Chinese General Practice

Interpretation of Updated NCCN Guidelines for Colon Cancer and Rectal Cancer （Version 1.2019）　

BAI Xueshan，LIN Guole

2019, 22(33): 4031-4034. DOI: 10.12114/j.issn.1007-9572.2019.00.655

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Compared with NCCN Guidelines for Colon Cancer and Rectal Cancer （Version 4.2018），the NCCN Guidelines for Colon Cancer and Rectal Cancer （Version 1.2019） have made some significant updates that can change clinical practice.This paper analyses and interprets the most important updates in the NCCN Guidelines for Colon Cancer and Rectal Cancer （Version 1.2019），which mainly include：（1） BRAF WT was added as an indication for treatment，where KRAS and NRAS WT are noted；（2） Microsatellite Instability （MSI） or Mismatch Repair （MMR） Testing was modified and supplemented：BRAF V600E mutation and the diagnosis of Lynch syndrome，the result and meaning of immunohistochemistry；（3）The following regimens were added as treatment options in subsequent therapy：dabrafenib + trametinib + （cetuximab or panitumumab），encorafenib + binimetinib + （cetuximab or panitumumab）.The purpose of this article was to provide a reference for clinical selection of diagnosis and treatment options of colorectal cancer.

Interpretation of Guidelines for Primary Care of Cough 2018 in China from the Perspective of General Practice　

TAN Wei，YANG Guili，HUANG Zhaolan

2019, 22(33): 4035-4040. DOI: 10.12114/j.issn.1007-9572.2019.00.502

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Cough is one of the most common chief complaints in the clinical practice．Due to complicated etiology and therapy of cough，limited diagnosis tools and experience of primary care providers can cause misdiagnosis or overtreatment of cough．Guideline for Primary Care of Cough 2018 based on Cough Diagnosis and Treatment Guideline 2015 was initiated by Chinese Medical Association for the first time to meet the characteristics of primary care system and the needs of general medical practice，and promote the standardization of cough diagnosis and treatment for general practitioners.This article aims to give a brief interpretation to the Guideline about its important update，application and operability for general practitioners，expect to attract attention and discussion from general practitioners, and promote the implementation of the guidelines and cough research.

Interpretation of 2019 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults　

SHU Bing，LIU Yulong，ZHANG Shengyu，SHEN Aizong

2019, 22(33): 4041-4046. DOI: 10.12114/j.issn.1007-9572.2019.00.435

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The Beers criteria is currently the most widely used evaluation tool for potentially inappropriate medication use in older adults.American Geriatrics Society（AGS） updated the criteria on January 29，2019，and this paper is an interpretation of the criteria.The 2019 Beers criteria follows the Delphi method in the 2015 editon，and all five types in 2015 Beers criteria are retained，but the specific contents have been added，deleted or modified according to the new medical evidence，including 30 categories of drugs that are avoided to be used in the elderly in general，40 categories of drugs that should be avoided or used with caution in certain diseases or syndromes，and revisions of 16 criteria，such as the removal of drugs that are not used，used less，or not unique to the elderly in the United States，the supplementation of drugs that should be avoided in the elderly associated with falls or fractures，Parkinson's disease or insomnia and the drug-drug interactions，and a more detailed interpretation of the criteria for the evaluation of some drugs.The basic framework and general content of the 2019 Beers criteria which is a powerful tool to ensure the rational use of drugs for the elderly is not much different from the 2015 edition，but the target group is clearer and the content is more concise.

Effect of Late-evening Snack on Energy Metabolism and Blood Sugar in Patients with Liver Cirrhosis and Diabetes Mellitus　

DONG Jinling，JIA Lin，WANG Zhongying，ZHU Yueke，HU Zhongjie，YU Hongwei，MENG Qinghua

2019, 22(33): 4047-4053. DOI: 10.12114/j.issn.1007-9572.2019.00.654

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Background　Many patients with liver cirrhosis and diabetes mellitus（DM）suffer from protein-energy malnutrition as well as disorder of glycometabolism.With poor glycogen reserve and insulin resistance，these patients are prone to hypoglycemia in the morning.Previous studies have reported that late-evening snack（LES） is able to shorten the time of hunger and reduce the energy supply of oxidative decomposition of fat and protein to prevent hypoglycemia in the next morning in patients with cirrhosis.However，whether LES plays a role in cirrhosis patients with DM is still worth exploring.Objective　To investigate the effect of 200 kcal of LES on energy metabolism and glucose metabolism in patients with liver cirrhosis and DM.Methods　Twenty-five patients with hepatitis B cirrhosis and DM who met the research criteria were selected from January 1，2015 to December 30，2017 in the Department of Severe Liver Diseases in Beijing You'an Hospital，Capital Medical University. They were divided into high-carbohydrate LES management group with low-glycemic index（intervention group，n=13） and cirrhosis and DM diet group（non-intervention group，n=12） according to the random number table method.All patients continued to have antiviral，liver protection and hypoglycemic treatment.The non-intervention group maintained three meals a day；the intervention group changed the traditional three meals to four meals，and each meal reduced 67 kcal（16.7 g carbohydrate），and added a meal one hour before bedtime.The baseline demographic data（sex and age），baseline anthropometric data（body mass and BMI）before and after three-month intervention，dietary intake（carbohydrate，fat，protein and energy），energy metabolism index〔resting energy expenditure（REE），predicted resting energy expenditure（PREE），percentage of PREE（PREE%），respiratory quotient（RQ），carbohydrate oxidation rate（CHO%），fat oxidation rate（FAT%） and protein oxidation rate（PRO%）〕，glucose metabolism index〔glycosylated hemoglobin（HbA1c），fasting blood glucose （FBG） and fasting insulin （FINS）〕，insulin resistance index（HOMA-IR），islet B cell function index （FBCI） and liver function index （ALT，AST，TBIL，TP，ALB，PALB，CHE and PTA） were compared between two groups.Results　There was no significant difference in body mass，BMI，carbohydrate intake，fat intake，protein intake and energy intake between the two groups at baseline and three months after intervention（P>0.05）．There was no significant difference in REE，PREE and PREE% between the two groups after three-month intervention（P> 0.05）．RQ and CHO% in the intervention group were higher than those in the non-intervention group after three-month intervention，while FAT and PRO% were lower（P<0.05）．RQ and CHO% after three-month intervention in intervention group were higher than those at baseline in the same group，while FAT and PRO% were lower（P<0.05）．HbA1c，FBG，FINS and HOMA-IR in intervention group were lower than those in non-intervention group at 3 months after intervention（P<0.05）．There was no significant difference in FBCI between the two groups at 3 months after intervention （P> 0.05）．HbA1c，FBG，FINS and HOMA-IR in the intervention group at 3 months after intervention were lower than those in the same group at baseline（P<0.05）．TP，ALB and PALB in the intervention group at 3 months after intervention were higher than those in the same group at baseline（P<0.05）．Conclusion　Before going to bed，200 kcal of food with low-glycemic index and high-carbohydrate can improve nutritional metabolism and blood sugar control in patients with hepatitis B cirrhosis and DM，reduce insulin resistance and prevent hypoglycemia caused by disorders of glucose metabolism.

Application Value of Inspiratory Capacity in Differentiating Chronic Obstructive Pulmonary Disease from Asthma-chronic Obstructive Pulmonary Disease Overlap　

WANG Fang，JIANG Chenyu，LUO Xuping，CHEN Fang

2019, 22(33): 4053-4057. DOI: 10.12114/j.issn.1007-9572.2019.00.572

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Background　Bronchial dilation test is mostly used as an important step in differentiating chronic obstructive pulmonary disease（COPD） from bronchial asthma-chronic obstructive pulmonary disease overlap（ACO），but it does not identify all COPD and ACO.Studies have shown that inspiratory capacity（IC） has a good sensitivity to reflect the degree of pulmonary hyperinflation and respiratory difficulty in patients with severe COPD，so we aim to study whether IC can be used as an indicator to distinguish patients with COPD from patients with ACO.Objective　To evaluate the diagnostic value of IC in identifying COPD and ACO.Methods　Twenty patients with COPD（COPD group） and 21 patients with ACO（ACO group） who were admitted to the respiratory department of the First Hospital Affiliated to Zhejiang Chinese Medical University and met the study criteria were enrolled from March to September in 2018.All patients underwent pulmonary ventilation function test，whose data were recorded as pre bronchial dilation test data，and then bronchial dilation test.After the bronchial dilation test，the pulmonary ventilation function test was performed again，whose data were recorded as post bronchial dilation test data.The general information（including height，mass，BMI，gender and age），indicators of pulmonary ventilation function 〔forced expiratory volume in 1 second（FEV1），forced vital capacity（FVC），IC，peak expiratory flow（PEF），forced expiratory flow after 25% of FVC（FEF25），forced expiratory flow after 50% of FVC（FEF50），forced expiratory flow after 75% of FVC（FEF75），maximum mid-expiratory flow（MMEF）〕，the pre and post bronchial dilation test data and their absolute value changes（Δ），and improvement rate between patients in two groups were compared.The correlation between IC improvement rate and Δ FEV1，improvement rate of FEV1，Δ FVC，improvement rate of FVC，Δ PEF，improvement rate of PEF among patients with ACO and COPD was analyzed.The improvement rate of IC was analyzed to show its diagnostic value of ACO.Results　The age of patients in the ACO group was smaller than that in the COPD group（P<0.05）．When compared with the COPD group，the ACO group showed higher ΔFEV1 and improvement rate of FEV1，higher ΔFVC and improvement rate of FVC，higher ΔPEF and improvement rate of PEF，and improvement rate of IC（P<0.05）．There was no correlation between the improvement rate of IC and ΔFEV1，improvement rate of FEV1，ΔFVC，improvement rate of FVC，ΔPEF and improvement rate of PEF in ACO group（P>0.05）．Improvement rate of IC was positively relevant with improvement rate of FVC in the COPD group（rs=0.501，P=0.021） and was not related with ΔFEV1，improvement rate of FEV1，ΔFVC，ΔPEF and improvement rate of PEF（P>0.05）. In ROC analysis，the improvement rate of IC presented an area under the ROC curve of 0.714（P=0.019）；the optimal cutoff value was 13.11%，with a sensitivity of 61.90% and specificity of 85.00%.Conclusion　IC has a certain value in evaluating the response of bronchodilator in patients with mild-moderate COPD，but it is not as sensitive as FEV1 in a certain extent.IC does show good sensitivity and specificity in the ACO diagnosis，and has a large clinical reference value.However, whether IC can be used as an indicator to identify COPD and ACO needs further study.

Factors Affecting Margin Positivity in Frozen-section Analysis during Breast-conserving Surgery　

CHEN Xiao，LI Ying，JING Yi，YANG Xiaonan，ZHANG Sheng

2019, 22(33): 4058-4063. DOI: 10.12114/j.issn.1007-9572.2019.00.310

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Background　Breast-conserving surgery combined with whole breast radiotherapy has become the standard treatment for early breast cancer，but the most important disadvantage of breast-conserving surgery is that there may be tiny residual lesions at or close to the margin.Several studies have demonstrated that intraoperative frozen-section analysis（FSA） can assess the situation of margins，and prevent reoperation and reduce the local recurrence rate.Objective　To explore the factors influencing surgical margin positivity in FSA during breast-conserving surgery.Methods　According to the study criteria，we enrolled 629 patients undergoing FSA during breast-conserving surgery Tianjin Medical University Cancer Institute and Hospital from August 1，2014 and October 31，2016.We collected their clinical data，and analyzed the prevalence and associated factors of initial positive margin，the value of the distance from the mass to the nipple in the diagnosis of initial positive margin，and factors associated with the number of initial positive margins.Results　Among the 629 patients，434（69.0%） were found with initial negative margins，other 195 （31.0%） with initial positive margins.After extended resection，the margins of 92 （47.2%） patients became negative，but the margins of 7 （3.6%） patients were still positive.96 patients （49.2%） immediately underwent total mastectomy after being found with initial positive margins.526 patients （83.6%） had successful breast-conserving surgery.Those with initial positive margins and initial negative margins showed significant differences in terms of the distance from the mass to the nipple，tumor distribution along the duct，pathological type and lymph node metastasis prevalence （P<0.05）．Multivariate logistic regression analysis showed that the distance from the mass to the nipple〔OR=0.830，95%CI （0.700，0.982），P=0.030〕，and tumor distribution along the duct〔OR=0.232，95%CI （0.103，0.521），P<0.001〕，pathological type 〔invasive carcinoma of no special type：OR=0.268，95% CI （0.090，0.798），P=0.018〕，lymph node metastasis〔OR=0.154，95%CI （0.075，0.318），P<0.001〕 were the influencing factors of the initial positive margin in breast-conserving surgery．The ROC curve of the distance from the mass to the nipple for the diagnosis of initial positive margin was drawn，the area under the ROC curve was 0.572〔95%CI（0.520，0.624）〕，the optimal cut-off value was 4.55 cm，and the sensitivity was 0.815，the specificity was 0.333.The prevalence of 1，2，3 and 4 or more initial positive margins was 50.8%（99/195），28.2%（55/195），11.3%（22/195），and 9.7%（19/195），respectively.Menopause，and implementation of preoperative breast MRI were associated with less initial positive margins（P<0.05）．Conclusion　The distance from the mass to the nipple，tumor distribution along the duct，pathological type （mainly invasive carcinoma of no special type），and lymph node metastasis are the influencing factors of the initial positive margin in breast-conserving surgery.Non-menopausal patients and those receiving no preoperative breast MRI are more likely to be found with more initial positive margins.

Clinical Significance of Thyroid Hormones and Antibodies in Patients with Primary Biliary Cholangitis　

ZHANG Yajun，GUO Xiaomin，JIANG Yufeng

2019, 22(33): 4064-4068. DOI: 10.12114/j.issn.1007-9572.2019.00.249

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Background　Patients with autoimmune liver disease may be accompanied by extrahepatic autoimmune disease，and autoimmune thyroid disease（AITD）is the most common.In primary biliary cholangitis（PBC）patients，the incidence of extrahepatic autoimmune disease can be up to 42.3%.The study of thyroid hormone and antibody secretion in patients with PBC may provide evidence for the diagnosis and evaluation of PBC.Objective　To analyze the clinical significance of thyroid hormones and antibodies in patients with PBC，offering evidence for early diagnosis and treatment of PBC.Methods　We conducted a retrospective study among 121 PBC inpatients from the Affiliated Hospital of Southwest Medical University from June 2013 to July 2018，among whom 65 progressed to cirrhosis（Child-Pugh grade：39 cases of grade A，19 cases of grade B，7 cases of grade C）and other 56 did not.A total of 101 healthy physical examinees were selected from the hospital during the same period.General data，thyroid hormone and antibody indices were collected.Thyroid hormone and antibody were compared between PBC patients and healthy people，cirrhosis patients and non-cirrhosis patients and healthy people，cirrhosis patients with different liver function grades. Results　 Compared with the healthy controls，lower average levels of FT3 and FT4，and higher average level of TSH as well as higher rates of TPOAb and TGAb positivity were found in PBC patients（P<0.05），and in cirrhosis patients and non-cirrhosis patients（P<0.05）．Cirrhosis patients had lower average levels of FT3 and FT4，and lower rate of TGAb positivity，but higher average level of TSH than non-cirrhosis patients（P<0.05）．Compared with those with grade B or C cirrhosis，patients with grade A cirrhosis showed higher average level of FT3 and lower average level of TSH（P<0.05）．The average level of FT4 in those with grade C cirrhosis was lower than that of those with grade A cirrhosis（P<0.05）．Patients with grade C cirrhosis showed lower average levels of FT3 and FT4，and higher average level of TSH than those with grade B cirrhosis（P<0.05）．Conclusion　There are differences in thyroid hormones and antibodies between PBC patients and healthy subjects.Decreased levels of FT3 and FT4 and elevated level of TSH in PBC patients with cirrhosis indicate that TSH may play a role in promoting hepatic fibrosis，but FT3 and FT4 may be involved in delaying the progression.The level of FT3 increases with the increase of Child-Pugh grade while the level of TSH decreases with that in PBC patients.The levels of FT3 and TSH reflect the severity of liver function impairment indirectly.

Heart Rate Variability in Patients with Generalized Anxiety Disorder and Depressive Disorder　

LIU Zhipeng，WU Hailin，HU Maorong

2019, 22(33): 4069-4072. DOI: 10.12114/j.issn.1007-9572.2019.00.597

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Background　Both generalized anxiety disorder （GAD） and depressive disorder （MDD） could lead to reduction in heart rate variability （HRV），increasing the risk of comorbid cardiovascular diseases.However，the effects of anxiety and depression on HRV parameters and the underlying mechanisms are still unclear.And studies about the impact of comorbid MDD on HRV in GAD patients are also very rare.Objective　To investigate the relationships of HRV with GAD and MDD by examining HRV features in such patients.Methods　A total of 140 participants were recruited from Jiangxi Mental Hospital during January 2015 to December 2016，including 90 outpatients and inpatients〔30 with GAD alone（GAD group），30 with GAD and MDD（GAD and MDD group），and 30 with MDD alone（MDD group）〕，and 50 clinic health examinees（control group）．A survey was conducted to collect demographic data〔age，sex，BMI，systolic blood pressure（SBP），diastolic blood pressure（DBP），weekly exercise time〕 of patients group at baseline，and of the control group at one week after grouping using a clinician-developed demographic questionnaire.The 17-item version of Hamilton Anxiety Rating Scale（HAMA-17） and Hamilton Depression Rating Scale（HAMD） were used to identify anxiety and depression symptoms，respectively.HRV was measured in patients group at one week after treatment，and in control group at one week after grouping.And the measurement results，time-domain parameters〔standard deviation of average NN intervals （SDANN），and the square root of the mean squared differences of successive normal sinus intervals （RMSSD）〕，and frequency-domain parameters〔low frequency （LF） and high frequency （HF）〕，were analyzed.Pearson correlation analysis was used to assess the correlations of HAMA-17 and HAMD scores with HRV.Results　Sex ratio，mean age，BMI，SBP，DBP，and weekly exercise time did not differ significantly across the three patients groups and the control group （P>0.05）．GAD，and GAD with MDD groups had significantly higher mean HAMA-17 scores than MDD group and control group（P<0.05）．GAD with MDD and MDD groups showed higher mean HAMD scores than GAD group and control group（P<0.05）．Mean LF value of GAD with MDD group was much lower than that of other two patients groups and control group（P<0.05）．Mean LF value of GAD group was much lower than that of MDD group and control group（P<0.05）．Mean HF value of GAD with MDD group was much lower than that of other two patients groups and control group（P<0.05）．Mean HF value of GAD group was much lower than that of MDD group and control group（P<0.05）．MDD group showed much lower mean values of HF and LF than control group（P<0.05）．The values of HF and LF were lower in MDD group than those in control group（P<0.05）．Furthermore，LF，HF，and LF/HF values were negatively correlated with the scores of HAMA-17 and HAMD in GAD and MDD patients（P<0.05）．Conclusion　Our present study demonstrated that both GAD and MDD can lead to reduction in HRV，and HRV was significantly correlated with the severity of anxiety and depression，suggesting that reduced HRV might be a psychopathological indicator of GAD.Since GAD comorbid MDD may result in a further reduction in HRV，the risk of cardiovascular diseases in these patients need clinicians to pay more attention.

Epidemiological Characteristics of Patients with Postpartum Hemorrhage in Northern Guizhou before and after the Implementation of Comprehensive Two-child Policy and Its Influencing Factors in ICU Admission：a Single-center Study　

LUO Shiyu，LUO Shuju，WANG Shaojun，GENG Zhengguang，FU Xiaoyun

2019, 22(33): 4073-4077. DOI: 10.12114/j.issn.1007-9572.2019.00.492

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Background　With the implementation of the comprehensive two-child policy，the number of advanced age and critically ill parturient women have a significant increase in recent years，so it is very necessary to analyze the high risk factors of postpartum hemorrhage and the risk factors associated with ICU admission.It can effectively prevent the occurrence of postpartum hemorrhage and the resulting series of harms，thereby reducing the incidence of postpartum hemorrhage.Objective　To investigate the epidemiological characteristics of postpartum hemorrhage in pregnant women before and after the implementation of the comprehensive two-child policy in the north area of Guizhou province，and to further analyze the risk factors associated with ICU admission in pregnant women with postpartum hemorrhage.Methods　Taking the implementation of the comprehensive two-child policy on January 1，2016 as the time point，clinical data of patients with postpartum hemorrhage（961 cases） admitted to Affiliated Hospital of Zunyi Medical College during the comprehensive policy implementation time point were collected and retrospectively analyzed.Postpartum hemorrhage patients were compared before implementation（January 2014 to December 2015） and after the implementation（January 2016 to December 2017）．Clinical characteristics of patients before and after the implementation of the comprehensive two-child policy were collected，including age，senior age（≥35 years），maternal delivery，gestational weeks of delivery，regular checkups，scar uterus，mode of delivery，number of fetuses，incidence of hypertension during pregnancy，placenta previa，placenta adhesion/implantation，neonatal body weight，blood transfusion，hysterectomy，interventional therapy，drug therapy alone，ICU admission，bleeding volume，death and major bleeding causes.Multivariate Logistic regression analysis were used to identify possible factors affecting ICU admission.Results　After the implementation of the comprehensive two-child policy，the incidence of postpartum hemorrhage was significantly increased （P=0.029）；further comparison of clinical data of patients with postpartum hemorrhage found that after the implementation of the comprehensive policy，maternal age and advanced age，gestational times，delivery times，scar uterus，cesarean section，hypertensive disorder complicating pregnancy，placental adhesion/implantation，ICU admission and bleeding volume and uterine contraction in the ICU increased significantly （P<0.05）．Multiple Logistic regression showed that scar uterus〔OR=3.064，95%CI（1.877，5.033），P<0.001〕，hypertensive disorder complicating pregnancy〔OR=3.107，95%CI（1.721，5.608），P<0.001〕，placenta previa〔OR=1.901，95%CI（1.155，3.128），P=0.011〕，liver damage during pregnancy〔OR=14.718，95%CI（2.998，72.260），P=0.001〕 and combination with heart disease during pregnancy〔OR=20.535，95%CI（4.419，95.434），P<0.001〕 were independent risk factors of ICU admission in patients with postpartum hemorrhage.Conclusion　After the implementation of the comprehensive two-child policy，the incidence of postpartum hemorrhage has increased in the north area of Guizhou province.Advanced age，hypertensive disorder complicating pregnancy，scar uterus and placental adhesion/implantation are risk factors for postpartum hemorrhage；scar uterus，hypertensive disorder complicating pregnancy，placenta previa，pregnancy with heart disease and pregnancy with hepatic dysfunction are independent risk factors for ICU admission in postpartum hemorrhage.

Low-dose Zopiclone Delayed Controlled-release Tablets for Dysphylaxia：an Experimental Study　

ZHOU Qida，FAN Jian，QIN Lin，HUA Jian，HAN Yang，ZHA Leilei，ZHOU Wei，ZHOU Yujie

2019, 22(33): 4078-4082. DOI: 10.12114/j.issn.1007-9572.2019.00.483

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Background　Insomnia is manifested by symptoms of difficulty falling asleep，sleep-maintenance disorder，and waking up too early in the morning，and so on.At present，the effects of available pharmacological treatments for insomnia are limited，and targeted pharmacological treatments for different types of insomnia as well as related reports are rare.Objective　To study the effect of low-dose zopiclone delayed controlled-release tablets（ZDCT） in the treatment of dysphylaxia.Methods　This study was carried out between October 2016 and January 2018．（1） 40 male clean grade SD rats were equally divided into control groupⅠ，low-dose group（2.5 mg/kg zopiclone），high-dose（5.0 mg/kg zopiclone） 30 minutes group and high-dose 60 minutes group.The sleep latency and sleep duration of rats in each group were observed by sleep time-prolongation test with pentobarbital sodium．（2） Evenly mixed zopiclone with sodium carboxymethyl starch，lactose，5% PVPK30 and magnesium stearate，the compressed the mixture into tablet cores.Next，by mixing evenly glycerol sorbate，lactose，5% PVPK30 and magnesium stearate，the coated granules were obtained.Then，placing the cores at the center of the coating and the delayed-release tablets were prepared by pressing．（3） 60 male clean grade SD rats were randomly and evenly divided into control group Ⅱ，ZDCT group （2.5 mg/kg zopiclone） and zopiclone solution group （5.0 mg/kg zopiclone）．The sleep latency and sleep duration were compared across the groups.Results　There were significant differences in sleep duration between the control group Ⅰ 〔（126.3±18.6） min〕，low-dose group 〔（175.3±18.1） min〕，high-dose 30 minutes group 〔（151.8±19.2） min〕and high-dose 60 minutes group 〔（181.5±15.6） min〕（F=19.651，P<0.01）．The sleep duration of the control group Ⅰ was shorter than that of low-dose group，high-dose 30 minutes group，and high-dose 60 minutes group（P<0.05）．Low-dose group had longer sleep duration than high-dose 30 min group（P<0.05）．The sleep duration of high-dose 60 minutes group was longer than that in the high-dose 30 minutes group （P<0.05）．The difference of sleep duration between ZDCT group〔（188.3±25.0） min〕，zopiclone solution group〔（194.0±28.1） min〕and controlⅡgroup〔（130.2±25.6） min〕 was significant （F=30.400，P<0.05）．Control groupⅡ had shorter sleep duration than that of ZDCT group and zopiclone solution group （P<0.05）．Conclusion　 Low-dose（2.5 mg/kg dosage form） ZDCT prepared by us orally administered to SD rats can release zolpidem after the rats falling asleep，which showed the same effectiveness as high-dose（5.0 mg/kg dosage form） ZDCT given to SD rats by gavage 60 minutes before sleep，indicating that low-dose ZDCT may be a promising drug for dysphylaxia in adults.

Effects of Celery Leaves on Endothelial Nitric Oxide Synthase and Long Non-coding RNA-sONE in Spontaneously Hypertensive Rats　

CUI Lingzhi，WANG Zichao，TANG Cunliang，HUANG Guanhua

2019, 22(33): 4082-4086. DOI: 10.12114/j.issn.1007-9572.2019.00.430

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Background　Hypertension is an important risk factor for cardiovascular disease and all-cause death.Previous studies have shown that the abnormal expression of long non-coding RNA （LncRNA） is closely related to the occurrence of cardiovascular diseases.Objective　To investigate the effects of celery leaves on endothelial nitric oxide synthase （eNOS） and LncRNA-sONE in spontaneously hypertensive rats.Methods　In September 2015，48 spontaneously hypertensive rats （10 weeks old，SPF grade，half males and half females） were purchased.After being fed with normal diet （forage containing 0.25% NaCl） for 2 weeks，they were randomly and evenly divided into high salt group，normal salt group and high salt celery leaf group，with balanced sex ratio，receiving another 12-week diet intervention with forage containing 5.00% NaCl，12-week diet intervention with forage containing 0.25% NaCl，and 8-week synthetic forage containing 5.00% NaCl and 10.00% celery leaves，respectively.In addition，each group was given adequate other diets.Body weight and systolic blood pressure（SBP） of three groups were measured and compared before intervention，and after 4，8 and 12 weeks of intervention.Western blotting was used to detect the expression of eNOS protein.qPCR was used to detect the expression of LncRNA-sONE and eNOS mRNA.Results　Normal salt group showed higher body weight than other two groups after 8 and 12 weeks of intervention （P<0.05）．Normal salt group demonstrated lower SBP than other two groups after 4，8 and 12 weeks of intervention （P<0.05）．High salt celery leaf group had lower SBP than high salt group after 12 weeks of intervention （P<0.05）．By the end of the 12th week of intervention，compared with normal salt group，high salt group showed lower expression level of eNOS protein but higher expression levels of LncRNA-sONE and eNOS mRNA（P<0.05），high salt celery leaf group showed higher expression levels of eNOS protein and eNOS mRNA（P<0.05）．High salt celery leaf group demonstrated higher expression levels of eNOS protein and eNOS mRNA and lower expression level of LncRNA-sONE when the intervention ended compared with high salt group （P<0.05）．Conclusion　Celery leaves could increase the expression levels of eNOS protein and mRNA，and decrease the expression level of LncRNA-sONE in spontaneously hypertensive rats.In addition，eNOS and LncRNA-sONE may be involved in the antihypertensive mechanism of celery leaves.

Clinical Study on the Treatment of Pulmonary Hypertension in Pulmonary Emphysema with Video Assisted Thoracoscopic Lung Volume Reduction Surgery at High-altitude Regions　

LIANG Zhong，WEI Zhenhong，HU Weidong，ZHU Zijiang，JIN Gang

2019, 22(33): 4087-4090. DOI: 10.12114/j.issn.1007-9572.2019.00.532

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Background　Air dryness in plateau area makes it a high-risk area of respiratory diseases.At the same time，the low oxygen content in plateau area aggravates respiratory and cardiovascular diseases.However，pulmonary emphysema，bullae，and hypertension have a great impact on the respiratory system and cardiovascular system.The pathophysiological process of patients with hypoxemia and pulmonary hypertension in plateau area is quite different from those in the low-altitude regions，and the problems and difficulties faced by lung volume reduction surgery（LVRS） are also quite different.Objective　To investigate the clinical efficacy of thoracoscopic LVRS in the treatment of chronic obstructive emphysema with pulmonary hypertension in high-altitude regions.Methods　A total of 56 patients with chronic obstructive emphysema with pulmonary hypertension treated with LVRS through thoracoscopic surgery or video-assisted minithoracotomy in Gansu Provincial Hospital from September 2009 to December 2016 were enrolled，including 40 cases of unilateral LVRS，and 16 cases of bilateral LVRS.Observing the general condition of the patients after treatment and comparing their forced expiratory volume in one second（FEV1），pulmonary artery pressure，stroke volume，partial pressure of oxygen（PaO2），arterial partial pressure of carbon dioxide（PaCO2），and stair climbing test before treatment，at two weeks and two months after treatment.The quality of life was assessed by the postoperative improvement of diet，sleep quality，supine，chest tightness and shortness of breath，and landing test（positive or negative subjective feelings）．Results　40 cases of unilateral LVRS，two patients underwent bilateral LVRS within six months later，and 14 cases underwent bilateral LVRS in the same period died.During the operation，20% to 70% of each side of the lung volume was resected.FEV1，stroke volume，PaO2 and stair climbing test at two weeks and two months after operation were higher than those before operation，pulmonary artery pressure，PaCO2 at two weeks and two months after operation were lower than those before operation（P<0.05）．The improvement rate of patients' sleep quality and stair climbing test increased from 60% to 90% and more in two weeks after operation，and the improvement rate of chest tightness and shortness of breath increased from 75% to 90% in two weeks after operation.Conclusion　LVRS at high altitude can significantly improve patient's condition and quality of life.It is safe and effective，and is suitable for the treatment of emphysema with pulmonary hypertension in the underdeveloped inland plateau area.

Risk Factors of Understanding Doctors' Explanation for Patients with Cardiovascular Diseases in Communities　

SHI Lingyan，LU Shangxin，XIA Shijun，DU Xin，ZHANG Hongjia

2019, 22(33): 4091-4094. DOI: 10.12114/j.issn.1007-9572.2019.00.600

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Background　Incidence of cardiovascular disease keeps increasing in recent years，severely jeopardizing human health.However，the incomprehension of doctors' explanation is very common among patients in clinical practice.To date，few studies have investigated factors affecting the understanding of doctors' explanation in patients with cardiovascular disease.Objective　To analyze the influencing factors of understanding doctors' explanation in patients with cardiovascular disease in communities.Methods　 Patients with cardiovascular disease in Beijing Anzhen Hospital，Capital Medical University and Financial Street Community Health Service Center of Xicheng District were enrolled in this investigation from October to December 2012.Questionnaires were administered in 258 eligible patients.Patients were divided into two groups，one group that can fully understand doctors' explanation and the other group that cannot fully understand or completely fail to understand doctors' explanation.Factors influencing the understanding of doctors' explanation by patients with cardiovascular diseases，and the relationship between understanding doctors' explanation and following doctors' advice by patients with cardiovascular diseases were analyzed.Results　Among 258 patients （mean age of 64.1 years，55.8% were male），106 patients completely understood doctors' explanation while 152 patients could not or partly understood the explanation.Multivariate Logistic regression showed that low education level （lower than high school educational level）〔OR=3.185，95%CI （1.703，5.959），P<0.001〕，daily life affected by disease〔OR=2.436，95%CI （1.227，4.835），P=0.011〕，primary consultation〔OR=5.330，95%CI（2.710，10.483），P<0.001〕，male doctors〔OR=2.080，95%CI （1.155，3.744），P=0.015〕were individual risk factors for poor understanding of doctors' explanation.Ninety-five patients（89.6%） in the group with complete understanding followed the doctor's advice，while 121 patients（79.6%） in the group with incomplete understanding or incomprehension followed the doctor's advice，with significant difference（χ2=4.598，P=0.032）．Conclusion　Low education level （lower than high school educational level），daily life affected by disease，primary consultation，male doctors are independent risk factors for low-level understanding of doctors' explanation.

Role of Self-monitoring of Urine Glucose in the Management of Type 2 Diabetes Mellitus　

CONG Rizhao，JU Xinghua，LU Yanhui，LI Mingzi

2019, 22(33): 4095-4098. DOI: 10.12114/j.issn.1007-9572.2019.00.166

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Diabetes mellitus is a common and frequently-occurring disease threatening human health.Poor glycemic control and management can lead to multi-system complications causing a heavy burden on families and society.Self-monitoring of urine glucose（SMUG）is an important tool for patients with type 2 diabetes to monitor their disease evolvement，manage their diet and medication in their daily lives.This review described the origin and evolution of SMUG，introduced its effectiveness and advantages，and summarizes its influencing factors，usage and considerations.This paper pointed out that SMUG，as an ancient monitoring tool，was an appropriate approach for diabetes management because of its painless，low price and good compliance.It was further suggested that in some undeveloped areas or among people who have no access to blood glucose monitoring，SMUG should be taken into consideration for its significance and value.Moreover，the community physicians as well as the government officers may need to promote the use of SMUG along with some correct guidance and strong support.Meanwhile，more related researches on SMUG should be conducted by professionals to standardize its monitoring methods and considerations，so that SMUG could play a greater role in the health economics.

Application Effect of Regional Collaborative Diabetic Healthcare Management Model in Diabetic Patients　

GUO Kai，ZHANG Chunyan，QIAN Min，LIAN Wen，TANG Jian，CHENG Wei，ZHOU Zunhai

2019, 22(33): 4099-4104. DOI: 10.12114/j.issn.1007-9572.2019.00.327

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Background　The prevalence rate of diabetes in China is increasing year by year，bringing a heavy economic burden on patients and their families，and the society.However，domestic current diabetes management modes are insufficient and there is still a lot of room for improvement.Diabetic patients' healthcare needs and the recent development of community health centers and hierarchical medical system，make it essential to explore a better diabetes management mode suitable for China's conditions.Objective　To explore the application effect of regional collaborative diabetic healthcare management model in diabetic patients.Methods　A prospective follow-up study was conducted from January to December 2017.The enrolled participants were 198 cases of diabetes from Yangpu Hospital，Tongji University，Yangpu District Changbai Community Health Center，and Yangpu District Jiangpu Community Health Center.According to the preference of treatment modality，they were divided into the experimental group （n=70），and the control group （n=128），treated with 12-month regional collaborative diabetic healthcare management，current treatment consists of mainly community-based management for another 12 months，respectively.Body mass index （BMI），waist-to-hip ratio （WHR），fasting blood glucose （FBG），glycosylated hemoglobin （HbA1c），triglyceride （TG），total cholesterol （TC），high-density lipoprotein cholesterol（HDL-C），low-density lipoprotein cholesterol （LDL-C），and health behaviors （health-related knowledge，regular diet，regular monitoring of blood sugar，and regular exercise） of two groups before and after the intervention were compared.Results　Mean HbA1c in the experimental group was higher than that in the control group before intervention （P<0.05）．After intervention，compared with the control group，experimental group showed lower mean BMI，FBG，TG，and LDL，higher mean HDL（P<0.05），but similar WHR，HbA1c，and TC （P>0.05）．In the control group，FBG，HbA1c，TG，TC，and LDL-C after the intervention were markedly lower，whereas HDL-C was higher （P<0.05）．In the experimental group，BMI，FBG，HbA1c，TG，TC，and LDL-C after the intervention were significantly lower，while HDL-C was higher （P<0.05）．After the intervention，the experimental group showed higher rates of mastering health-related knowledge（67.1% vs 52.3%），eating a regular diet（78.6% vs 44.5%），regular monitoring of blood glucose（71.4% vs 46.1%） and regular exercising（55.7% vs 32.8%） than the control group （χ2=4.058，21.342，11.738，9.818，P<0.05）．Conclusion　Our study indicates that regional collaborative diabetic healthcare management is effective for diabetic patients，which improves the BMI，glycemic and serum lipids control effects as well as the complicance to health behaviors.Overall，it is a beneficial attempt in diabetes management.

Application of Diabetes Management Module in Electronic Contracted Family Doctors Services Management Platform：a Survey in Wuhou District　

WANG Qian，LI Ailin，YI Min，DONG Ting，LI Qixian，LIU Xiaoling，CHEN Zhaoyang

2019, 22(33): 4105-4109. DOI: 10.12114/j.issn.1007-9572.2019.00.518

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Background　With the increasing prevalence of diabetes and the number of diabetic patients，diabetes management in primary care is becoming increasingly arduous.How to further give play to the role of information technology，raise working efficiency，promoting standardized management and management quality has become the aim and objective of diabetes management information construction.Objective　To explore the application of diabetes management module in Electronic Contracted Family Doctors Services Management （ECFDSPM） platform in Wuhou District，Chengdu；to provide basis for further optimizing health management information system，by which type 2 diabetes management procedure in primary care can be standardized and the management quality and efficiency can be improved.Methods　From November to December 2017，a total of 52 family doctor teams with 170 members were selected by random sampling from 13 community health centers in Wuhou District，Chengdu.They received an online survey with a self-designed questionnaire named as Application of Diabetes Health Management Information System，consisting of knowledge，belief and practice （total 6 items） of "health management service specification for type 2 diabetic patients in Wuhou District" and "health management service technical specification for type 2 diabetic patients in Wuhou District"（hereinafter referred to as "Specification"），intention of using diabetes management module （1 item），optimizing requirements of the diabetes management module （1 item for overall optimizing requirement，5 items for clinical path management optimizing requirement，3 items for intelligent decision function optimizing requirement），and subjective selection of health workers responsible for the application of specific diabetes management submodules （total 6 items） in the ECFDSPM system.Results　The survey achieved a response rate of 97.6%（166/170）.Of the respondents，the ratio of general practitioners（GPs） to physician assistants，health promoters and other assistant members was about 4∶4∶1∶1.The rate of knowing the contents of the Specification was 97.0%（161/166），but only 39.2%（65/161） of them thought that the diabetes management module in the ECFDSPM platform was the same as the management pathway in the Specification，and 57.8%（96/166） thought that the module could effectively manage diabetes patients effectively in a standardized way.The rate of intending to use the available diabetes management module was 59.6%（99/166）.In terms of the submodules in the available diabetes management module，90.4%（150/166） reported that they needed diabetes diagnosis submodule （diagnosis，diabetes duration and complication），67.5%（112/166） needed the thyroid palpation submodule，88.0%（148/166） needed the submodule for examining foot pain，temperature and vibration，92.8%（154/166） thought that the evaluation submodules for diabetic complications should be integrated into one，89.2%（148/166） needed the referral submodule，97.6%（162/166）proposed to develop a submodule including the target objectives（glucose，glycosylated hemoglobin，lipid and blood pressure） which could be generated automatically based on the evaluation results of each patient's pervious information，and all of them proposed to develop a comprehensive evaluation submodule，and 99.4%（165/166） proposed to develop a personalized health guidance submodule（dietary，exercise，weight loss，smoking cessation and alcohol limitation prescriptions），generated automatically based on the evaluation results of each patient's pervious information.In terms of healthcare providers responsible for using specific submodules of the diabetes management module，physician assistants were thought to be principal responsible persons for basic information collection by 66.9%（111/166） of the respondents，GPs were thought to be principal responsible persons for disease information collection，health assessment，development of individualized control objectives and individualized health instruction by 56.6%（94/166），79.5% （133/166），85.5%（142/166） and 57.2%（95/166） of the respondents，respectively，and nurses were thought to be principal responsible persons for follow-up services by 72.3%（120/166） of the respondents.The selection of major responsible persons for basic information collection and disease information collection submodules among physician assistants，health promoters and other assistant members were significantly different（P<0.05）.Conclusion　The family doctor teams in Wuhou District generally think that the existing diabetes health management module in ECFDSPM system has certain guiding significance for clinical practice，but it still needs further optimization.And the systematic functions expected to be optimized first are clinical management path and intelligent decision making.

Reliability and Validity of the Chinese Version of the De Jong Gierveld Loneliness Scale　

YANG Bing，GUO Leilei

2019, 22(33): 4110-4115. DOI: 10.12114/j.issn.1007-9572.2019.00.319

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Background　Loneliness has become a common psychological problem in the elderly in China，a population group increasing year by year.Early screening of loneliness can improve the level of mental health and quality of life in the elderly.The UCLA Loneliness Scale is a widely used measurement tool，but its items are many，and the measurement process is time-consuming.In contrast，De Jong Gierveld Loneliness Scale（DJGLS），a scale specially designed for the elderly，has less entries，is time-saving and efficient.Objective　To test the reliability and validity of the Chinese version of DJGLS among rural elderly people in China.Methods　The DJGLS was Chinesized following Brislin's classic model for translation and validation of instruments guidelines for cross-cultural research，including translation，and back-translation，done independently by two translators.Then it was tested in 515 rural elderly people selected from 6 villages（Hongqi，Shangliyuan，Xialiyuan，Chagou，Lifang，Huangjia），Anshan，Liaoning Province between March and June，2018 by use of convenience sampling.General personal characteristics were collected by a self-designed Demographic Characteristic Questionnaire at the same time.This round of survey achieved a response rate of 97.1%（500/515）．Two weeks later，the Chinese version of DJGLS was retested in a convenience sample of 50 out of the 500 respondents.The reliability and validity of the Chinesized DJGLS were analyzed after the retest.Results　The Cronbach' α for the Chinese version of DJGLS，and the two subscales of social loneliness，emotional loneliness was 0.820，0.792，0.737，respectively.The scale's Guttman split-half reliability coefficient was 0.806，test-retest reliability coefficient was 0.889.The content validity index（S-CVI/UA）of scale level was 0.909，the content validity index（I-CVI）of item level ranged from 0.833 to 1.000，and the（S-CVI/Ave）was 0.985.The total scores of the scale were sorted from high to low，and 27%（155 cases，critical value was 7）of the top ranked and 27%（191 cases，critical value was 3）of the bottom ranked were assigned to high，and low score groups，respectively.The average score of each item achieved by the high score group was higher than that obtained by the low score group（P<0.05）．Item-total correlation coefficients ranged from 0.439 to 0.746（P<0.05）．Correlation coefficients of social loneliness，emotional loneliness with the total score were 0.913，0.772，respectively（P<0.05）．By exploratory factor analysis using principal component analysis with varimax rotation，two common factors with eigenvalue >1.000 were obtained，explaining 50.87% of the total variance.The loading values of items were from 0.405 to 0.832.Confirmatory factor analysis showed that，the fit indices were χ2/df=2.479，GFI=0.966，AGFI=0.945，IFI=0.967，TLI=0.956，CFI=0.967，PGFI=0.600，RMSEA=0.054，RMR=0.011.The CAIC for the default model，independence model，and saturated model was 281.993，1 976.182，and 476.164，respectively.The amended standardized regression coefficient ranged from 0.24 to 0.89.Conclusion　The Chinese version of DJGLS has good reliability and validity.It could be used to assess the level of loneliness among China's rural elderly.

Development，Reliability and Validity of a Questionnaire on Doctors' Intention Towards Using the Internet-based Healthcare Delivery Model　

CHEN Xiuyan，ZHANG Yuanni，DENG Guangpu，CHEN Yige，ZHANG Zehao，XU Feng，LI Wenyuan

2019, 22(33): 4116-4122. DOI: 10.12114/j.issn.1007-9572.2019.00.517

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Background　The implementation of Internet-based healthcare is conducive to the innovation of healthcare delivery models to meet residents' growing healthcare needs.However, searching the literature at home and abroad found that there were relatively few studies exploring the use of Internet medicine by doctors. Objective　To develop a questionnaire on doctors' intention towards using the Internet-based healthcare delivery model and to evaluate its reliability and validity.Methods　The initial draft of Questionnaire on Doctors' Intention Towards Using the Internet-based Healthcare Delivery Model（QDIUIHDM） was developed based on the frameworks of UTAUT and VAM models，including 10 dimensions and 27 items.Then，the questionnaire was used in a survey in an accidental sample of doctors from 3-6 pubic hospitals in 3 cities （Guangzhou，Shengzhen，Zhaoqing，1-2 pubic hospitals were sampled from each city） of Guangdong Province from November 2017 to January 2018.According to the survey results，the initial draft of questionnaire was evaluated by reliability analysis and the exploration factor analysis（EFA）.Then the questionnaire was modified in accordance with the analysis results，and was evaluated by confirmatory factor analysis（CFA），and after this，the final draft of the QDIUIHDM was developed.Results　A total of 350 doctors participated in the survey，and 309 of them（88.3%） responded effectively.The Cronbach's α coefficient for the initial draft of QDIUIHDM was 0.912，and for its dimensions ranged from 0.738 to 0.929.The KMO index was 0.914，and Bartlett's test was also acceptable with P<0.001 （χ2=5 227.92），thus EFA can be performed.Eight factors with eigenvalue greater than 1.000 were extracted by principal component analysis，and the cumulative contribution rate of which was 74.764%.Based on the results of EFA and research topic，dimensions of perceived usefulness and perceived effectiveness were incorporated in the perceived benefits dimension，but the dimensions of individual creativity and self-efficacy were retained.Thus the revised initial draft of QDIUIHDM includes 9 dimensions and 27 items.The CFA result showed an acceptable fit with χ2/df=1.682，GFI=0.900，RMSEA=0.047，CFI=0.961，NFI=0.911，IFI=0.962，PGFI=0.742，PNFI=0.783.The factor loading was between 0.638 and 0.894，the squared multiple correlation was between 0.407 and 0.837，the composite reliability was between 0.750 and 0.930，and the average variance extracted was between 0.502 and 0.815.Therefore，there are 9 dimensions in the final draft of the questionnaire：perceived benefits（6 items），perceived complexity of use（3 items），perceived risk （3 items），perceived value
（2 items），social influence（3 items），facilitating conditions（3 items），individual creativity（2 items），self-efficacy
（2 items） and intention-to-use （3 items）.Conclusion　The QDIUIHDM has been proved to be reliable and valid，which can be used to evaluate the doctors' intention toward using the Internet-based healthcare delivery model and its influencing factors.

Delivering Contracted Family Doctor Services in Rural Areas during the Implementation of Health Poverty Alleviation Project：Critical Problems and Recommendations　

WU Lihong，PU Chuan

2019, 22(33): 4123-4127. DOI: 10.12114/j.issn.1007-9572.2019.00.570

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Background　The implementation of health poverty alleviation project in China has entered a critical stage.One of its present difficult task is，how to implement contracted family doctor services（CFDSs） to make comprehensive coverage of CFDSs for poor people in rural areas.Objective　To identify the key problems in delivering CFDSs in rural areas of China，an important initiative for the implementation of the health poverty alleviation project，providing recommendations for further development of CFDSs in such areas.Methods　From August 1 to September 22，2018，the databases of CNKI，Wanfang Data，and VIP were searched for articles published during January 2012 to September 2018 by use of keywords of "rural + family doctor" and "rural +signing a health services contract with a family doctor+ problems/current situation/research".After careful retrieval in accordance with the inclusion and exclusion criteria of this study，18 articles were finally included.Relevant data were extracted following articles reviewing，and key problems during the implementation of CFDSs in rural areas were summarized，of which those needing to be solved most urgently were determined by use of TOPSIS.Results　Sixty-one problems were summarized initially.With reference to the results of further discussion and expert consultation，17 problems were included in the problem database finally.The top three most important problems that need to be solved first are as follows：No.6 problem（insufficient family doctors）（Ci=0.997），No.10 problem（backward informatization construction and lack of information management system）（Ci=0.898），and No.4 problem（unsatisfied capability level of family doctors in rural areas（Ci=0.800）．Conclusion　The most prominent problems existing in the implementation of CFDSs in rural areas are about the delivery system structure of such services.Priorities for future work should be given to primary care workforce construction and intra-regional informatization construction.

Demonstration of Remote TCM Pulse Diagnosis System and Family Doctor Platform Based on Smart Phones　

YANG Guoyu，LEI Chunhong，LI Yuting，GAO Wenyan，LIN Yifan，HU Wenping

2019, 22(33): 4128-4132. DOI: 10.12114/j.issn.1007-9572.2019.00.168

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Relying on modern electronic communication and information technology，the long-distance Traditional Chinese Medicine （TCM） intelligent pulse diagnosis system and mobile family doctor platform based on smart phones are constructed，to carry out remote mobile revisit，and help patients achieve cross-regional TCM syndrome differentiation and treatment，re-visit and mediation prescription.The intelligence pulse diagnosis system and family doctor platform could realize accurate analysis and long distance transmission of pulse presentations；together with synchronal upload of tongue images and medical history，patients could receive tele-consultation，re-consultation，prescription，drug delivery or near-by drug service without leaving their houses.The intelligence pulse diagnosis system and family doctor platform provide a good way to overcome the obstacle of time and space for further consultation of TCM，and is a effective path to implement tele-consultation and family doctor model in the field of TCM.

Roles of County/region-level Medical Centers in Promoting the Implementation of Contracted Family Doctor Services：an Analysis from Perspectives of Value Chain and Stakeholders　

CONG Ziwei，YANG Yang，HUANG Jinling，ZENG Zhirong

2019, 22(33): 4133-4137. DOI: 10.12114/j.issn.1007-9572.2019.00.104

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The development of contracted family doctor services（CFDSs） requires the cooperation and support of each part of the health care system.County/region-level medical centers own large amounts of high-quality local medical resources，and are the leader among the institutions in the local health care system.Moreover，they play important roles in supporting the delivery of CFDSs in the local area.From the perspectives of value chain and stakeholders，we determined their roles in the local development of CFDSs，which are as follows：a platform for providing health care technology supports for the local implementation of CFDSs；a trainer for the local family doctor teams；a supplier of high-quality medical resources for the local family doctor teams；a part of the supply chain ensuring the continuity of CFDSs.So，during the implementation of CFDSs，efforts should be taken to make county/region-level medical centers play their full roles，thereby promoting the synergetic development of both the two.

Mortality and Potential Years of Life Lost Associated with Cancer among Residents from a Community in Shanghai，2010—2016　

XU Hua1，LI Xiaopan，CHEN Yichen，FU Liyun，GU Weigang，YANG Chunli，QIAN Mengcen

2019, 22(33): 4137-4141. DOI: 10.12114/j.issn.1007-9572.2019.00.429

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Background　Cancer mortality rate in China has increased significantly in recent years with vast geographic disparities.Along with accelerated urbanization-induced great changes in living environment and lifestyle，variation has been found in cancer mortality profile in suburban residents，which deserves great attention.Objective　To explore the epidemiological characteristics and trends of cancer associated deaths in a community in Shanghai's Pudong New Area from 2010 to 2016，providing guidances for the development of intervention measures．Methods　This study was conducted between June and November 2018.Data about causes of death during 2010—2016 stemmed from Liuzao Community part of Pudong New Area death records database.Causes of death were coded based on the 2010 International Classification of Diseases （ICD-10），in which codes for cancers range from C00 to C97.Primary outcomes are crude and standardized mortality rate，potential years of life lost （PYLL），PYLL rate and average years of life lost （AYLL）．Results　The crude cancer mortality rate showed a year-over-year increasing trend 〔annual percentage change （APC）=5.44%，Z=2.750，P=0.040）〕．The standardized mortality rate showed an increasing trend during 2010—2013 （APC=13.00%，Z=4.380，P=0.048），in contrast，no obvious changes were observed during 2013—2016 （APC=-4.74%，Z=-1.740，P=0.224）．During 2010—2016，the crude cancer mortality rate was higher among males than that of females （u=5.60，P<0.001）．There was an increasing trend in the crude cancer mortality rate among males （APC=6.79%，Z=3.383，P=0.020）．The increasing trend of standardized mortality rate for males was not statistically significant （APC=1.57%，Z=0.572，P=0.591）．There was no apparent changes in the crude cancer mortality rate for females （APC=1.27%，Z=0.996，P=0.365）．The standardized mortality rate for females showed an increasing trend （APC=7.54%，Z=2.843，P=0.036）．The PYLL，PYLL rate，and AYLL were 2 865.20 person years，11.72‰，and 5.32 years per person，respectively.PYLL showed an increasing trend （APC=6.79%，Z=3.383，P=0.019），but AYLL showed no apparent trend of changes （APC=1.27%，Z=0.996，P=0.394）．Conclusion　There was an increasing trend in the crude cancer mortality and PYLL due to cancer in the study community.The results suggest that we need to improve the implementation of targeted cancer prevention and control programs，and to further promote early detection of cancer in the community.

Spatial Distribution Characteristics and Spatial Autocorrelation Analysis of Budd-Chiari Syndrome in Xuzhou City from 1990 to 2014　

TANG Cheng，ZHU Shuai，CHEN Xiaoxiao，ZHANG Jing，ZHANG Jiawei，LU Zhaojun

2019, 22(33): 4142-4146. DOI: 10.12114/j.issn.1007-9572.2019.00.401

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Background　Budd-Chiari syndrome（BCS） is a general term for various symptoms caused by obstruction of the hepatic vein or inferior vena cava outflow tract.The range of the outflow tract obstruction can be any vessel between the hepatic vein and the inferior vena cava or any vessel between the hepatic vein and the right atrium.The etiology of BCS in China is still unclear.Geographic information systems（GIS） is a comprehensive discipline that combines maps and geo-spatial analysis methods.It is not only used in geography，but also widely used in the study of spatial distribution of diseases.In this study，GIS was used for the first time to describe the spatial distribution and characteristics of BCS patients in Xuzhou area.Objective　To analyze the spatial distribution characteristics and spatial autocorrelation of BCS in Xuzhou from 1990 to 2014，to provide reference for etiological study and prevention of BCS.Methods　The medical records of all newly diagnosed BCS patients in Xuzhou were collected from medical records information system of the Affiliated Hospital of Xuzhou Medical University，Feng Xian People's Hospital，Pei County People's Hospital，Pizhou People's Hospital，Xinyi People's Hospital and Suining People's Hospital.We summarized the personal demographic information of the cases，including name，sex，age，family address，date of hospitalization，diagnosis，etc.The incidence of BCS in Xuzhou area from 1990 to 2014 was counted every 5 years.Based on ArcGIS 10.4 software，global spatial autocorrelation Moran's I index analysis and local spatial autocorrelation Getis-Ord index analysis were used for spatial autocorrelation analysis.Results　From 1990 to 2014，there were 568 newly diagnosed BCS patients in Xuzhou.The incidence of BCS in Xuzhou increased year by year from 1990 to 2014（from 0.08 / 100 000 in 1990—1994 to 0.35 / 100 000 in 2010—2014）．The global spatial autocorrelation analysis of BCS incidence at the town level in Xuzhou area from 1990 to 2014 using Moran's I index was performed.The results showed that P values were all > 0.05，indicating that the spatial distribution of BCS incidence rates in Xuzhou from different time periods during 1990 to 2014 was not significantly correlated（P>0.05）．The results of local spatial autocorrelation analysis using Getis-Ord index showed that high-incidence（"hot spots"） areas of BCS in Xuzhou from 1990 to 1994 were boundary areas between Feng County，Xuzhou southeastern urban areas and Suining County.From 1995 to 1999，the high-incidence areas of BCS were boundary areas between Xuzhou urban areas，Feng County and Pei County，and the low-incidence（"cold spots"） areas were the boundary areas between Pizhou City and Suining County.From 2000 to 2004，the high-incidence areas of BCS were areas surrounding the Weishan Lake in Pei County，and the low-incidence area was southern Suining County.From 2005 to 2009，the high-incidence areas of BCS were areas surrounding the Weishan Lake in Pei County，and the low-incidence areas were boundary areas between Xuzhou urban areas，Feng County and Pei County.From 2010 to 2014，the high-incidence areas of BCS were southeastern Suining County，areas adjacent to the Weishan Lake in Pei County，and Xuzhou urban areas，and the low-incidence areas were eastern Pizhou City，Xinyi City and Feng County.Conclusion　In different time periods during 1990 to 2014，high-incidence areas of BCS in Xuzhou mainly were Xuzhou urban areas，Feng County，Pei County，Suining County and towns polluted by the water of the Weishan Lake，and the low-incidence areas of BCS mainly were Pizhou City and Xinyi City.The high-incidence areas of BCS are mostly in heavy industrial zones and polluted areas，suggesting that environmental pollution and heavy physical work may be the risk factors of BCS.

Blue Rubber Bleb Nevus Syndrome：a Case Report and Literature Review　

PAN Yan，LI Liangping，LI Hanhua

2019, 22(33): 4147-4149. DOI: 10.12114/j.issn.1007-9572.2019.00.052

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Blue rubber bleb nevus syndrome（BRBNS）is a rare disease characterized by multiple venous malformations and hemangiomas in the skin and visceral organs，especially in gastrointestinal tract.Only about 200 case reports were published to date.Due to its low incidence，it is usually misdiagnosed or miss diagnosed.We reported a male BRBNS patient who referred to Sichuan Provincial People's Hospital for recurrent abdominal pain and gastrointestinal bleeding.After relevant auxiliary examinations，we confirmed the diagnosis of BRBNS.The main objective of this case report is to present diagnostic and treatment features of this condition and to help physicians to enhance the awareness of this syndrome.

Isolated Pyogenic Pancreatic Abscess：a Case Report and Literature Review　

MENG Xue，ZHENG Jimin，WANG Yuzhen

2019, 22(33): 4150-4152. DOI: 10.12114/j.issn.1007-9572.2019.00.210

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Isolated pyogenic pancreatic abscess（IPPA） is a relatively rare disease with clinical manifestations of abdominal pain，fever，and elevated white blood cell（WBC）count.In the case of infections such as tuberculosis and salmonella，especially when it is found in diabetic patients，it is necessary to be alert to IPPA.The etiology and pathogenesis of IPPA are still unclear.This article reported a patient who was diagnosed with IPPA in the Department of Gastroenterology of Hebei General Hospital on March 26，2018.The clinical pathological data and treatment process were retrospectively analyzed.It was found that IPPA was easy to be misdiagnosed as pancreatic head cancer or pancreatic cyst.It was considered that it was necessary to combine the abdominal enhanced computed tomography，tumor markers and pathological features of endoscopic biopsy to further confirm the diagnosis of IPPA，so that it could be early diagnosed and treated avoiding misdiagnosis and missed diagnosis.

Acromegaly Caused by Diabetic Ketoacidosis：a Case Report　

NING Lili，SHEN Hong，WANG Lijuan，CAI Hanqing

2019, 22(33): 4153-4156. DOI: 10.12114/j.issn.1007-9572.2019.00.363

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Acromegaly is an endocrine disease due to excessive growth hormone secreted by pituitary adenoma .It is uncommon and physical changes occur gradually，so its diagnosis and treatment are often delayed.The diagnosis and treatment of one patient with acromegaly first diagnosed with diabetic ketoacidosis is analyzed retrospectively.The related literature is reviewed，so as to improve clinicians' understanding of acromegaly caused by diabetic ketoacidosis.

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