Table of Content

15 July 2019, Volume 22 Issue 20

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Monographic Research

Interpretation of the Updates in the Use of Antiarrhythmic Drugs during Resuscitation of Patients with VF/pVT Cardiac Arrest or Immediately after ROSC in 2018 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations　

SHANG Na，ZHOU Rongbin

2019, 22(20):  2393-2397.  DOI: 10.12114/j.issn.1007-9572.2019.00.296

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In 2018，the American Heart Association （AHA） and the International Liaison Committee on Resuscitation （ILCOR） updated the guidelines on cardiopulmonary resuscitation and emergency cardiovascular care，mainly focused on the use of antiarrhythmic drugs during and immediately after shock-refractory ventricular fibrillation （VF） and pulseless ventricular tachycardia （pVT） cardiac arrest.The updates address the role of use of antiarrhythmic drugs or placebos or using no drugs during cardiopulmonary resuscitation or the period immediately （within one hour） after return of spontaneous circulation （ROSC） in the prognosis of the patient.AHA and ILCOR systematically reviewed and summarized the most recent published evidence，updated the procedure and management of advanced life support task force，and published the documents on the AHA official website and in Circulation.This review aimed to interpret the updates.


Admission and Discharge Criteria of Rehabilitation at All Levels in Patients with Stroke in Communities　

YAN Hua，SHI Jianhua，ZHOU Jianfeng，YU Wenjun，ZHAO Zongliang，XIE Yimin，XU Ning，WANG Jianbo

2019, 22(20):  2398-2405.  DOI: 10.12114/j.issn.1007-9572.2019.00.174

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Background　Rehabilitation is an important part of work in community health service institutions.The unsound rehabilitation network system has increased the needs of stroke rehabilitation in communities.Building a community stroke rehabilitation service system is in line with the health service needs of community residents，and it is also the functional embodiment of primary health care institutions in the medical and health system.Objective　To establish a standard for admission and discharge of strokes in communities in Shanghai，so as to guide the community to screen out the population that is truly in the category of stroke rehabilitation and urgently needed care，and to regulate admission and discharge of patients with stroke in rehabilitation at all levels.Methods　A total of 18 managers and executors related stroke rehabilitation from general hospitals and community health service centers were invited to participate in the two rounds of Delphi consultation from April to July 2018.Experts' advice about the admission and discharge standards of patients who needed stroke rehabilitation in community center wards，nursing institutions，community center outpatient clinics and home-based rehabilitation services were collected.Results　The positive coefficient of both rounds of experts consulting was 100.0%，and the final round of expert authority was 0.74.According to the definition of admission and discharge standard for service targets，the criteria for rehabilitation of stroke patients in communities were sorted out from the aspects of intervention time，neurological function，motor dysfunction，tactile and proprioceptive disorders，cognitive impairment，mood disorder，language and communication disorders，dysphagia，urinary and fecal disorders，daily living ability and quality of life，and social support.Conclusion　The standards for admission and discharge which were established for the community center wards，nursing institutions，center outpatient clinics，and home-based rehabilitation services have a high degree of credibility.The standards have practical application for community rehabilitation，which has also laid the foundation for the operation of the rehabilitation and referral mechanism of stroke at all levels in the community.


Effects of Levocarnitine on Abnormal Myocardial Enzymes and Cardiac Function in Critically Ill Children at Early Stage of Cardiopulmonary Failure with HFMD Infected by EV71　

LIU Zichun，SONG Chunlan，CHEN Fang，LI Peng，CUI Yajie，WANG Lingling

2019, 22(20):  2406-2410.  DOI: 10.12114/j.issn.1007-9572.2018.00.313

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Background　Hand，foot and mouth disease（HFMD）is a acute infectious disease in children.Severe HFMD is mostly caused by Enterovirus 71 （EV71）．Some patients with severe HFMD face short-term cardiopulmonary failure or even death.It is not clear whether levocarnitine，as the cardioprotection therapy，can improve the prognosis of patients with abnormal cardiac function and myocardial enzymes before cardiopulmonary failure.Objective　To evaluate cardiac function and the levels of myocardial enzyme before and after treatment in critically ill children at the early stage of cardiopulmonary failure with HFMD infected by EV71，and to explore the efficacy of adjuvant therapy with levocarnitine on myocardial injury and cardiac dysfunction and improvement of clinical prognosis and outcomes.Methods　A total of 120 critically ill HFMD patients infected by EV71 admitted to Children's Hospital Affiliated of Zhengzhou University from April 2016 to September 2017 were enrolled and randomly divided into conventional group （n=60） and levocarnitine group （n=60）．All patients were given the conventional therapy as the basic treatment，and subjects in levocarnitine group were treated with additional levocarnitine injection as adjuvant therapy.The levels of blood creatine kinase （CK），creatine kinase isoenzyme （CK-MB） and troponin T （cTnT），brain natriuretic peptide （BNP），N-terminal pro-brain natriuretic peptide （NT-proBNP）were measured before and 24 hours after treatment in two groups.Left ventricular ejection fraction （LVEF），left ventricular fractional shortening （FS） and cardiac index （CI） were measured by three-dimensional echocardiography.The curative effect was determined on the seventh day of treatment，and the occurrence of complications was recorded．Results　Of the 120 cases，57 （47.5%） had abnormal CK，70 （58.3%） had abnormal CK-MB，40 （33.3%） had abnormal cTnT，75 （62.5%） had abnormal BNP，81 （67.5%） had abnormal NT-proBNP，61 （50.8%） had abnormal LVEF，and 53 （44.2%） had abnormal FS.There was no significant difference in the abnormal rates of CK，CK-MB，cTnT，BNP，NT-proBNP，LVEF and FS between the two groups （P>0.05）．After the treatment，the levels of blood CK，CK-MB，cTnT，BNP and NT-proBNP in levocarnitine group were significantly lower than those in conventional group；CK level in conventional group was lower than that before treatment （P<0.05）；levels of CK，CK-MB，cTnT，BNP，NT-proBNP in levocarnitine group were lower than those before treatment （P<0.05）；LVEF，FS and CI in levocarnitine group were higher than those in conventional group （P<0.05）．LVEF，FS and CI after the treatment in two groups were all higher than those before treatment （P<0.05）．After the treatment，the clinical efficacy of levocarnitine group was better than that of conventional group （Z=-2.317，P=0.013）．The incidence of pulmonary edema and pulmonary hemorrhage in levocarnitine group was lower than that in conventional group （P<0.05）．Conclusion　Abnormal heart function and abnormal levels of myocardial enzyme are found in critically ill children at the early stage of cardiopulmonary failure with HFMD infected by EV71.Levocarnitine can improve clinical efficacy，prognosis and outcome by effectively improving myocardial cells and cardiac function in short-term.


The Incidence and Influential Factors of Anxiety in Pre-diabetic Patients　

CHEN Zhixiong，ZENG Ailin，HU Yaqin，LIU Jingdong

2019, 22(20):  2411-2415.  DOI: 10.12114/j.issn.1007-9572.2019.00.030

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Background　At present，there may be as many as 113.9 million adult diabetic patients and nearly 500 million pre-diabetic patients in China.The prevalence of anxiety in diabetic patients is 40%，which is much higher than that in healthy people.However，there are few studies on anxiety in pre-diabetic patients.Objective　To clarify the anxiety status of pre-diabetic patients through the investigation and analysis of anxiety in pre-diabetic patients，and analyze its influential factors，so as to provide scientific basis for psychological intervention of pre-diabetic patients.Methods　A total of 100 pre-diabetic patients screened by oral glucose tolerance test （OGTT） from March to September 2015 in the outpatient of endocrinology or physical examination department of Jiangxi Provincial People's Hospital were selected as the research objects.The self-designed questionnaire about general situation and self-rating anxiety scale （SAS） were used to carry out the questionnaire survey，and the clinical indicators were tested.According to the results of SAS score，subjects were divided into non anxiety group and anxiety group.The differences between the two groups were compared.The influential factors of anxiety in pre-diabetic patients were analyzed by multivariate logistic regression.Results　Atotal of 100 questionnaires were distributed and 100 valid questionnaires were collected，with the valid rate of 100.0%.There were 22 patients （22.0%）in the anxiety group，including 20 patients （90.9%）were mild anxiety，2 patients （9.1%）were moderate anxiety，and there were 78 patients （78.0%）in the non anxiety group．There were significant differences in monthly income and body mass index（BMI）between the two groups（P<0.05）．Anxiety was negatively correlated with family monthly income（rs=-0.256，P<0.05），and had no linear correlation with sex（rs=0.026），age（rs=-0.160），education level（rs=0.100），types of medical insurance（rs=0.140），BMI（rs=0.142），smoking （rs=0.095），alcohol consumption（rs=0.027），carotid atherosclerosis （rs=0.167），lower extremity atherosclerosis（rs=0.077），family history of diabetes（rs=0.049），hypertension（rs=0.061），hyperlipidemia （rs=0.032），FPG（rs=0.122），2 hPG（rs=0.034），HbA1c（rs=0.121，P>0.05）．Multivariate logistic regression analysis showed that family monthly income 〔OR=1.636，95%CI（1.010，2.648）〕was the influential factor of anxiety in pre-diabetic patients（P=0.045）．Conclusion　Anxiety is prevalent in pre-diabetic patients，and family monthly income is the main factor influencing their emotions.Therefore，doctors should pay attention to patients with relatively poor economic conditions，strengthen early screening and early intervention measures.


Relationship of Nutritional Status with Urine Gonadotropin and Sex Hormones in Preschool Boys　

WANG Yong，CHEN Chunmei，MA Yaping，HANG Biao，HANG Yin，RUI Fang，YAO Min，QIN Liqin，BEN Ze，NIE Shuang，XU Zhuangjian

2019, 22(20):  2416-2421.  DOI: 10.12114/j.issn.1007-9572.2019.00.031

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Background　Nutritional status may affect gonadotropin（Gn）and sex hormone levels in children.Currently，related studies mainly focus on the effect of nutritional status on the above hormones in blood of children over 7 years old，with relatively small sample sizes.Objective　To explore the levels of urine Gn and sex hormones in normal preschool boys with different nutritional status，providing a reference for epidemiological study and clinical application of urine Gn and sex hormones using non-invasive approaches.Methods　Preschool boys at least 3 years of age but less than 7 were selected from Mashan Street and Hudai communities，Jiangsu's Wuxi from May 2015 to December 2016.Height and weight were measured，and height-for-age Z-score（HAZ），weight-for-age Z-score（WAZ）and BMI-for-age Z-score（BAZ）were calculated.According to HAZ，WAZ and BAZ，they were divided into 6 groups，respectively.The first morning urine samples were collected.The urinary luteinizing hormone（ULH），urinary follicle-stimulating hormone（UFSH），urinary estriol （UE3），urinary estradiol（UE2），and urinary testosterone（UT）were determined by immunochemiluminometric assay.Kruskal-wallis H test was used to compare the differences among HAZ，WAZ and BAZ groups，respectively.Kruskal-wallis one-way ANOVA was conducted to compare the differences between HAZ，WAZ and BAZ groups，respectively.Spearman rank correlation was performed to analyze the correlations of urine Gn and sex hormones with HAZ，height，WAZ，weight，BAZ and BMI.Results　A total of 871 boys who met the inclusion criteria with successful urine specimen collection were included.The detection rates of ULH，UFSH，UE3，UE2 and UT were 6.7%（58/871），99.4%（866/871），99.7%（868/871），99.8%（869/871）and 98.0%（854/871），respectively.UE3 showed significant differences among HAZ groups（P<0.05），in particular，UE3 in Hc group was much lower than that of He and Hf groups，and UE3 in He group was much higher than that of Hd group（P<0.05）．UE2 differed significantly among HAZ groups（P<0.05），to be specific，UE2 in Hb group was much higher than that of Ha，Hc and Hd groups，and UE2 in Hc group was much lower than that of He and Hf groups（P<0.05）．UT varied significantly among HAZ groups（P<0.05），to be specific，UT in Hc group was much lower than that of He and Hf groups，and UT in Hd group was obviously lower than that of He group （P<0.05）．UFSH，UE3，UE2 and UT differed significantly among WAZ groups（P<0.05）．In particular，Wf group had much higher UFSH than Wc，Wd and We groups（P<0.05）；Wf group showed obviously higher UE3 than Wc，Wd and We groups（P<0.05）；Wc group had much lower UE2 than Wb group，and Wf group demonstrated significantly higher UE2 than Wc，Wd and We groups （P<0.05）；Wf group presented significantly higher UT than Wc，Wd and We groups（P<0.05）．UFSH，UE3，UE2 and UT varied significantly among BAZ groups（P<0.05）．Specifically，Bf group had much higher UFSH than Bb，Bc and Bd groups（P<0.05）；Bd group had much lower UE3 than Bb group，and Bf group showed obviously higher UE3 than Bc，Bd and Be groups （P<0.05）；Bd group had much lower UE2 than Bb group，and Bf group demonstrated much higher UE2 compared with Bc，Bd and Be groups （P<0.05）；Bf group demonstrated much higher UT compared with Bb，Bc，Bd and Be groups（P<0.05）．The correlation analysis showed that UFSH was positively correlated with height（rs=0.095，P<0.05）．UE3 was positively correlated with HAZ（rs=0.106），height（rs=0.231），WAZ（rs=0.082），BAZ（rs=0.106）and BMI（rs=0.084，P<0.05）．UE2 was positively correlated with HAZ（rs=0.081），height（rs=0.164）and BAZ（rs=0.081，P<0.05）．UT was positively correlated with HAZ（rs=0.102），height（rs=0.217），WAZ（rs=0.074），weight（rs=0.070），BAZ（rs=0.102） and BMI（rs=0.080，P<0.05）．Conclusion　In normal preschool boys，the ULH content is low，and urine Gn and sex hormones differ by nutritional status.UE3，UE2 and UT tend to be increased with the improvement of nutritional status in a short period of time.Therefore，the nutritional status in this population should be concerned in order to ensure their healthy growth.


Clinical Characteristics and Influencing Factors of Ankylosing Spondylitis with Hypo-high-density Lipoproteinemia　

LI Dongxia，CHEN Yingying，HAN Mei，TAO Qingwen

2019, 22(20):  2422-2425.  DOI: 10.12114/j.issn.1007-9572.2018.00.401

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Background　Ankylosing spondylitis （AS） is a serious public health problem with high rates of morbidity and disability.Clinical studies show that the prevalence of hypo-high-density lipoproteinemia（hypo-HDL） is higher in AS patients than that of normal people.Objective　To explore the clinical characteristics and influencing factors of AS with hypo-HDL.Methods　This retrospective study was conducted in 266 consecutive AS patients aged 18-60 who were hospitalized in Department of TCM Rheumatology，China-Japan Friendship Hospital from January 1，2016 to June30，2017.Participants with hypo-HDL and those without were assigned to AS with hypo-HDL group and AS group，respectively.Clinical characteristics were compared between the groups.Multivariate Logistic regression analysis was performed to identify the influencing factors of AS with hypo-HDL.Results　Of the 266 cases，there were 179（67.3%） with hypo-HDL，and other 87 （32.7%）without.There were significant differences in the distribution of sex，average age，age of onset，body mass index （BMI），erythrocyte sedimentation rate （ESR），C-reactive protein （CRP），total cholesterol（TC），triglyceride（TG），family history of AS，type of inflammatory response and HLA-B27 genotype between the two groups （P<0.05）．The average course of onset，course of diagnosis，and low-density lipoprotein，and HLA-B27 positive rate did not differ significantly between the groups （P>0.05）．Multivariate Logistic regression analysis showed that sex 〔OR=9.453，95%CI（3.692，24.203）〕，TC〔OR=0.308，95%CI（0.181，0.524）〕，TG level〔OR=8.431，95%CI（3.334，21.332）〕，family history of AS〔OR=4.932，95%CI（1.586，15.343）〕，inflammatory response type〔OR=3.148，95%CI（1.325，7.478）〕were the influencing factors of AS with hypo-HDL （P<0.05）．Conclusion　AS with hypo-HDL had the characteristics of high morbidity，male predominance，early onset age，high level of inflammatory markers，high prevalence of family history of AS，high prevalence of acute inflammations，and is possibly associated with increased BMI and dyslipidemia and other metabolic syndrome.Male，decreased TC and increased TG，family history of AS，and acute inflammation are risk factors for AS with hypo-HDL.

Associations of Neutrophil-to-lymphocyte Ratio and Procalcitonin with the Prognosis in Patients with Acute Severe Carbon Monoxide Poisoning and Hospital-acquired Pneumonia　

MA Guoying，HAN Yongyan，YANG Junli，SUN Wei，WANG Weizhan

2019, 22(20):  2426-2430.  DOI: 10.12114/j.issn.1007-9572.2019.00.229

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Background　Acute carbon monoxide poisoning is a common toxicological event in daily life，or occupation related that can cause multisystem organ dysfunction，which has become a most common emergency encountered in hospital.Neutrophil-to-lymphocyte ratio （NLR） is an integration parameter generated under the state of inflammation and physiological stress.Procalcitonin （PCT） has become one of the indicators for disease evaluation and prognosis after infection.There are many studies on the relationships of NLR and PCT with sepsis，but no studies on the those of NLR and PCT with the prognosis of acute severe carbon monoxide poisoning （ASCOP） with hospital-acquired pneumonia （HAP）．Objective　To investigate the combined prognostic value of NLR and PCT in patients with ASCOP and HAP by evaluating the correlations of them with APACHEⅡ score in such patients.Methods　 Sixty-eight inpatients with ASCOP and HAP were recruited from Department of Emergency Medicine，Harrison International Peace Hospital Affiliated to Hebei Medical University from 2015 to 2017.Clinical data such as WBC，neutrophil count，lymphocyte count and PCT were collected，NLR was calculated，and APACHEⅡ score was derived based on the worst value of physiologic variables within 24 hours.All of them were given a 28-day follow-up，during which 45 survived （survival group） and 23 died （death group）．ROC analysis was performed to evaluate the prognostic values of NLR and PCT in ASCOP with HAP.Results　The survival group and death group showed no differences in sex ratio，and average age and WBC （P>0.05）．Compared with survival group，the values of average NLR，PCT and APACHEⅡ score in death group were all significantly increased （P<0.05）．The values of NLR and PCT were significantly correlated with APACHEⅡ score （rs=0.611，0.415，P<0.01）．The area under the ROC curve （AUC） of PCT for predicting prognosis was significantly greater than that of NLR {0.804 〔95%CI （0.645，0.930）〕 vs 0.776 〔95%CI （0.621，0.930）〕（Z=2.12，P<0.01）}.When the cut-off value of PCT was 0.155 μg/L，the sensitivity was 92.3%，and the specificity was 70.8%.When the cut-off value of NLR was 8.00，the sensitivity was 90.3%，and the specificity was 54.2%.Conclusion　Both NLR and PCT are significantly correlated with APACHEⅡ score.PCT can be a better indicator for evaluating the prognosis in ASCOP with HAP.


Clinical Outcome and Severe VEEG Abnormalities in Response to ACTH in Infants with Spasms and Different MC2R Genotypes　

LI Baoguang，LI Aixia，YANG Huafang，ZHENG Huacheng，ZUO Yuexian，LIU Lan，WANG Xin，WU Wenjuan，LIU Zhengyan

2019, 22(20):  2431-2435.  DOI: 10.12114/j.issn.1007-9572.2019.00.177

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Background　Infantile spasms（IS） is a common catastrophic epilepsy in infancy and early childhood with poor response to many anti-epileptic drugs.Even if the patients use adrenocorticotropic hormone（ACTH），an agent as the first choice for this disease，only 60%-80% of them have responses.Identifying the factors associated with the response to ACTH in IS patients，and making use of advantages and avoiding disadvantages to improve it，become a hot and difficult research topic.Objective　To study the clinical outcome and severe VEEG abnormalities in response to ACTH in infants with IS and different MC2R genotypes.Methods　Fifty-six inpatients with IS who were treated in Children's Hospital of Hebei Province during October 2016 to October 2018 were enrolled.Data concerning physical examination，VEEG，and whole exomesequencing were collected.According to the haplotypes constituted by 4 SNPS in the promoter region of MC2R gene，they were divided into TCCT carrying group （n=46）（TCCT/TCCT or TCCT/0） and TCCT non-carrying group（n=10）（0/0）．All of them received 28-day ACTH treatment at a dose of 1 U/kg×3 d+2 U /kg×25 d（the maximum amount not exceeding 25 U）．Clinical outcome and severe VEEG abnormalities in response to ACTH in both groups were observed.Results　Post-treatment status showed that，treatment response rate was 78.2% in TCCT carrying group（36 were responsive to ACTH and 10 were not），and 3/10 in TCCT non-carrying group（3 were responsive to ACTH and 7 were not），showing significant intergroup difference（χ2=9.26，P<0.05）．Of the 43 cases（36 in TCCT carrying group and 7 in TCCT non-carrying group） detected with severe VEEG abnormalities，the rate of having reduced abnormalities was 66.7% in TCCT carrying group（24 achieved improvement while 12 did not），and was 3/7 in TCCT non-carrying group（3 achieved improvement while 4 did not），indicating insignificant intergroup difference（χ2=1.46，P>0.05）．Conclusion　IS patients with MC2R gene TCCT showed good responses to ACTH.But the rates of reduction in VEEG abnormalities were similar in those with MC2R gene TCCT and without.


Epidemiology of Cholecystolithiasis in Uygur，Kazakh and Han Women in the Xinjiang Uygur Autonomous Region　

LYU Fujun，DING Dandan，LIU Jiangwei，JI Feng，JIAO Dongxiao

2019, 22(20):  2436-2440.  DOI: 10.12114/j.issn.1007-9572.2019.00.046

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Background　It is found that the prevalence of cholecystolithiasis in Xinjiang Uygur Autonomous Region is relatively high，and its prevalence in women is higher than that in men，but there is a lack of research on the prevalence of cholecystolithiasis in women in Xinjiang Uygur Autonomous Region.Objective　To study the prevalence and the influential factors of cholecystolithiasis in Uygur，Kazakh and Han women in Xinjiang Uygur Autonomous Region，and to provide evidence for the prevention and treatment of cholecystolithiasis in Uygur，Kazak and Han women.Methods　female residents in Xinjiang Uygur Autonomous Region were selected from June to September 2011 by using the method of typical sampling followed by multi-stage stratified random sampling.Self-made general data questionnaires were used and translated into Uygur.Abdominal ultrasound examinations of liver and gallbladder were performed on the subjects.The prevalence of cholecystolithiasis in women of different ethnic groups and different ages of menarche，irregular menstruation，the number of babies，age of childbirth in each ethnic group were compared，and the influential factors of the prevalence of cholecystolithiasis in women were analyzed by multivariate Logistic regression.Results　A total of 3 508 questionnaires were distributed and 3 175 were valid，with an effective recovery rate of 90.5%.The prevalence of cholecystolithiasis in female was 16.9%（535/3 175）in Xinjiang Uygur Autonomous Region，and the prevalence of cholecystolithiasis in Uygur，Kazakhs and Han women was 24.0%（222/924），10.8%（94/873）and 15.9%（219/1 378），respectively.The prevalence of cholecystolithiasis among the three ethnic groups was statistically significant （χ2=57.913，P<0.001）．Multivariate Logistic regression analysis showed that the age of menarche 〔OR=1.167，95%CI（1.007，1.353）〕，irregular menstruation 〔OR=6.486，95%CI（4.636，9.532）〕，the number of births 〔OR=1.355，95%CI（1.237，1.483）〕 were influential factors of Uygur women with cholecystolithiasis （P<0.05）；the age of menarche 〔OR=1.296，95%CI（1.007，1.668）〕，the number of births 〔OR=1.240，95%CI（1.022，1.504）〕 were influential factors of Kazakh women with cholecystolithiasis （P<0.05）；the number of births 〔OR=1.341，95%CI（1.214，1.482）〕，age of childbirth 〔OR=0.942，95%CI（0.892，0.996）〕 were influential factors of Han women with cholecystolithiasis （P<0.05）．Conclusion　In Xinjiang Uygur Autonomous Region，the prevalence of cholecystolithiasis in female is higher，and the prevalence of cholecystolithiasis in Uygur female is related to age of menarche，irregular menstruation and the number of babies.The prevalence of cholecystolithiasis in Kazakh women was related to the age of menarche and the number of babies.The prevalence of cholecystolithiasis in Han women is mainly related to the number of babies and the age of childbirth.Therefore，the clinical work should focus on women with delayed menarche，large number of babies，and young age of childbirth，especially in the Uygur population who have higher prevalence of cholecystolithiasis.


Max Testing：a Preliminary Experimental Report of a Clinical Approach to Verify whether Individualized Symptoms Limit Cardiopulmonary Exercise Testing is the Maximum Extreme Exercise　

ZHANG Ye，SUN Xingguo，HAO Lu，LIU Qin，ZOU Yuxin，WANG Ruolan，SONG Ya，GE Wangang，ZHANG Tianjing，LIU Fang，XING Ran，MA Lanyu，LI Hao，CI Zheng，ZHAI Wenxuan，LIU Yanling

2019, 22(20):  2441-2447.  DOI: 10.12114/j.issn.1007-9572.2019.00.146

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Background　Guidelines from various medical specialties have different definitions for maximum extreme exercise.By analyzing the data of cardiopulmonary exercise test （CPET） included in the fourth edition of Principles of Exercise Testing and Interpretation，we found that if a peak RER or a blood pressure reading is used as the termination criterion，some patients' functional indicators will be underestimated，or some patients will not reach the specific value.In the CPET，in order to objectively quantify and accurately ensure that the results of the CPET are accurate，the Max testing is feasible.Objective　To clinically verify whether the CPET is a maximum extreme exercise，and to design the Max test to verify the accuracy of the objective quantitative functional assessment of CPET results and whether it is feasible to use the specific value of a specific index as the criterion for stopping the exercise.Methods　Sixty cases from Fuwai Hospital were enrolled during December 2017 to June 2018，including 20 physcial examinees（control group） and 40 with cardiovascular diseases（patient group）．All of them first performed individualized symptom-limited maximal CPETs，during which 12-lead ECG parameters，oxygen saturation，noninvasive blood pressure level and pulmonary gas exchange were measured with PFT Ergo Omnia 1.6.2 produced by COSMED S.R.L，Italy.When the CPET ended，they had a 5-minute break，then underwent the Max testing，during which，they cycled with a velocity of ≥60 r/min，at a constant intensity equivalent to to 130% of peak oxygen consumption，until exhausted.The difference and percentage difference between the peak heart rate and the peak oxygen uptake were calculated.If the percentage difference between heart rate，and that between oxygen uptake are all less than -10%，then the participant's Max testing is thought to be succesful，otherwise it is failed.Results　Patient group's peakO2 （L/min，ml?min-1?kg-1，%pred），anaerobic threshold（L/min，ml?min-1?kg-1，%pred），peak VO2P（ml/time，% pred），peak RER，peak SBP，peak WR，peak heart rate，OUEP（ratio，%pred） were lower than those of the control group（P<0.05）．The E/CO2-lowest （ratio，%pred） and E/CO2 slope（ratio，%pred） were higher in the patient group than in the control group （P<0.05）．No adverse events occurred during the CPETs and Max testing in all cases.Among the healthy controls，16（80.0%） were successful in completing the Max testing.And CPET was proved to be maximum extreme exercise，non-maximum extreme exercise，and failed for 12 cases（75.0%），4（25.0%），and 4（20.0%），respectively.In the patients，Max testing was successful in 37 cases（92.5%）．CPET was proved to be maximum extreme exercise for 34 cases（91.9%），non-maximum extreme exercise for 3 cases（8.1%），and failed in 3 cases（7.5%）．Conclusion　For CPET with a low peak RER and a maximum challenge，the Max testing can be completed after 5 minutes to confirm the accuracy of the objective quantitative assessment of CPET.Max testing is safe and feasible，and deserves further research and clinical application.


Effects of the Inhibition of Reelin Expression in Spinal Cord on Pain Behaviors in Neuropathic Pain Adult Rat Models　

HU Jie，KUANG Xin，ZHANG Qianlu，LI Huanyan，YANG Qiaoyun，PENG Liangyu

2019, 22(20):  2448-2454.  DOI: 10.12114/j.issn.1007-9572.2019.00.003

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Background　Reelin is a large secreted extracellular matrix glycoprotein that modulates neuronal development and participates to the functioning of adult central synapses.After migrations have ceased，neurons within the spinal cord especially in the superficial dorsal horn continue to express Reelin.The expression of spinal dorsal horn Reelin down-regulates significantly in neuropathic pain rats，while the role of Reelin in nociceptive processing and pain is still unknown.Objective　To investigate the effects of intrathecal injection of Reelin shRNA on pain behaviors in adult rats.Methods　A total of 119 8-10-week-old healthy male SD rats of SPF grade were selected and treated with intrathecal catheter implantation in 2015.The 108 rats with successful implantation were randomly assigned to normal group （Norm gourp，n=12），RNA interference group （RNAi group，n=12），sham-operation group （Sham group，n=12），sham plus RNA interference group （SR group，n=6），chronic compression injury （CCI） of sciatic nerve group （CCI group，n=27），CCI plus RNA interference group （CR group，n=27），and CCI plus empty vector group （EV group，n=12），respectively.Groups of CCI，CR and EV received a partial sciatic nerve ligation to establish CCI models.RNAi，SR and CR groups were intrathecally treated with lentiviral vector of Reelin shRNA，while EV group received intrathecal injection of an empty lentiviral vector.Western blotting was used to test the expression level of Reelin protein on the 4th，7th，10th，14th and 21st days of intervention.Immunohistochemical technique was used to observe the localization of Reelin in the spinal dorsal horn on the 10th day of intervention.Paw withdrawal mechanical threshold（PWMT） and paw withdrawal thermal latency（PWTL） were tested before and on the 1st，4th，7th，10th，14th，17th and 21st days of intervention，respectively.Results　On the 10th day of intervention，compared with rats in Norm group，the mean expression level of Reelin protein increased significantly on both right and left sides of spinal dorsal horn of rats in RNAi group （P<0.05）；the mean expression level of Reelin protein in the left spinal dorsal horn in CR group was significantly lower than that of in sham and CCI groups （P<0.05）；the mean expression level of Reelin protein in the right spinal dorsal horn in Sham group was significantly higher than that of CCI，CR and EV groups （P<0.05）；the mean expression level of Reelin protein in the right spinal dorsal horn in CR group was significantly lower than that in CCI group （P<0.05）． The mean expression level of Reelin protein in the right spinal dorsal horn was significantly lower than that in the left spinal dorsal horn in CCI group on the 4th day of intervention and the same was true of CR group （P<0.05）． The mean expression level of Reelin protein in the left spinal dorsal horn in CCI group was much higher than that of Reelin protein in the right spinal dorsal horn in CCI group and that of Reelin protein in the left spinal dorsal horn in CR group on the 7th，10th，14th，and 21st days of intervention （P<0.05）． The mean expression level of Reelin protein on right spinal dorsal horn in CR group was lower than that of the right spinal dorsal horn in CCI group on the 7th，10th，14th，and 21st days of intervention （P<0.05）． Reelin diffusely localized in laminae Ⅰ，Ⅱ，Ⅴ of spinal dorsal horn and in the lateral spinal nucleus （LSN） of rats in normal group.Only a small amount of filament proteins were found in lamina Ⅰ-Ⅱ and LSN of bilateral spinal dorsal horn，and a small amount of expression was found in lamina Ⅴ of the spinal dorsal horn in RNAi group.Reelin protein on both right and left sides of spinal dorsal horn had no changes in Sham group.Reelin protein in the right spinal dorsal horn was less than the contralateral level in CCI group.Only a very small amount of Reelin protein could be detected on both right and left sides of superficial dorsal horn in CR group.Empty vector had no obvious effects on the expression of spinal Reelin protein in EV group.Compared with rats in Sham group，both mean PWMT and PWTL of rats in CCI，CR and EV group were significantly decreased on the 1st，4th，7th，10th，14th，17th，21st days of intervention （P<0.05）． Both mean PWMT and PWTL in CR group were lower than those of CCI group on the 7th，10th，14th，17th，21st days of intervention （P<0.05）． Conclusion　Spinal Reelin may have no significant effects on pain threshold under physiological condition while spinal Reelin downregulation may contribute to the development of neuropathic pain after peripheral nerve injury.


Network Meta-analysis of the Effectiveness and Safety of Novel Oral Anticoagulants in Patients with Atrial Fibrillation　

HUO Lichao，LI Mengli，SONG Minghui，ZHANG Yanxia，XUE Penglong，QIAO Chengdong

2019, 22(20):  2455-2464.  DOI: 10.12114/j.issn.1007-9572.2019.00.083

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Background　Atrial fibrillation （AF） is one of the most common arrhythmias encountered clinically.Thrombosis is a common complication of AF.For a long time，warfarin was a first choice for anticoagulation in patients with AF.But adverse reactions of warfarin have been troubled clinicians and patients.At present，with the new anticoagulants generated，and their efficacies have been verified by large-scale clinical trials，this problem has been solved.But there is still lack of direct comparative studies of such anticoagulants.Objective　To evaluate the therapeutic effect of novel oral anticoagulants in patients with AF by network meta-analysis.Methods　Databases of PubMed，EMBase，the Cochrane Library，Web of Science，CBM，Wanfang Data，CNKI were searched for randomized controlled trials （RCTs） concerning novel oral anticoagulants in patients with AF from inception to July，2018.Quality assessment and data extraction from the included RCTs were performed.Statistical analyses of the incidence of embolization，intracranial hemorrhage，ischemic stroke，myocardial infarction，and gastrointestinal bleeding，and all-cause mortality were conducted with R 3.4.3 and Stata 14 software.Surface under the cumulative ranking （SUCAR） was used to rank the value of the treatments.Results　A total of 28 RCTs were included，involving 261 272 patients.The results of network meta-analysis showed that the incidence of embolic events associated with warfarin was higher than that caused by dabigatran（150 mg），rivaroxaban （20 mg），apixaban （10 mg），and edoxaban （60 mg） （P<0.05）．The incidence of intracranial hemorrhage related with warfarin was higher than that caused by dabigatran （110 mg），dabigatran（150 mg），rivaroxaban （20 mg），apixaban （10 mg），edoxaban （30 mg）and edoxaban （60 mg）（P<0.05）．Warfarin was associated with a higher incidence of ischemic stroke compared with dabigatran （150 mg） （P<0.05）．Other treatments，except for ximelagatran （36 mg） and rivaroxaban （15 mg），were associated with lower all-cause mortality compared with warfarin （P<0.05）．Warfarin was associated with a higher incidence of myocardial infarction compared with ximelagatran （36 mg） （P<0.05）．But it was associated with a lower incidence of gastrointestinal bleeding compared with rivaroxaban （20 mg） （P<0.05）．SUCAR values of all the interventions demonstrated that，dabigatran （150 mg） was associated with lower incidence of embolization and all-cause mortality；edoxaban（30 mg） was related to lower incidence of intracranial hemorrhage and gastrointestinal bleeding；ximelagatran （36 mg） was associated with lower incidence of ischemic stroke and myocardial infarction.Conclusion　Available evidence shows that apixaban （10 mg） may be a promising treatment.The overall quality of the included studies is high，and the analysis results have certain guiding significance.However，considering the unsatisfied quality of the included domestic studies，our results need to be verified by more high-quality domestic studies.


The Value of Magnetic Resonance Spectroscopy in Differentiating Gliomas from Brain Metastases：a Meta-analysis　

CHEN Xianrui，HUANG Jianqi，XU Jinping，WU Jinzhun，BAI Haitao

2019, 22(20):  2464-2471.  DOI: 10.12114/j.issn.1007-9572.2018.00.360

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Background　Magnetic resonance spectroscopy （MRS） imaging can non-invasively analyze the changes of various metabolites in living tissue，and has great clinical value for the diagnosis，pathological grading and prognosis evaluation of tumor properties.In recent years，it has been gradually applied to differential diagnosis of glioma and brain metastatic tumor，but the research conclusions reported in domestic and foreign literatures are inconsistent.Objective　To evaluate the clinical value of MRS in differentiating gliomas from brain metastases using meta-analysis methods.Methods　Digital knowledge service platforms，such as Cochrane Library，PubMed，EMBase，EMCC，OVID，CNKI，VIP and Wanfang Data Knowledge Service Platform were searched for relevant articles of MRS in differentiating glioma （glioma group） from brain metastases （brain metastases group） published in English and Chinese up to February 2018.Two researchers independently extracted data and assessed the relevant system evaluation literature according to diagnostic Newcastle-Ottawa Scale （NOS） tool.Meta analysis was performed by using Stata 12.0 software.Results　Fourteen articles and 460 patients were included.The results of meta-analysis showed that in the around tumor，the NAA/Cr and NAA/Cho in the glioma group were lower than those in the brain metastases group 〔SMD=-0.59，95%CI（-0.96，-0.22），P=0.002；SMD=-1.90，95%CI（-3.30，-0.51），P=0.007〕，and Cho/NAA and Cho/Cr were higher than those of brain metastases group 〔SMD=1.51，95%CI（0.95，2.07），P<0.001；SMD=1.42，95%CI（0.84，2.00），P<0.001〕.In the tumor area，there were no statistically significant differences in NAA/Cr，NAA/Cho，Cho/Cr between glioma group and brain metastases group 〔SMD=-0.28，95%CI（-0.67，0.10），P=0.153；SMD=-0.47，95%CI（-1.80，0.86），P=0.488；SMD=0.38，95%CI（-0.10，0.86），P=0.117〕.Cho/NAA in glioma group was higher than that in brain metastases group 〔SMD=0.47，95%CI（0.16，0.78），P=0.003〕.Conclusion　In the around tumor，the NAA/Cr，NAA/Cho in the glioma are lower than those in brain metastases，and Cho/NAA，Cho/Cr in the glioma are higher than those in brain metastases.In the tumor area，the Cho/NAA in the glioma is higher than that in brain metastases.It has important clinical value for the differentiation of glioma and brain metastases by contrasting analysis of the ratio of NAA/Cr，NAA/Cho，Cho/NAA and Cho/Cr in the peritumoral area through MRS.


Visual Analogue Scale in the Diagnosis of Influenza　

WANG Fang，LUO Xuping，ZHANG Jiaying，CHEN Fang

2019, 22(20):  2472-2475.  DOI: 10.12114/j.issn.1007-9572.2018.00.298

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Backgroud　Visual analogue scoring scale has been widely used in clinical pain assessment，but few experiments have used it to describe the clinical characteristics of influenza patients.It is an innovative measure to improve the visual analogue scoring scale by combining with the related contents of the interview in TCM diagnostics.Objective　To evaluate the application of Visual Analogue Scale （VAS） on the symptoms of patients with influenza.Methods　A total of 34 patients who were screened for influenza at the general outpatient in Respiratory Department of the First Affiliated Hospital of Zhejiang Traditional Chinese Medical University，Xiasha from 30 January 2018 to March 10 2018 were selected.According to influenza virus detection，there were 24 patients with influenza A and 10 patients with influenza B.VAS was performed by a self-designed Clinical Symptom Assessment Scale for Influenza Patients was used to record patients' fear of cold，fatigue，headache and other symptoms and signs.Results　Patients with influenza A were older than those with influenza B （P<0.05）．Patients with influenza A who had a median of 3 to 5 points of mild symptoms in VAS had a fear of cold，fatigue，headache，muscle soreness，nasal congestion，sneezing，runny nose，dry mouth，pharyngalgia，cough，sweating，and loss of appetite.Patients with influenza B had median symptom score of 3 to 5 for cough and expectoration，and VAS for all other symptoms was 0 to 2.There were no statistically significant differences between patients with influenza A and influenza B in symptoms of coldness of extremities，tiredness，headache，muscle aches，nasal congestion，sneezing，nose and pharynx itch，snivel，mouth dryness，pharyngodynia，hoarseness，cough，sweating，chest tightness，poor appetite，poor sleep，flushing on face and conjunctival congestion （P>0.05）．But the VAS of expectoration in patients with influenza B was higher than that of patients with influenza A （P<0.05）．There was no linear correlation between the age of patients with influenza A and influenza B and the VAS of expectoration （rs=0.200，P=0.373；rs=0.051，P=0.889）．Conclusion　VAS is a new method to study the subjective symptoms of patients with influenza，but its scientific nature needs further verification.


Progress of Measurement Tools on Locus of Control　

ZHU Tingting，LIU Dongling，ZHANG Jing，GAO Qiaoqiao

2019, 22(20):  2476-2481.  DOI: 10.12114/j.issn.1007-9572.2018.00.384

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Locus of control is an important dimension of personality traits，and the locus control tendency can guide and predict an individual's mental health and behavior.There are relatively well-developed measurement instruments for locus of control in foreign countries，while domestic researches in this field are relatively scarce.Therefore，we summarizes the main contents and characteristics of measurement tools on locus of control，so as to provide reference for domestic development of such measurement tools and intervention.


Problems and Countermeasures in Community-based Management of Stroke in China　

WEN Juncheng，CAO Chunshui

2019, 22(20):  2482-2487.  DOI: 10.12114/j.issn.1007-9572.2019.00.100

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Stoke is the leading cause of death in China，which has high incidence，high disability rate，and high cost of treatment.It not only seriously impairs the health and quality of life of patients，but also poses a heavy socioeconomic burden to many families and the nation.Providing effective and comprehensive community-based interventions for stroke，and actively delivering services for long-term prevention and treatment of stroke，are important part of community-based health management.This article reviews the existing problems in community-based management of stroke，and puts forward corresponding countermeasures.


Construction and Significance of Traditional Chinese Medicine Intervention Model in Patients with Ischemic Stroke in Communities　

TAO Qiongying，TANG Wei

2019, 22(20):  2488-2494.  DOI: 10.12114/j.issn.1007-9572.2019.00.184

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Background　At present，the community has achieved progress in exploring traditional Chinese medicine （TCM） intervention for stroke patients，but the process of TCM intervention is lack of scientific，standardized and authoritative evidence-based support.And the community lacks a reference process on how to establish TCM intervention model.Objective　To construct a patient-centered secondary TCM prevention model for ischemic stroke，and lay the foundation for the secondary prevention and management of ischemic stroke in the community.Methods　A retrospective study was conducted to summarize current researches on secondary prevention of stroke in China and abroad from CNKI，Wanfang Data Knowledge Service Platform，Web of Science，PubMed Database in August，2018.Expert consultation was carried out in September 2018，and the collection of secondary prevention tools for ischemic stroke at home and abroad was evaluated and screened.Based on the results of expert consultation，the basic framework of TCM intervention model for secondary prevention of ischemic stroke was constructed in October，2018.Results　The Community TCM intervention model for patients with ischemic stroke mainly consisted of three steps.First，TCM health practitioners in communities conducted health education for patients with ischemic stroke，to raise awareness of secondary prevention in the community；second，community health practitioners conducted Essen risk assessment and TCM intervention，and referred suspected patients with recurrent stroke to the hospital；third，after confirming the diagnosis by imaging examination and treating in the general hospital，patients in stable recovery period were referred to the corresponding community health service center，and included in the high risk reservoir management of ischemic stroke recurrence.Conclusion　The establishment of community TCM intervention model in patients with ischemic stroke has formed a practical and feasible implementation scheme，which has realized the patient-centered and rational application of TCM intervention and improved the secondary prevention of ischemic stroke in communities.


Follow-up and Analysis of Appropriate Techniques of Traditional Chinese Medicine in Patients with Ischemic Stroke　

TANG Wei，TAO Qiongying

2019, 22(20):  2495-2498.  DOI: 10.12114/j.issn.1007-9572.2019.00.185

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Background　Rehabilitation and secondary prevention of ischemic stroke is a long-term process，and community intervention of traditional Chinese medicine （TCM） is an effective means.However，there is no literature on the distribution of patients' demand for appropriate technique of TCM，the mastery of appropriate technique and the relationship between them.Objective　To provide a reference for the community to carry out TCM intervention in patients with ischemic stroke by analyzing the needs and long-term mastery of appropriate technique of TCM in communities.Methods　A total of 17 patients who met the inclusion criteria with ischemic stroke were selected by convenience sampling in Jiading Community Health Service Center，Shanghai，from August to September 2016，including 13 patients who participated in follow-up intervention.Epidemiological questionnaires were used to interview patients，including general information，stroke risk and physical condition assessment，and demand for stroke prevention services.From September 2016 to February 2017，13 patients with ischemic stroke were intervened on the spot once every 2-3 weeks on average，with a total of 9 on-the-spot interventions.At the end of each intervention，patients self-evaluated their mastery of appropriate TCM techniques.Results　Only one of the 17 patients did not need any suitable techniques of TCM.More than half of the patients needed TCM herbal tea，Chinese patent medicine，health exercises，medication guidance，dietary guidance and other appropriate techniques of TCM.Patient's demand for appropriate TCM techniques such as Chinese herbal decoction pieces，acupuncture，acupoint pressing and emotion regulation is low.Thirteen patients who participated in nine follow-up interventions were able to grasp the appropriate techniques of TCM，such as acupoint pressing，TCM herbal tea，health exercises，dietary guidance，daily living and emotional regulation.The complete mastery rate of TCM herbal tea，dietary guidance and emotional regulation was 100.0%.Conclusion　The application of TCM intervention on ischemic stroke should comprehensively consider the actual needs and long-term mastery of appropriate techniques of TCM to improve patient compliance and TCM intervention efficiency.


Successful Treatment of Influenza B-associated Acute Necrotizing Encephalopathy of Childhood：a Case Report and Literature Review　

HE Bo，YU Shufeng，LU Jun，WANG Hongxia

2019, 22(20):  2499-2501.  DOI: 10.12114/j.issn.1007-9572.2018.00.455

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Acute necrotizing encephalopathy （ANE） is a rare acute encephalopathy of brain characterized by bilateral thalamic lesions，and develops secondarily to viral infections.Influenza viruses are the most common etiological agents of ANE.The prognosis of ANE is usually poor with a high mortality rate and neurological sequelae.In this paper，we reported our clinical diagnosis and successful treatment of a case with influenza B-associated ANE of childhood.And the relevant literature was reviewed to improve the awareness of this rare disease and provide reference for clinical work．



Two Case Reports of Huntington Disease in One Family and Literature Review　

ZHAO Hong，LIU Zanhua，LI Shumin，LIN Jianwen，ZHAO Hongling，WANG Suping

2019, 22(20):  2502-2505.  DOI: 10.12114/j.issn.1007-9572.2018.00.454

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Huntington disease（HD） is an autosomal dominant，inherited disease that causes the progressive breakdown of nerve cells in the brain.It is caused by expanded CAG repeats in the gene IT15.The clinical manifestations are involuntary movement and cognitive impairment.Neuroimaging shows caudate nucleus atrophy and lateral ventricle enlargement，partially accompanied by cortical atrophy.The gene test is a significant diagnosis for HD.For people with a positive family history and typical clinical manifestations，the diagnostic rate of this disease is higher; however，missed diagnosis and misdiagnosis often occur in patients with untypical symptom or at early stage of this disease.To investigate HD diagnosis and treatment，this article summarizes imaging and the CAG repeats sequence of the gene IT15 in a clinical suspected HD case and her two family members.Meanwhile，combined with the latest literature，we elucidate the advancement in the treatment of HD so as to improve the understanding of this rare disease.There is no effective treatment for HD at present，but gene therapy offers a new direction for treatment.


Formation Mechanism of Professional Identity of General Practitioners：a Structural Equation Model Analysis　

CHEN Xin，WANG Jie，QIAN Ning，LI Li，SHEN Qun

2019, 22(20):  2506-2513.  DOI: 10.12114/j.issn.1007-9572.2018.00.364

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Background　Professional identity of general practitioners（GPs）can stimulate enthusiasm and initiative of GPs in primary health care.Driving forces of research and teaching and career expectations can affect the professional identity of GPs.However，their relationship and formation mechanism of professional identity are unclear.Objective　To explore the formation mechanism of professional identity of GPs，in order to provide effective incentive approaches of research and teaching for the improvement of GPs' professional identity.Methods　From September to November 2017，using stratified random sampling，we selected 397 GPs from community health centers in urban area，urban and rural intersections and suburbs of Shanghai.All of them were surveyed with 4 self-administered questionnaires，GPs' Basic Personal Characteristics Questionnaire，GPs' Self-perceived Driving Forces of Research and Teaching Scale （SDFRT），Career Expectation Scale （CES） and Professional Identity Scale （PIS）．On the basis of the survey results，we constructed a structural equation model （SEM） and tested it for the analysis of the formation mechanism of GPs' professional identity.Results　A total of 397 questionnaires were issued，383 of which were valid.The effective recovery rate was 96.5%.The mean scores of 4 dimensions of the SDFRT，resource support，organization management，performance incentive and innovation support，were （10.3±3.0），（11.4±2.9），（6.1±2.2），and （11.3±2.7），respectively.The mean scores of dimensions of career development，career achievement and work-life balance of the CES were （9.5±3.1），（6.7±1.9），and （6.8±1.8），respectively.The mean scores of 3 dimensions of the PIS，professional cognition，professional behavior and professional values were （10.5±3.0），（8.6±1.6），and （8.4±1.7），respectively.The mean scores of all the dimensions of the scales showed positive correlations （P<0.05） except that the mean score of career development presented no linear correlation with that of performance incentive and work-life balance （P>0.05）．Bootstrap analysis for the test of mediating effect showed that path coefficients from organization management，performance incentive and innovation support to professional cognition with career achievement，work-life balance as mediating variables did not include 0 in the 95% confidence interval （CI），indicating that mediating effects were significant.The results extracted from SEM showed that career expectation played a mediator role between organization management and professional identity completely，and played a mediator role between performance incentive，innovation support and professional identity partly.Organization management had mild positive effects on professional identity.Performance incentive positively influenced professional cognition，but negatively influenced both professional behavior and professional values.Innovation support produced strong positive effects on each dimensions of the PIS.Conclusion　The career expectation plays a mediator role between research and teaching driving forces and professional identity partly.Community health centers are suggested to strongly support the innovative research and teaching work of GPs，ensure the equity of resource allocation and management system，and improve the performance evaluation mechanism.


Multiple-site Physician Practices in Guangdong Province：a Survey of Stakeholders' Perspectives　

LIN Kaicheng，WANG Yuanyuan，XU Xirong，LI Wenyuan

2019, 22(20):  2514-2518.  DOI: 10.12114/j.issn.1007-9572.2019.00.257

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Background　Promoting multiple-site physician practices facilitates vertical and horizontal mobility of talents among different medical institutions and regional rational allocation of medical talents，gives supports for the development of primary healthcare institutions to the utmost extent，and provides a platform and opportunities for the training and growth of general practitioners.Since January 1st，2010，Guangdong Province，the first pilot province in China to put multiple-site physician practices into practice，has encountered an embarrassing situation of enthusiastic media coverage，public hospitals' indifference and multiple doctors' wait-and-see attitude.Objective　To investigate the levels of support for multiple-site physician practices from the perspectives of stakeholders （physicians，managers and health policy research experts） of such practices.Methods　A questionnaire survey was conducted among 425 physicians from 15 public hospitals and 119 medical administrators and health policy research experts from 10 public hospitals in Guangdong Province from May 2011 to August 2012.The survey covered the following aspects：attitude towards multiple-site physician practices，perceptions of the prospect of multiple-site physician practices，thoughts or impulses about/evaluation of multiple-site physician practices，and biggest beneficiaries and losers of multiple-site physician practices.Results　Multiple-site physician practices received supports from 70.4% （299/425） of the physicians，and 44.5% （53/119） of the medical administrators and health policy research experts.Patients，and the second practice setting were thought as the biggest beneficiaries of multiple-site physician practices in 38.6% （164/425），and 38.4% （163/425） of the physicians，respectively.But 16.9% （72/425） of the physicians，and 42.0% （50/119）of the medical administrators and health policy research experts thought that physicians were the biggest beneficiaries of multiple-site physician practices.The first practice setting was considered as the biggest loser of multiple-site physician practices by 71.1% （302/425） of the physicians，and 77.3% （92/119） of the medical administrators and health policy research experts.Conclusion　The stakeholders have different attitudes toward multiple-site physician practices.Although physicians and medical administrators and health policy research experts show different views on the biggest beneficiaries of multiple-site physician practices，all of them agree that the first practice setting of the physicians is the biggest loser of such practices.