Chinese General Practice

Interpretation of the Adult Well-male Examination by American Academy of Family Physician　

WANG Yang，XU Yanli

2019, 22(14): 1637-1640. DOI: 10.12114/j.issn.1007-9572.2019.00.144

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Health examination is a basic ways and effective mean for disease prevention and health management.In December 2018，the American Family Physician published the latest guidelines for adult well-male examination.There is still no universally accepted guideline in this field in the United States.Therefore，it is the first evidence-based guideline for to men's health examination in primary care published by American Academy of Family Physician （AAFP）．This article refines and summarizes the core content of the guideline，and compares it with Expert Consensus about Basic Project in Physical Examination，to provide external reference for general practitioners and patients in China.

Interpretation of Canadian Pediatric Society Clinical Practice Recommendations for Children and Adolescents with Attention-deficit Hyperactivity Disorder（Version 2018）　

LIU Huanzhong，ZHONG Yi

2019, 22(14): 1641-1647. DOI: 10.12114/j.issn.1007-9572.2018.00.452

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Attention-deficit hyperactivity disorder（ADHD） is a common chronic neurodevelopmental disorder in children，which has become a global public health problem.For the diagnosis and treatment of ADHD，various academic organizations in the world have published relevant guidelines，and updated them with the development of research in recent years.On October 24，2018，the Mental Health and Developmental Disabilities Committee under the Canadian Pediatric Society led the development of the latest guidelines for the diagnosis and treatment of ADHD.This guideline covers all available ADHD clinical evidence and treatment standards so as to provide good evidence-based treatment strategies for clinicians as many as possible.The aim of this paper was to interpret the key contents of the guideline，and compare it with the 2018 NICE Guideline：Attention-deficit Hyperactivity Disorder：Diagnosis and Management（NG87） as well as the current guidelines in China.

The Enlightenment of Primary Care Research Network in North America and Europe to Chinese General Practice　

WANG Yang，YAO Mi，XU Zhijie，HAN Jianjun，XU Yanli，YANG Hui

2019, 22(14): 1648-1654. DOI: 10.12114/j.issn.1007-9572.2019.00.147

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European General Practice Research Network （EGPRN） was founded in 1974.Practice-based research networks （PBRN） in North America was founded in 1983.They both have more than 30 years' history，and have greatly promote primary care scientific research in Europe and the United States.This article reviewed their development history，current situation，scientific achievement，current major challenges and reform strategies，compared their characteristics，discussed whether Chinese general practitioners needs to build general practice scientific research network and its possible challenges，and finally，pointed out the importance of obtaining evidence based on China，and further discussions based on integrating external reference，evidence with high credibility，and stakeholders' experience.

Complex Dynamic Analysis of Community-based Hypertension Management Pattern Based on System Dynamics　

XU Liping，CHEN Jie，GUO Feina，YI Chuntao

2019, 22(14): 1655-1662. DOI: 10.12114/j.issn.1007-9572.2018.00.398

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Background　At present，single index method，multiple linear regression，grey model and ARIMA model make mostly use of studying the management effect of chronic diseases in communities.These methods often depend on the completeness of data indicators and the length of time series.We present the application of the system dynamics model，which the simulation results are closer to the real situation and the data requirements are more relaxed.This study provides a new method for decision optimization of single disease management path in community.Objective　To explore a dynamic complex model for community-based management pattern of hypertension，providing a reference for quantitative research on the effect and improvement of community-hypertension management pattern.Methods　From January to May 2017，by use of semi-structured interviews with the front-line key health workers of Xuhui District Fenglin Community Health Center，Shanghai，we obtained the data concerning the process of hypertension management used in this center，and we collected the data regarding community-based hypertension management between 2015 and 2017 by web searching.Using systems thinking approach and system dynamics modeling software，we constructed a systems thinking models of community-based hypertension management on the basis of the interview results，literature review of the collected study data and policy documents，and drew causal loop diagrams using the identified key factors in the management system among which causal relationships exist.Results　The system of hypertension community-based hypertension management pattern includes community-dwelling population classification subsystem，high-risk population for hypertension management subsystem，hypertension population management subsystem and community input subsystem.The causal relationships between the factors included in the community-based hypertension management pattern are explained well by the causal loop diagrams of quantity control of targeted populations under community-based hypertension management and quality control in community-based hypertension management for targeted populations.Conclusion　The systems thinking models of community-based hypertension management can be used as an important assistant tool for assessing the performance of the standardized community-based hypertension management system and for optimizing the management procedure.Moreover，the systems thinking models and causal loop diagrams provide references for the development of community-based management patterns of other single diseases.

Prediction of Hypertension Management Input in Community Based on System Dynamics　

XU Liping，LI Ting，HUANG Tao，SU Jin，YI Chuntao

2019, 22(14): 1663-1671. DOI: 10.12114/j.issn.1007-9572.2018.00.326

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Background　After receiving the management objectives issued by the superior units，there is no definite answer on the service volume change of hypertension management in the community and the number of medical stuffs needed.Objective　To forecast the annual service volume and community input of hypertension management in by system dynamics method，so as to provide suggestions for the improvement of hypertension management system in community.Methods　Fenglin Street Community Health Center，Xuhui District of Shanghai，was selected as the research subject from September 2017 to March 2018.Historical data query and questionnaire survey were conducted to collect the data about service volume and community input of hypertension management from 2007 to 2016.System dynamics software Vensim PLE was used to forecast the annual service volume and community input in hypertension management.The results showed that the absolute value of the relative error was less than 0.05 between forecasting data and actual data concerning the newly increased number of people involved in hypertension management and the number of people with hypertension under management at the beginning of the year.This indicated that the model could basically reflect the operation of hypertension management system，and could be used to forecast the volume of hypertension management service and community input in Fenglin Street Community Health Center.Results　The results showed that the annual increase number in hypertension management in Fenglin Street Community Health Center was expected to be nearly equal to the loss number from 2018，thus basically stabilizing the number of people with hypertension in management at about 17 000，and the annual community input is expected to reach about 1 million yuan.Conclusion　Based on the system dynamics model，hypertension management service volume and input prediction in community are scientific，and the prediction results reveal the pressure of this system.Therefore，it is suggested that the hypertension management system in community should pay more attention to the performance of its executors in the near future，and make efforts in informationization and training low-cost personnel in the long run.

Design and Verification of Behavioral Activation Intervention Program for Post-stroke Subthreshold Depression：a Pilot Trial　

XU Hailian，LYU Yumei，HE Yudi，JIN Yisi，SU Jing

2019, 22(14): 1672-1677. DOI: 10.12114/j.issn.1007-9572.2018.00.427

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Background　At present，little attention has been paid to patients with post-stroke subthreshold depression in China，and the effect of behavioral activation therapy on such patients is still unclear.Objective　To explore the effect of behavioral activation therapy on depressive symptoms and behavioral characteristics and incidence of post-stroke depression in post-stroke subthreshold depression patients.Methods　We enrolled 30 cases suffering from post-stroke subthreshold depression for no more than 3 months from Department of Neurology or Department of Rehabilitation，Daqing People's Hospital during October 2017 to March 2018.By use of a random number table，we equally divided them into intervention group （n=15） and control group （n=15）.Both groups were given the conventional mental health intervention，the intervention group were also treated with a 6-week behavioral activation therapy（once a week，30-60 min at a time）．Center for Epidemiological Survey，Depression Scale （CES-D），Behavioral Inhibition System and Behavioral Activation System Scale （BIS/BAS），and 17-item Hamilton Depression Scale （HAMD-17） were used to assess the depressive symptoms，behaviors and depressive state，respectively，at baseline，at the end of intervention and 3 months after the intervention.Intervention outcomes of both groups were evaluated by scores of CES-D，BIS/BAS and HAMD-17.Results　Both the method and duration of intervention had obviously interactive effect on the average scores of CES-D and BAS （P<0.05）．And they produced significant main effects on the average scores of CES-D and BAS （P<0.05）．Intergroup comparisons showed that at the end of intervention and 3 months after intervention，the intervention group had lower average score of CES-D and higher average score of BAS （P<0.05）．The average score of CES-D decreased significantly and that of the BAS increased notably in both groups at the end of intervention and 3 months after intervention compared to the baseline （P<0.05）．The outcome of post-stroke subthreshold depression was similar in both groups at the end of the intervention （P>0.05），but it was much better in the intervention group 3 months later（P<0.05）．Conclusion　Our trial shows that behavioral activation therapy can improve the depressive symptoms and behavioral characteristics of patients suffering from post-stroke subthreshold depression for no more than 3 months，and reduce the incidence of post-stroke depression within 6 months after stroke.

Retrospective Study of the Incidence of Heart Failure in Southwest China　

MA Lilan，YANG Ying，CHEN Zhangrong，WU Xinhua，CHEN Anqi，LIU Hong，LIU Quanyi，YANG Wei，ZHANG Jian

2019, 22(14): 1678-1683. DOI: 10.12114/j.issn.1007-9572.2019.00.025

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Background　In China，with the intensification of population aging，the incidence of heart failure（HF） is on the rise year by year，with a 5-year mortality rate of over 50%.HF has become a “fortress” in the field of cardiovascular medicine that needs to be conquered.The prevention and treatment of HF are an important health task in our country，so understanding the clinical manifestations of HF is of great significance.Objective　To explore the clinical characteristics of HF patients in southwest China，offering a scientific basis for the prevention and treatment of HF in this region.Methods　This study was conducted following a retrospective design.Participants were 3 674 HF inpatients selected from 12 hospitals（the First Affiliated Hospital of Dali University，Baoshan People's Hospital，the First People's Hospital of Zhaotong，Dehong People's Hospital，Qujing First People's Hospital，Guizhou Provincial People's Hospital，Qiannan People's Hospital，Xingyi People's Hospital，Qiandongnan People's Hospital，Qianxinan People's Hospital，the People's Hospital of Guang'an City，the First Affiliated Hospital of Chongqing Medical University） in Southwest China from January 2009 to October 2016.After excluding those with incomplete，missing or wrong data，3 516 cases were finally included.Sex，age，NYHA class，etiology，levels of left ventricular ejection fraction （LVEF），left ventricular end-diastolic diameter （LVEDD），brain natriuretic peptide （BNP），electrolytes，thyroxine，anemia，total bilirubin，uric acid and other clinical characteristics were compared between them.Results　Among the participants，the percentages of NYHA class Ⅱ，Ⅲ，and Ⅳ HF were 25.40%（893/3 516），41.67%（1 465/3 516） and 32.93%（1 158/3 516），respectively.The percentages of HF caused by coronary heart disease，hypertension and cardiomyopathy were 32.45%（1 142/3 516），19.45%（684/3 516） and 13.00%（457/3 516），respectively.Except for 777 cases，2 739 had echocardiography results.The percentages of reduced ejection fraction（HFrEF），mid-range ejection fraction（HFmrEF） and preserved ejection fraction（HFpEF） were 26.76%（733/2 739），12.23%（335/2 739） and 61.01%（1 671/2 739），respectively.Worse cardiac function was associated with higher prevalence of HFrEF and HFmrEF，lower prevalence of HFpEF and LVEF，higher LVEDD and higher BNP（P<0.05）．The prevalence of hypokalemia and hyperkalemia was 16.21%（481/2 967），and 1.38%（41/2 967），respectively.Worse cardiac function was associated with higher prevalence of hypokalemia（P<0.05）．Serum sodium level varied significantly by NYHA class（P<0.05）．NYHA class Ⅳ HF patients had lower average serum sodium level than NYHA class Ⅱ and Ⅲ HF patients（P<0.05）．Except for 677 cases，all the cases （n=2 839） had serum calcium data.The prevalence of hypocalcemia and hypercalcemia was 66.43%（1 886/2 839），and 2.40%（68/2 839），respectively.Cardiac function showed a negative association with serum calcium level （P<0.05）．NYHA class was positively associated with the prevalence of ESS，but negatively associated with serum FT3 and TT3 levels（P<0.05）．The prevalence of anemia changed according to NYHA class（P<0.05）．NYHA class Ⅲ and Ⅳ HF patients had higher prevalence of anemia than NYHA class Ⅱ HF patients（P<0.01）．The worse the cardiac function was，the higher the prevalence of hyperbilirubinemia and hyperuricemia，and serum total bilirubin and uric acid became （P<0.05）．Conclusion　Most of the HF patients in Southwest China are the young old.HF is mainly caused by coronary heart disease，with HFpEF as a major manifestation.Serum potassium，sodium and calcium levels are all associated with NYHA class.Moreover，the prevalence of ESS，anemia，hyperbilirubinemia and hyperuricemia is also associated with NYHA class.

The Value of Transcutaneous Oxygen Measurement in Predicting Healing of Diabetic Foot

LI Xiaohong，YANG Caizhe，ZHU Di，CHEN Ying，WANG Liangchen，WANG Luning，XIAO Li，WANG Chenrui，ZHANG Da，CHEN Hongmei，LI Juan

2019, 22(14): 1684-1688. DOI: 10.12114/j.issn.1007-9572.2018.00.275

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Background　In recent years，the prevalence of diabetes is rising rapidly in China. Diabetic foot（DF）is one of the most severe chronic complications of diabetes. About 25% of patients with diabetes may have DF. Many factors affect the occurrence and development of DF. Lower limb artery occlusion and microcirculation dysfunction are mainly responsible for its prolonged treatment. As one method for detecting vascular lesions，transcutaneous oxygen measurement（TcPO2）can diagnose lower extremity arterial disease and evaluate microcirculation state. Objective　To investigate the value of TcPO2 in predicting healing of DF．Methods　A total of 102 patients with DF admitted in the Department of Endocrinology，Air Force General Hospital，PLA from February to June 2017 were enrolled.All subjects were divided into severe ischemia group （24 cases，TcPO2≤20 mm Hg），mild-to-moderate ischemia group （42 cases，20 mm Hg<TcPO2<40 mm Hg） and non-ischemia group （36 cases，TcPO2≥40 mm Hg）．The general data and laboratory indexes of patients were collected.Ankle brachial index （ABI） of dorsum pedis and posterior tibia，toe-brachial index （TBI） and dorsal pedal artery blood flow were recorded.TcPO2 was detected and the healing was recorded after 12 weeks of follow-up.Results　Age and HbA1c levels in severe ischemia group were higher than those in non-ischemia group，triacylglycerol （TG），ABI of dorsum pedis and TBI were lower than those in non-ischemia group，the percentage of lower extremity arterial occlusion was higher than that of mild-to-moderate ischemia group，and ABI of dorsum pedis was lower than those of mild-to-moderate ischemia group （P<0.05）；the level of HbA1c in mild-to-moderate ischemia group was higher than that of non-ischemia group，and TBI of affected limb was lower than those of non-ischemia group （P<0.05）．After 12-week follow-up，1 case （4.2%） healed in severe ischemia group，12 cases （28.6%） in mild-to-moderate ischemia group，and 31 cases （86.1%） in non-ischemia group.The healing rate after 12 weeks of severe ischemia group and mild-to-moderate ischemia group was lower than that of non-ischemic group （P<0.017）．Receiver operating characteristics （ROC） curve showed that the area under ROC curve （AUC） of TcPO2 and ABI of dorsum pedis and posterior tibia predicting DF healing were 0.874，0.691 and 0.650，respectively. When the optimal critical value of TcPO2 was 38.5 mm Hg，Youden index was 0.687，sensitivity was 77.3%，and specificity was 91.4%. Age and HbA1c were negatively correlated to TcPO2 level （P<0.05），TG，ABI of posterior tibia，TBI，blood flow of dorsalis pedis artery were positively correlated to TcPO2 level （P<0.05），12-week healing rate was correlated to TcPO2 level （P<0.05）．Conclusion　TcPO2 is better in predicting DF healing.The higher the level of TcPO2，the more likely DF is to heal.

Effect of Levetiracetam on Electroencephalogram and Cognitive Function in Children with Partial Seizures　

DU Yakun，CHEN Fang，WANG Lei，ZHAO Dengyan，LIU Jing，SUN Suzhen

2019, 22(14): 1689-1695. DOI: 10.12114/j.issn.1007-9572.2019.00.027

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Background　A large number of studies have proved that levetiracetam（LEV）is safe and effective in the control of partial seizures in children，but studies in improving the number of electroencephalogram（EEG）discharge quantity，background activity and cognition are incomprehensive.In addition，there are few reports on the association between EEG electrophysiology and cognitive function.Objective　To discuss the changes of clinical effect，the number of EEG discharge quantity，brainwave relative power and intelligence test of LEV monotherapy in partial seizures，and analyze the association of EEG result with the intelligence test and cognitive function.Methods　A total of 100 children with partial seizures diagnosed and treated in outpatient and ward of Children's Hospital of Hebei Province were selected from December 2014 to December 2017.The children were divided into control group and observation group by random number table method，each with 50 cases.The control group were given oxcarbazepine（OXC）orally，and the observation group were given LEV orally.Before and 3-6 months after treatment，the two groups were monitored EEG，recorded interictal epileptiform activity（IEA），and calculated the δ-band，θ-band，α-band，β-band brainwave relative power and discharge index.Verbal intelligence quotient （VIQ），performance intelligence quotient（PIQ）and full intelligence quotient（FIQ）were tested by Wechsler Intelligence Scale for Children（WISC）．Subsequently we evaluated the clinical effect before and after the treatment according to seizure frequency，evaluated EEG according to IEA after treatment，and classified intelligence level according to FIQ.Results　The total effective rate of the control group was 86.0%（43/50），and of the observation group was 82.0%（41/50）．There was no statistically significant difference in total effective rate between the two groups（χ2=0.128，P=0.720）．The total EEG effective rate of the observation group was 78.0%（39/50），which was higher than that of the control group of 52.0%（26/50）（χ2=7.429，P=0.006）．After the treatment，the δ-band and θ-band relative power in the observation group was lower than those in the control group，and its β-band relative power was higher than that in the control group（P<0.05）．δ-band andθ-band relative power in both groups after the treatment was lower than that before the treatment，and α-band relative power was higher than that before the treatment（P<0.05）；the β-band relative power in the control group after the treatment was lower than that before the treatment（P<0.05）；the β-band relative power in the observation group after treatment was higher than that before the treatment（P<0.05）．The VIQ，PIQ and FIQ were significantly higher in the observation group than those in control group after the treatment（P<0.05）．The VIQ，PIQ and FIQ were significantly higher after the treatment than those before the treatment in both groups（P<0.05）．The FIQ of observation group was negatively correlated with EEG discharge index（r=-0.286，
P<0.05），the ΔFIQ was positively correlated with the Δα-band and Δβ-band relative power（r=0.285，P<0.05；r=0.296，P<0.05）．Conclusion　Monotherapy of LEV is effective in the treatment of all types of partial seizures in children.In addition，the results were significant in improving the number of EEG discharges，background activity and cognition，and the changes in neuro-physiological parameters in epileptic children may be associated with improved cognitive function.

Risk Factors and Prognosis of Early-onset Peritoneal Dialysis-associated Peritonitis　

ZHANG Ning，ZHANG Beiru，HE Ping，YU Rui，BAI Yu，WU Yan，ZHANG Yongzhe

2019, 22(14): 1696-1701. DOI: 10.12114/j.issn.1007-9572.2018.00.274

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Background　 With an increasing number of patients with chronic renal failure in recent years，peritoneal dialysis，as a simple alternative treatment for residual renal function，has attracted doctors' attention. Peritoneal dialysis associated peritonitis（PDAP）is the major complication of peritoneal dialysis. Therefore，finding the risk factors of PDAP is crucial to avoid or delay the occurrence of PDAP and prolong the survival time of patients on peritoneal dialysis.Objective　To analyze the risk factors and prognosis of early-onset PDAP． Methods　We selected 116 patients with PDAP from Shengjing Hospital of China Medical University from January 2008 to June 2016，and divided them into the early-onset PDAP group （n=32） and late-onset PDAP group （n=84） based on the first onset time.We collected the clinical data，laboratory results and bacterial culture results.We recorded their outcomes and survival time obtained from a follow-up that ended on the date of death or ended by March 2017 or by the time that the peritoneal dialysis was superseded by long-term hemodialysis.Results　The rates of violation of aseptic manipulation and living in bungalow in the early-onset PDAP group were much higher than those of the late-onset PDAP group （P<0.05）．The differences in terms of peritoneal dialysis operators between the two groups were significant （P<0.05）．The average hemoglobin and albumin levels of the early-onset PDAP group were obviously lower than those of the late-onset PDAP group （P<0.05）．Of the 82 cases underwent bacterial culture of peritoneal dialysis fluid，59 （72.0%） had positive results，including 14 of early-onset PDAP and 45 of late-onset PDAP．The distribution of pathogens in the two groups showed no significant differences （χ2=0.982，P=0.612）．Binary Logistic regression analysis revealed that violation of aseptic manipulation 〔OR=4.127，95%CI （1.353，12.589）〕，living in bungalow 〔OR=4.785，95%CI （1.455，15.846）〕，decreased hemoglobin levels 〔OR=0.947，95%CI （0.917，0.978）〕 and decreased albumin levels 〔OR=0.890，95%CI （0.799，0.978）〕 were the risk factors of early-onset PDAP （P<0.05）．There were no significant differences in treatment outcomes between the two groups （χ2=1.488，P=0.475）．Kaplan-Meier analysis showed that by the end of the follow-up，the median survival time of the early-onset PDAP group was shorter than that of the late-onset PDAP group 〔24.0 （11.2，36.8） months vs 40.0 （34.4，45.6） months（χ2=7.221，P=0.007）〕．Conclusion　Patients with early-onset PDAP often have shorter survival time.Violation of aseptic manipulation，poor living environment，decreased hemoglobin and albumin were the independent risk factors of early-onset PDAP.It is necessary to take effective measures to prevent and decrease the incidence of early-onset PDAP and prolong the survival of such patients.

Reasons and Influencing Factors of Lost to Follow-up for Patients with Lung Cancer after Thoracoscopic Lobectomy：a Retrospective Study　

ZHENG Xi，XU Dan，HUANG Yue，QIU Pei，TANG Xiaojun，YUAN Yong

2019, 22(14): 1702-1706. DOI: 10.12114/j.issn.1007-9572.2018.00.423

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Background　Follow-up facilitates early detection of delayed complications and disease recurrence after lobectomy，but quite a few patients may lose contact through telephone interview during follow-up.Objective　To explore reasons and influencing factors of lost to telephone follow-up after thoracoscopic lobectomy.Methods　By retrospective study design，we reviewed medical records of 267 patients with non-small cell lung cancer who received thoracoscopic lobectomy in Lung Cancer Center and Department of Thoracic Surgery in West China Hospital of Sichuan University from November 2013 to March 2015，collected relevant sociodemographic and clinical materials which may affect the postoperative follow-up，and tried to identify influencing factors of lost to follow-up by multivariate Logistic analysis.Results　Thirty-five patients （13.1%） were lost to follow-up.Among them，11（31.4%） had wrong or non-existence numbers，5（14.3%） had no answer，3（8.6%） had cell phone shutdown，3（8.6%） had phone overdue，1（2.8%） had phone with no signal，and 12（34.3%） were reluctant to respond.The results of univariate analysis of telephone follow-up after thoracoscopic lobectomy revealed that types of phone （χ2=7.950，P=0.019） and TNM staging （Z=7.823，P=0.005） showed statistical difference between patients who completed follow-up and who did not.The results of multivariate Logistic regression analysis further confirmed that types of phone and TNM staging were independent prediction factors of follow-up responses （P<0.05）．Conclusion　For patients with lung cancer who are to receive thoracoscopic lobectomy，phone number changes，dissatisfaction of medical services and therapeutic effects，and distrust of the follow-up phone number are possible reasons of lost to follow-up.Patients who only leave landline phone numbers on their medical record and patients with advanced TNM stages are more likely to lost in the telephone follow-up.It is justified for health organizations to take more measures to improve response rate in those postoperative patients with high risks.

Effect of Symptom Intervention Combined with Spiritual Care on Malignant Fungating Wound　

DU Xinyan，LIU Junxia，TAN Bibo

2019, 22(14): 1707-1711. DOI: 10.12114/j.issn.1007-9572.2018.00.353

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Background　The massive exudation，odor，and pain of malignant fungating wounds can cause physical and psychological pain to patients.Objective　To investigate the effect of symptom intervention combined with spiritual care on malignant fungating wound.Methods　A total of 59 patients with malignant fungating wound in Outpatient Dressing Room，the Fourth Hospital of Hebei Medical University were selected from December 2015 to December 2017.By combining healing and palliative care ，malignant fungating wound was treated with symptom intervention and spiritual care.Pain level，degree of exudation，and odor level were measured and quality of life was evaluated by WHO Quality of Life-BREF （WHOQOL-BREF） before and after 2 and 4 weeks of intervention.Results　There were significant differences in Numerical Rating Scale （NRS） score，exudation degree，odor level，scores of physiology field （PHYS），psychological field （PSYCH），independence field （IND），social relation field （SOCIL），environment field （ENVIR），and spiritual pillar/religion/personal belief （DOM6） before and after intervention （P<0.05）；2 weeks after intervention，exudation degree and odor level were lower than those before intervention，and scores of PHYS，PSYCH，IND，ENVIR，and DOM6 were higher than those before intervention； 4 weeks after intervention，NRS score，exudation degree，and odor level were lower than those before and 2 weeks after intervention，and scores of PHYS，PSYCH，IND，SOCIL，ENVIR，DOM6 were higher than those before and 2 weeks after intervention（P<0.05）.Conclusion　Symptom intervention combined with spiritual care has a good effect on malignant fungating wound，which can improve patients' somatic symptoms，so as to improve their quality of life，and comfort their minds.Therefore，it is worthy of clinical popularization.

Recent Advances in the Prognosis and Influencing Factors of Attention Deficit Hyperactivity Disorder in Children　

ZHAI Qian，FENG Lei，ZHANG Guofu

2019, 22(14): 1712-1716. DOI: 10.12114/j.issn.1007-9572.2019.00.080

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Over 50% of the persons who suffer from attention deficit hyperactivity disorder （ADHD） in childhood，still have obvious ADHD symptoms in adulthood.If the symptoms are poorly controlled，they can continue to exert negative impacts on the patient and his family，hinder the patient's academic，social functioning and emotional functioning and behavioral normal development，resulting in poor academic performance，low occupational status，increased risk of drug abuse，and even committing a crime.ADHD seriously impairs the patient an social functioning and quality of life，even leads to mental or personality disorders.Many factors，such as severe ADHD symptoms in childhood，comorbidities，inappropriate treatment，poor family and social environments，and biogenetic causes are associated with the poor prognosis of the disease in adulthood.This article mainly expounds and analyzes recent advances in the prognosis of childhood-onset ADHD in adulthood and influencing factors.

Research Progress of Aripiprazole in Children with Tic Disorder　

ZHAI Qian，FENG Lei，ZHANG Guofu

2019, 22(14): 1717-1721. DOI: 10.12114/j.issn.1007-9572.2019.00.001

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Tic disorder is a neuropsychiatric disorder characterized by chronic，recurrent motor and vocal tics，and most occur in childhood or adolescence.It had the characteristics of relapse，long course，high comorbidities and prevalence rate，and difficult to treat.It has a great impact on the physical and mental health of the child.At present，the main treatment is still drug treatment，and aripiprazole，as one of the effective therapeutic drugs，offers a new prospect for the treatment of children with tic disorders.In this article，the treatment of children with tic disorder by aripiprazole was discussed.
Tic disorders；Aripiprazole；Therapy；Review

Interacting Effect of Deviant Peer Affiliation and COMT rs4680 Polymorphism on Adolescent Behavioral Problems　

ZHANG Jingwen，LI Xinying

2019, 22(14): 1722-1725. DOI: 10.12114/j.issn.1007-9572.2018.00.309

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Background　Teenage behavior problems include aggression，violation of discipline，substance abuse，and impaired concentration，which not only affects physical and mental health development of teenagers，but also undermines the harmony of families，the operational rules of schools and society，and even causes juvenile delinquency.Therefore，it is very important to explore the formation mechanism of adolescent problem behaviors.The existing evidence has shown that the formation of adolescent problem behaviors results from the joint action of environmental and genetic factors.Objective　To investigate the interacting effect of deviant peer affiliation and rs4680 polymorphism of catechol-O-methyl-transferase（COMT） gene on adolescent behavioral problems.Methods　Data of 780 adolescents aged from 11 to 17 years were drawn from Beijing Twin Registry from 2011 to 2012.Deviant Peer Affiliation Questionnaire and Achenbach Youth Self Report were used for assessing deviant peer affiliation and behavioral problems，respectively.Saliva samples were collected and genome DNA was extracted for genotyping the COMT rs4680 polymorphism.Multiple linear regression analysis was used to detect factors influencing scores of adolescent problem behaviors.Results　Average scores of behavioral problems for AA group，AG group and GG group of rs4680 in COMT gene were（13.5±9.1），（13.0±10.7） and（12.3±10.8），respectively.Difference among the three groups was not significant（F=0.55，P=0.577）.Multiple linear regression model revealed there was statistical significance in the interacting effect of age，deviant peer affiliation，deviant peer affiliation and COMT gene on behavioral problems 〔β=0.90，95%CI（0.47，1.18），P<0.001；β=1.08，95%CI（0.98，1.44），P<0.001；β=0.44，95%CI（0.08，0.75），P=0.014〕.Further analysis found that GG group was more vulnerable to deviant peer affiliation，and more behavioral problems were developed when exposing to negative peer environments.Conclusion　Adolescent behavioral problems are affected by both genetic factors and environmental factors.Adolescents with certain genetic propensity are more vulnerable to negative peer environments.

Correlation between Cancer-related Fatigue and Quality of Life in Children with Umbilical Cord Blood Stem Cell Transplantation in Different Ages　

HUANG Lu，WU Yun，SONG Guiqi

2019, 22(14): 1726-1729. DOI: 10.12114/j.issn.1007-9572.2018.00.347

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Background　Cancer-related fatigue（CRF），as a common，multidimensional，and subjective sense of tiredness related to cancer，severely affects the quality of life. Compared to standard chemotherapy，cord blood stem cell transplantation is a more intensive treatment that its side effects of chemotherapy，infection and graft-versus-host disease can easily appear，and can increase the risk of fatigue. Objective　To investigate the status and correlation of CRF and quality of life in children with umbilical cord blood stem cell transplantation from different ages.Methods　A total of 32 cases with umbilical cord blood stem cell transplantation admitted to Department of Hematology ，the First Affiliated Hospital of University of Science and Technology of China from November 2016 to January 2018 were selected by convenience sampling method.Patients were divided into children group （age of 8 to 12 years，15 cases） and adolescent group （age of 13 to 17 years，17 cases）.Pediatric Quality of Life Inventory Multidimensional Fatigue Scale （PedsQLTM MFS） and PedsQLTM3.0 Cancer Module were used to evaluate the fatigue level and quality of life 1 to 3 days before discharge.Results　There were no significant differences in general fatigue，cognitive fatigue and PedsQLTM MFS total score between children group and adolescent group （P>0.05）.Rest fatigue score of children group was higher than that of adolescent group （P<0.05）.No significant differences were found in pain，nausea and vomiting，procedure anxiety，treatment anxiety，worry，cognition，appearance，communication and PedsQLTM3.0 Cancer Module total score （P>0.05）.The total score of PedsQLTM MFS was positively correlated with PedsQLTM3.0 Cancer Module （r=0.620，P<0.001）.The score of general fatigue was associated with scores of nausea and vomiting，procedure anxiety，treatment anxiety，worry and cognition positively in all subjects （P<0.05）.The score of rest fatigue was positively related with scores of pain，nausea and vomiting，procedure anxiety，treatment anxiety，worry and cognition （P<0.05）.The score of cognitive fatigue was positively related with scores of procedure anxiety，treatment anxiety，worry，cognition，appearance and communication （P<0.05）.Conclusion　Patients with umbilical cord blood stem cell transplantation suffered heavy CRF，especially in adolescent group.They have poor quality of life，positively associated with fatigue.

Analysis of Preoperative Frailty and Its Influencing Factors in Elderly Patients Undergoing Elective Abdominal Surgery　

CAO Ting， QUAN Yue， ZHANG Jinjin， LI Yin， LYU Dan， TIAN Li

2019, 22(14): 1730-1735. DOI: 10.12114/j.issn.1007-9572.2018.00.322

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Background　The proportion of elderly patients in the surgical operation increases year by year and is accompanied by a higher incidence of adverse outcomes. More and more evidence shows that preoperative frailty is a risk factor for postoperative adverse outcomes. Objective　To investigate preoperative frailty of elderly patients undergoing elective abdominal surgery and to explore its influencing factors. Methods　A total of 156 elderly patients undergoing elective hepatobiliary and gastrointestinal surgery from July to December 2017 in Tianjin Third Central Hospital were selected according to the convenience sampling method. The data were investigated by questionnaires of general condition， comprehensive geriatric assessment and FRIED frailty phenotype and the influencing factors of preoperative frailty in elderly patients undergoing elective abdominal surgery were screened out by univariate analysis and ordered Logistic regression analysis. Results　Among 156 elderly patients undergoing elective abdominal surgery， the number of robust， pre-fragile and fragile patients were 51 （32.7%）， 48 （30.8%） and 57 （36.5%）， respectively. The results of univariate analysis showed that there were significant differences in age， central obesity， educational level， marital status， living status， family monthly income， physical exercise， health self-assessment status， ability of daily living （ADL）， instrumental ability of daily living （IADL）， balance function， cognitive status， depression，innutrition， comorbidity， polypharmacy， decreased vision， hearing loss， oral problems， urinary incontinence， sleep disorders， and pain scores （P<0.05）．The results of ordered Logistic regression analysis showed that aging， solitary living， low income， poor self-rated health， decreased ADL and balance function， dementia， depression and malnutrition were risk factors of preoperative frailty in elderly patients undergoing elective abdominal surgery （P<0.05）．Conclusion　Preoperative frailty in elderly patients undergoing elective surgery is not optimistic and affected by many factors. We should pay attention to patients' frailty， identify potential risks， and take multi-disciplinary，multi-angle measures to optimize preoperative conditions， so as to reduce the incidence of postoperative adverse events.

Adjustable Turning Pillow on the Rehabilitation of Patients with Idiopathic Scoliosis after Scoliosis Correction　

ZHOU Yuanyuan，CHEN Zhengxiang，CHEN Wenyue，FU Qiaomei，MAO Saihu

2019, 22(14): 1736-1739. DOI: 10.12114/j.issn.1007-9572.2018.00.370

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Background　Patients receiving spinal internal fixation and bone graft fusion need to stay in bed for 7 to 10 days，which increases the risk of pressure ulcers. The axial turning can effectively prevent pressure ulcers，but the previous turning pillow has only one angle，which cannot meet the needs of different patients in different periods for turning angle. Designed adjustable pillow can adjust the angle of support，which can meet the different needs of patients. Objective　To analyze the effect of adjustable turning pillows on the rehabilitation of patients with idiopathic scoliosis after scoliosis correction.Methods　A total of 61 patients with idiopathic scoliosis admitted to Department of Spine Surgery，Nanjing Drum Tower Hospital，the Affiliated Hospital of Nanjing University Medical School from January 2015 to June 2016 were selected.They were randomly divided into fixation group （31 cases） and adjustment group （30 cases） by random number table method.The fixation group used the conventional R-type turning pillow for axis turning，and the adjustment group used the adjustable turning pillow （utility model patent number：ZL2014 2 0699793.6） in the postoperative period.Patients' general data were recorded，pain was evaluated by Visual Analogue Scale （VAS），comfort level by General Comfort Questionnaire （GCQ），and body turning frequency and pressure ulcers were recorded within 72 h after surgery.Results　The differences in gender，age and Braden score were not statistically significant （P>0.05）．The angle of Cobb was greater in the adjustment group than that in the fixation group （P<0.05）．The VAS score of patients in the adjustment group was lower than that in the fixation group，GCQ score was higher than that in the fixation group，and body turning frequency was less than that in the fixation group （P<0.05）．There was no pressure ulcer in both groups.Conclusion　After operation，patients with scoliosis can use adjustable turning pillow to alleviate pain，reduce body turning frequency，improve the comfort level，and lessen the occurrence of pressure sores，thus improving their recovery.

Education Model of Cardiac Rehabilitation Based on Theory of Reasoned Action on Exercise Rehabilitation and Cardiovascular Risk Factors for Patients after Percutaneous Coronary Intervention　

ZHAO Jiegang，YOU Yanli，LI Chunyan，SHANG Xiyan，JIA Zhumin，LI Zhuanzhen，CHEN Shifang

2019, 22(14): 1740-1745. DOI: 10.12114/j.issn.1007-9572.2018.00.422

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Background　According to Report on Cardiovascular Diseases in China 2017，there are 290 million Chinese people suffering from cardiovascular diseases.The benefits of cardiac rehabilitation are recognized internationally.Currently，cardiac rehabilitation in China is at the initial stage.How to improve the participation and compliance to cardiac rehabilitation under existing national conditions in China is the primary problem that needs to be solved urgently.Objective　To explore the effects of an education model of cardiac rehabilitation based on theory of reasoned action on exercise rehabilitation and cardiovascular risk factors for patients with coronary heart disease after percutaneous coronary intervention （PCI）．Methods　A total of 85 patients with coronary heart disease （CHD） who were discharged after PCI in the First Affiliated Hospital of Henan University of Science and Technology from March to December 2017 were selected as study objects by convenient sampling method.Of these，43 were assigned to the intervention group and 42 were assigned to the control group by simple randomization.Patients in the intervention group received a 12-week education of cardiac rehabilitation led by an outpatient nurse，while the control group received the routine health education.The 6-minute walk distance （6MWD），exercise compliance and cardiovascular risk factors were compared between the two groups before and after intervention.Results　Twelve weeks after the intervention，67 patients （78.8%） were followed up，with 34 in the intervention group and 33 in the control group.Compared with the control group，the 6MWD in the intervention group was longer than that of the control group after intervention （P<0.05）．In the intervention group，6MWD was prolonged after intervention （P<0.05）．Body mass index （BMI），diastolic pressure and low density lipoprotein cholesterol （LDL-C） level of patients in the intervention group were lower than those before intervention （P<0.05）．The rate of smoking cessation and alcohol restriction in the intervention group was higher than that in the control group （P<0.05）．The drug compliance rate of patients in the control group decreased after intervention （P<0.05）；there was no significant difference between drug compliance rate of patients in the intervention group before and after intervention （P>0.05）．Compliance rate of reasonable diets，smoking cessation and alcohol restriction in the intervention group increased after intervention （P<0.05）．Conclusion　Education model of cardiac rehabilitation based on theory of reasoned action promoted the exercise rehabilitation and improved risk factors of cardiovascular diseases of patients after PCI.

Spontaneous Coronary Artery Dissection：One Case Report and Literature Review　

NI Feihua，QU Baiming，CHEN Xi，WU Shengchang

2019, 22(14): 1746-1750. DOI: 10.12114/j.issn.1007-9572.2018.00.361

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Objective　To improve the understanding of pathogenesis，clinical features，diagnosis and treatment of spontaneous coronary artery dissection.Methods　One patient with chest pain was admitted to Zhejiang Provincial People's Hospital in 29 November 2017，diagnosed with spontaneous coronary artery dissection.The diagnosis and treatment process of the patient were analyzed and related literature was reviewed.Results　 A 45-year-old female patient was admitted to the hospital because of chest pain for 10 hours after a jump.Troponin I was positive，electrocardiogram （ECG）showed V1-V5 lead ST segment elevation.Coronary arteriongraphy showed rat tail sign in the anterior descending artery，and she was diagnosed as spontaneous coronary artery dissection.After percutaneous coronary intervention （PCI），antiplatelet，anticoagulation，lipid-lowering and plaque stabilization，inhibition of myocardial remodeling，nutritional myocardium for microcirculation were given in symptomatic supportive treatment.The symptom of chest pain was gradually improved.Chest pain did not recur in half a year after follow-up.Conclusion　 It is difficult to distinguish spontaneous coronary artery dissection with acute coronary syndrome due to coronary atherosclerotic heart disease，but the treatment and prognosis of them are so different.Reviewing relevant literature can improve the understanding of spontaneous coronary artery dissection，and facilitate differential diagnosis.

Misdiagnosis and Diagnosis Analysis of Three Cases of Pediatric Idiopathic Pulmonary Hemosiderosis　

2019, 22(14): 1751-1754. DOI: 10.12114/j.issn.1007-9572.2018.00.316

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Idiopathic pulmonary hemosiderosis （IPH） is a rare，long-term disease caused by pulmonary capillary exudation，hematolysis，and hemosiderin deposition in the lung.Common clinical symptoms are repeated cough，hemoptysis，shortness of breath，anemia，etc.Physical signs can be pale complexion，low-pitched breath sound，tachycardia，hepatosplenomegaly，clubbed fingers，jaundice，etc.Long-term repeated bleeding results in thickening of alveolar basement membrane，and ultimately leads to interstitial fibrosis.Currently，the etiology and pathogenesis of IPH are still unknown.This paper introduces 3 cases of pediatric IPH with anemia as the main symptom but without typical respiratory symptoms and all were misdiagnosed at admission.Combined with literature review，it enables clinicians to further understand the disease，thereby reducing the possibilities of misdiagnosis.

Clinical Characteristics and Prognosis Analysis of Children with Primary Immunodeficiency Disease　

FENG Yuan，NAN Nan，LI Xiaoqing，ZHANG Cui

2019, 22(14): 1754-1758. DOI: 10.12114/j.issn.1007-9572.2018.00.395

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Objective　To investigate clinical characteristics and prognosis of children with primary immunodeficiency diseases （PID）．Methods　The clinical data of 37 inpatients who were diagnosed with PID because of recurrent respiratory tract infection admitted to the Department of Immunology of Affiliated Children's Hospital of Xi'an Jiaotong University from June 2013 to February 2017，was retrospectively collected and analyzed.Among all patients，there were 17 cases with X-linked agammaglobulinaemia （XLA），4 cases with chronic granulomatous disease （CGD），4 cases with X-linked hyper-immunoglobulin M （XHIM），4 cases with Wiskott-Aldrich syndrome （WAS），3 cases with selective immunoglobulin A deficiency （sIgAD），2 cases with severe combination of immunodeficiency disease （SCID），2 cases with suspected neutrophil dysfunction and 1 case with DiGeorge syndrome （DGS）．Their baseline information，clinical manifestations，laboratory data，test results of gene and prognosis were respectively analyzed.Results　Thirty-five out of 37 patients with sIgAD were male.The age of patients ranged form 54 days to 10 years and 9 months.The age from onset to diagnosis were from 6 months to 8 years.Four cases had suspicious family history.Among 37 children with PID，24（64.9%） had antibody deficiency，6（16.2%） had phagocyte count and function deficiency，5（13.5%） had definite syndrome and 2（5.4%） had combined immunodeficiency.All patients had history of recurrent infections，and the most common sites were respiratory tract and digestive tract.The levels of immunoglobulin G （IgG），IgA，IgM，T lymphocyte count and B lymphocyte count decreased in most children.All 37 cases were diagnosed by gene test except 3 cases of sIgAD，1 case of SCID and 2 cases of suspected neurophil dysfunction.After 1 to 5 years of follow-up，one child with XLA underwent repeated blood routine examinations whose red blood cells，white blood cells and platelets decreased，which showed signs of ecchymosis and epistaxis on both lower limbs.Bone marrow puncture was recommended，but we lost contact with the patient after family members refused to do so.One child with SCID died of severe infection，and one child with XHIM lost follow-up after stem cell transplantation.All the other children survived.Conclusion　We should pay more attention to children who had recurrent infections，particularly those with severe infections who need intravenous antibiotics every time.We also need to consider the possibility of having PID by performing preliminary lymphocyte and humoral immune function screening.Early diagnosis and treatment plays an important role in improving patients' prognosis and life quality.

Outbreak of Norwegian Scabies in Internal Medicine Ward：Treatment and Management　

WANG Zengwen，ZHU Huaiyu，GUO Xiaoqing

2019, 22(14): 1759-1762. DOI: 10.12114/j.issn.1007-9572.2018.00.393

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Objective　To review the treatment and prevention of Norwegian scabies in one outbreak.Methods　One retired female teacher at the age of 83 years who suffered from Alzheimer's disease for many years was admitted to the internal medicine ward of Tsinghua University Hospital with lung infection in 23 October 2014.Upon admission，the patient was found to have a lot of rashes around the body and she kept scratching.During the treatment，the patient's care workers and many other patients，family members，and medical staff were found to have rashes as well.In 19 March 2015，the scraping microscopy of the primary patient revealed a large number of sarcoptes mites，eggs and feces，and the patient was confirmed with Norwegian scabies.We reported the Norwegian scabies outbreak immediately，and formed the Norwegian scabies prevention and control team after the diagnosis.All contact persons were tracked，treated，and isolated，and insecticide measures were implemented.Results　A total of 64 patients，personnel and their family members were treated，of whom only six found pathogens in their bodies.The primary patient was treated with topical drug for 2 months.After the treatment，her scars were shed，and there was no scaling between toes.After repeated microscopic examinations，no mites and eggs were found.Other patients were treated for two to four courses.All confirmed and suspected patients had no recurrence 2 months later，and no new patient was found.Conclusion　Early diagnosis and treatment of Norwegian scabies is the most important measure to manage outbreak.Once an outbreak occurs，it is necessary to pay attention to control the primary patients and to track all the patients in the ward contacting with the original patient.In the meantime，treatment and prevention are very important.

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