.From Department of Ophthalmology，Affiliated Renhe Hospital of China Three Gorges University，100 patients receiving a definite diagnosis of POAG（case proband group） and 100 receiving surgical treatment for cataract and without POAG（control proband group） were recruited during 2015 to 2017.First-degree relatives（parents，siblings and children） over 40 years of age of the case and control proband groups were included，named as case group（n=289）and control group（n=295），respectively.A glaucoma screening and a questionnaire survey were conducted in both case group and control group.Logistic regression analysis was performed to identify the factors associated with POAG.Results　The prevalence of POAG was much higher in the case group than that of the control group〔11.8%（34/289） vs 1.7%（5/295）〕（P<0.05）．Sex-specific subgroup analyses found that the prevalence of POAG was obviously higher either in males or females in case group compared with the control group（P<0.05）.Age-specific subgroup analyses revealed that the prevalence of POAG was obviously higher in individuals 50-59，60-69 and ≥70 years of age in case group compared with the control group（P<0.05）.Logistic regression analyses found that first-degree relatives（over 40 years of age）of the POAG patients were associated with increased risk of POAG compared with those of non-POAG patients（P<0.05）.And POAG patients' parents and children were independently associated with increased risk of POAG compared with their siblings（P<0.05）.Conclusion　First-degree relatives over 40 years of age of POAG patients had higher prevalence of POAG compared with those of non-POAG patients.So，glaucoma screening targeted at first-degree relatives of POAG patients is highly effective，yet inexpensive.


Teaching Modalities for General Practice Course for Undergraduate Medical Students　

QI Zhennan，DONG Aimei，HAN Xiaoning，QI Jianguang，ZHOU Guopeng，ZENG Hui，WEI Yanan，CHI Chunhua

2019, 22(7):  839-842.  DOI: 10.12114/j.issn.1007-9572.2019.07.018

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Undergraduate education is the enlightenment stage of medical education.Exploring teaching modalities for general practice course suitable for undergraduate medical students helps to motivate students' learning interests，and improve teaching effectiveness.Moreover，it can influence future career choice，promoting more students to be a general practitioner after graduation.As one of the first batch of universities offering general practice courses for undergraduate medical students in China，Peking University Health Science Center has established Department of General Practice，and gradually developed teaching modalities for general practice course suitable for undergraduate medical students characterized by "conceptual infiltration，theory inculcation，practice combination，community orientation" based on years of active exploration of highly effective，repeatable and propagable teaching modalities by management team construction，curriculum system optimization and diversification of evaluation methods.Strengthening general practice education in undergraduate medical students can facilitate the popularization of general practice ideas.This article discusses the above-mentioned teaching modalities developed by Peking University Health Science Center，in order to provide a reference for medical students choosing to be a general practitioner after graduation by introducing the essential concepts of general practice and duties of general practitioners，and for other colleges to implement teaching modalities for general practice courses suitable for undergraduate students in general practice.


General Evaluation and Demand for Improvements of Standardized Training for General Practitioners：a Study from Supply- and Demand-side Perspectives　

HAN Xiaojie，LI Bingying，XIE Siyi，HU Huijing，YANG Xiumei，HONG Zhefang，HE Xiaohua，ZHOU Ji

2019, 22(7):  843-848.  DOI: 10.12114/j.issn.1007-9572.2019.07.019

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Background　China's general practitioner（GP） training system is confronted with weak foundation，large scale of construction，and insufficient qualified GPs for meeting people's needs of primary health care.Minhang District of Shanghai cooperates with universities to help establish a collaborative service system for medical education and research with the help of Minhang District Municipal Commission of Health and Family Planning to promote the training of GPs.Objective　To investigate supply- and demand-side perspectives on the general status and needed improvements of standardized training for GPs，to explore strategies for effectively improving the quality of such trainings.Methods　We conducted this survey from April 2016 to June 2016.Participants were recruited from two standardized training bases for GPs in Minhang District of Shanghai，including teachers and teaching managers（supply-siders for GP training），and individuals who were undergoing a GP training and those who had an experience of such training in the past（demand-siders for GP training）．We used a self-designed questionnaire in the survey，which consists of basic personal information，levels of awareness，general evaluation，and demands for improvements of the standardized training for GPs.Results　A total of 120 cases received the survey，and 112 of them（including 36 teachers，10 teaching managers，36 individuals who were undergoing the training and 30 who had been trained in the past） responded effectively，obtaining a response rate of 93.3%.The standardized GP training system was well understood/comparatively well known in 84.8%（39/46）of the suppliers and 69.7%（46/66）of the demanders for GP training，and it achieved a very/relatively high level of satisfaction in 80.5%（37/46）of the work units of the formers，but obtained a fair level of satisfaction/dissatisfaction in 56.0%（37/66）of the work units of the latters.Moreover，it was thought to be reasonable but was implemented inappropriately in 80.5%（37/46）of the suppliers，and obtained dissatisfaction in 40.9%（27/66） of the demanders.As regard to the capabilities of GPs that should be improved foremostly，GPs' diagnostic and therapeutic procedures were reported by 43.5%（20/46） of the suppliers，and GPs' clinical diagnostic and therapeutic abilities were reported by 28.3%（13/46） of the suppliers，and 40.9%（27/66）of the demanders.The work unit evaluation and individual evaluation of the standardized GP training system，capabilities of GPs that should be trained and improved foremostly，aspects with the highest priority in performance assessment of GPs，and the most essential abilities of teachers for training GPs showed significant differences among different groups of suppliers and demanders（P<0.05）．Conclusion　The standardized GP training system was not implemented appropriately，and it achieved a very low satisfaction from the demanders.As for aspects of trainings for GPs that should be improved，GPs' clinical practice abilities were highlighted by both suppliers and demanders.And lastly，subjective general evaluation and demands for improvements of standardized training for GPs differed obviously among different groups of suppliers and demanders.


Association of Childhood Socioeconomic Status with Health in Middle-old Age　

ZHANG Xiaoning，CHEN Shuang，MENG Kun，LIN Meixiu

2019, 22(7):  849-854.  DOI: 10.12114/j.issn.1007-9572.2019.00.012

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Childhood socioeconomic status（SES） refers to the parental social class and parental education in childhood.Recent research has proved that SES influences the health in middle-old age.In particular，studies of the influencing factors for health in middle-old age from the perspective of life cycle show that low SES may lead to serious health conditions in middle-old age.Life course health development （LCHD），the pathway model and the social mobility model explain the association of childhood SES with health in middle-old age.The mechanism of childhood SES influences the health in middle-old age involves environmental factors，and the accessibility of health services.This paper introduces LCHD，the pathway model and the social mobility model，to explain the mechanism of the association of childhood SES with the health in middle-old age.


interRAI-LTCF-assessed Cognitive Impairment and Influencing Factors in Elderly People in Geriatric Nursing Facilities　

GUI Qian，WANG Yanjun，ZHANG Qin，CHEN Yujing，HE Fan，DING Yayuan，DING Huan，XU Jingxian，XU Guihua

2019, 22(7):  855-859.  DOI: 10.12114/j.issn.1007-9572.2019.00.037

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Background　With the aggravation of aging，the incidence of cognitive impairment in the elderly is increasing.To prevent and delay dementia timely and effectively，early screening，diagnosis and intervention of cognitive impairment should be taken based on studying the factors associated with cognitive impairment.Objective　To investigate the status of cognitive impairment and its influencing factors in the elderly in geriatric nursing facilities.Methods　This survey was carried out from April to June 2018.Participants were 369 elderly people aged ≥60 years old who were selected from a geriatric nursing facility in Jiangning District of Nanjing，China，by use of convenience sampling.They received a face-to-face survey with the interRAI-LTCF by qualified and well-trained evaluators.Cognitive impairment was determined by the interRAI Cognitive Performance Score（CPS）．Demographic characteristics and other evaluation factors were taken as independent variables for establishing the Logistic model.Multivariate Logistic stepwise regression analysis was used to explore the influencing factors of cognitive impairment.Results　Totally 338 responsive questionnaires were collected，obtaining a response rate of 91.6%.138 respondnets were identified with different degrees of cognitive impairment，accounting for 40.8%（138/338）．Multivariate Logistic stepwise regression analysis showed that sensory impairment，cerebrovascular disease，ADL score，depression score，pain score and social participation score influenced cognitive impairment significantly（P<0.05）．Conclusion　The prevalence of cognitive impairment is high among the elderly in geriatric nursing facilities.Sensory impairment，cerebrovascular disease，ADL dependence and depression are risk factors while high social participation is a protective factor assocatied with cognitive impairment.In view of this，active screening of cognitive impairment and targeted interventions should be taken for this population.


Relationship between Smoking and Mental Health Related Behaviors among Residents in the Main Urban Areas of Wuxi　

FENG Wei，YAO Jianjun，LI Shiming，WU Yue，ZHOU Dexiang，ZHANG Zijuan，YANG Queping

2019, 22(7):  860-864.  DOI: 10.12114/j.issn.1007-9572.2019.07.022

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Background　Psychological status is associated with smoking.Psychological problems may be a risk factor for initiating smoking behavior.Objective　To investigate the relationship between smoking and mental health related behaviors in residents，providing evidence for formulating tobacco control measures.Methods　By multiphase sampling，we enrolled 2 498 adult residents（aged ≥ 18） from the main urban areas of Wuxi，Jiangsu Province.From December 2013 to June 2014，we conducted a survey in them using a self-developed Socioeconomic Questionnaire and the Chinese version of 12-item General Health Questionnaire to collect the socioeconomic characteristics，prevalence of smoking and psychological status.The survey achieved a response rate of 95.92%（2 396/2 498）.Results　The overall prevalence of smoking among the respondents was 25.04%（600/2 396）.The prevalence of smoking varied significantly by sex，age，hukou status，marital status，occupational status，alcohol consumption，active access to health knowledge and mental health status in the respondents（P<0.05）.Moreover，it also changed obviously according to self-perceived level of making decision，self-perceived mental stress，self-perceived problem-solving ability，self-perceived enjoyment of life，self-perceived challenges，feeling pain or anxiety and low personal value （P<0.05）.Logistic regression analysis showed that sex，age，marital status，occupational status，alcohol consumption and mental health status were factors associated with the prevalence of smoking （P<0.05）.Conclusion　Smoking is relatively common in residents in the main urban areas of Wuxi，which is influenced by mental health status.In order to increase the level of self-perception of mental health problems and to achieve more successful smoking control，targeted interventions such as intensive propaganda and public education of smoking control and so on should be delivered in a comprehensive way based on the conditions involving mental health related behaviors in all populations，especially the susceptible populations.



Advances in Research on Factors Influencing Adherence to Urate-lowering Therapy in Patients with Gout　

LI Bohan，FANG Weigang，SHA Yue

2019, 22(7):  865-869.  DOI: 10.12114/j.issn.1007-9572.2019.07.023

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Gout has a direct impact on the quality of work and daily lives.79% of the patients can not work due to pain and hospitalization during gout flares.The goal of long-term therapy is to lower the serum urate level to reduce recurrent acute gout flares and improve prognosis of patients.Researches have demonstrated that low serum urate control rate is associated with poor adherence to urate-lowering therapy.This article reviews 5 factors that influence adherence to urate-lowering therapy in patients with gout，including sociodemographic，patient-related，healthcare team-related，condition-related and therapy-related，and discusses potential interventions to improve the adherence to urate-lowering therapy.


Advances in the Diagnosis and Treatment of Urinary Tract Infection in the Elderly　

HUI Miao，LI Yuehong

2019, 22(7):  869-872.  DOI: 10.12114/j.issn.1007-9572.2019.07.024

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Urinary tract infection（UTI） refers to the inflammatory response of tourothelium to the invasion of pathogenic bacteria，often accompanied by bacterial urine and pyuria.UTI in the elderly is generally divided into symptomatic and asymptomatic bacteriuria.As it often has no typical symptoms and signs，results of laboratory test，etiological examination and drug susceptibility testing should be taken into account when making a diagnosis or giving treatment guidance.Active and effective prevention，identification of atypical clinical manifestations，definite diagnosis，and rational use of antibiotics are the key to the management of UTI in the elderly.This article reviews the epidemiology and pathogens of UTI in the elderly，as well as the progress of diagnosis，treatment and prevention，in order to provide a reference for doctors to improve the treatment effect of UTI and the quality of life in the elderly.