Chinese General Practice

Analysis of the Epidemiological Characteristics of Post-stroke Complications and Suggestions for the Optimization of Grass-roots management in Grass-roots Management System　

JIANG Bin

2021, 24(12): 1445-1453. DOI: 10.12114/j.issn.1007-9572.2021.00.420

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Stroke is the leading cause of death among Chinese residents，with the improvement of hospital treatment level，the number of stroke survivors returning to the community is also increasing.This has greatly increased the demand for primary community health services，but also brought great challenges to the grassroots community health services.This article discusses the risk factors of stroke survivors in the community and the epidemiological characteristics of post-stroke complications，the grass-roots management plan after stroke recommended based on evidence or expert consensus，and how to establish and optimize the grass-roots management system after stroke，which aims to improve existing general medical services and provide suggestions and references for building a coordinated grassroots post-stroke management service system.

Comparison and Interpretation of Chinese and British Guidelines about Therapeutic Drugs for Alzheimer's DiseaseZHANG

Xiaolin，ZENG Jiawei1CHEN Xiao，YUAN Gang

2021, 24(12): 1454-1458. DOI: 10.12114/j.issn.1007-9572.2021.00.121

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The clinical symptoms of AD are various，mainly about cognitive function impairment，imposing huge mental and economic burdens on patients and their families.So far，there is no curative treatment for AD.It's widely admitted that acetylcholinesterase inhibitors and memantine could alleviate symptoms of AD，but the clinical efficacy，safety and cost-effectiveness of these drugs are different.To provide safe，effective and inexpensive pharmaceutical treatments for AD，in 2018，China issued the updated Chinese Guidelines for Diagnosis and Management of Cognitive Impairment and Dementia （Ⅱ）：Diagnosis and Treatment of Alzheimer's Disease，with explanation and elaboration of the diagnosis，drug therapies and their clinical efficacies for AD，and the U.K.'s NICE issued Evidence-based Recommendations on donepezil，galantamine，rivastigmine and memantine for the treatment of Alzheimer's disease，with comparative analysis of these common therapeutic drugs for AD in terms of clinical efficacy and pharmacoeconomics.We compared the similarities and differences of drug therapies for AD between these two guidelines，aiming to offer a reference for clinicians or primary care physicians prescribing drugs for AD.

The Interpretation about International Consensus on the Prediction and Identification of Long-term Damage to Survivors of Severe Illness by the Critical Care Medical Association in 2020

YIN Yue，DENG Yufang，SUN Yajun，ZHENG Gaigai，CHEN Shaoru，ZHANG Hongmei，WANG Peixi

2021, 24(12): 1458-1463. DOI: 10.12114/j.issn.1007-9572.2021.00.421

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This paper interprets "International Consensus on the Prediction and Identification of Long-term Damage to Survivors of Severe Illness by the Critical Care Medical Association"，published by the American Society for Critical Care Medical Association in November 2020.On the basis of the second "Improving Long-term Outcomes on Discharging from the Hospital for Intensive Care Survivors：a Report of Stakeholder Meetings" in 2012，three new aspects including how to identify high-risk survivors，which assessment and screening tools to use，and the timing of screening for severely ill survivors have been newly added.Considering the fact that there are no guidelines or consensuses specifically on the prediction and identification of long-term damage of survivors of severe illness，the interpretation of the "International Consensus on the Prediction and Identification of Long-term Damage to Survivors of Severe Illness by the Critical Care Medical Association" was intended to provide practical advice to clinical health care workers in China，hoping to improve the outcome of critical care for survivors of severe illness in this study.

Influencing Factors of Post-load Peak Insulin Level in Newly Diagnosed Type 2 Diabetic Patients　

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

2021, 24(12): 1464-1469. DOI: 10.12114/j.issn.1007-9572.2021.00.059

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Background　The ability of islets to secrete insulin in response to glucose could affect the long-term prognosis of newly diagnosed type 2 diabetes mellitus （T2DM），so studying the associated factors is of vital significance for clinical diagnosis and treatment of newly diagnosed T2DM.Objective　To explore the influencing factors of post-load peak insulin secretion （Imax） in newly diagnosed T2DM.Methods　411 newly diagnosed T2DM inpatients were recruited from Department of Endocrinology，Xiaogan Hospital Affiliated to Wuhan University of Science and Technology from October 2015 to October 2019.Data were collected，including demographics and other observation indicators，blood glucose levels measured at 0，30，60，120，180 minutes（G0，G30，G60，G120，G180） during a 3-hour 75 g oral glucose tolerance test（OGTT），and insulin levels measured at 0，30，60，120，180 minutes（I0，I30，I60，I120 and I180） in a 3-hour insulin response test），and calculated first-phase insulin secretion index（ΔI30/ΔG30 ratio），HOMA-β，and HOMA-IR.The post-load peak blood glucose （Gmax） and Imax were obtained by polynomial curve fitting.By post-load Imax tertiles，the patients were divided into low Imax group （Imax<21.40 mU/L，n=137），medium Imax group （21.40 mU/L≤Imax<48.10 mU/L，n=137） and high Imax group （Imax≥48.10 mU/L，n=137）.The influencing factors of Imax was explored by multivariate Logistic regression.Results　BMI，ΔI30/ΔG30，HOMA-β and HOMA-IR increased with the increment of Imax （P<0.05）.G0，G30，G60，G120，G180，Gmax and HbA1c decreased with the increment of Imax （P<0.05）.Low Imax group had higher proportion of men，and lower prevalence of hypertension and non-alcoholic fatty liver disease than other two groups （P<0.05）.The prevalence of uricemia of high Imax group was higher than that of other groups （P<0.05）.The red blood cell count and hemoglobin of high Imax group were lower than those of low Imax group （P<0.05）.Spearman correlation analysis indicated that Imax was positively correlated with BMI，ΔI30/ΔG30，HOMA-β，and HOMA-IR （P<0.05），while was negatively correlated with G0，G30，G60，G120，G180，Gmax，HbA1c，red blood cell count and hemoglobin （P<0.05）.Multivariate logistic regression analysis showed that gender 〔OR=0.392，95%CI （0.192，0.803）〕，hypertension 〔OR=1.745，95%CI （1.028，2.967）〕，hyperuricemia 〔OR=2.801，95 %CI （1.408，5.587）〕，G0 〔OR=0.679，95%CI （0.504，0.913）〕，G180 〔OR=0.875，95%CI （0.778，0.985）〕，HbA1c 〔OR=0.802，95%CI （0.688，0.935）〕，ΔI30/ΔG30 〔OR=2.394，95%CI（1.725，3.322）〕 and HOMA-IR 〔OR=1.829，95%CI（1.414，2.367）〕 were the influencing factors of Imax in patients with newly diagnosed T2DM （P<0.05）.Conclusion　Fasting blood glucose and HbA1c were negatively correlated with Imax for patients with newly diagnosed T2DM.Gender，hypertension，hyperuricemia，G0，G180，HbA1c，ΔI30/ΔG30 and HOMA-IR may be associated with Imax.Therefore，priority should be given to achieving the target level of HbA1c during glycemic control，which is contributive to improving the ability of islets to secrete insulin in response to glucose.

Characteristic Changes in Different Cognitive Domains in Preclinical Alzheimer's Disease　

YANG Ting，WU Jinsong，HAN Mengyu，FENG Tengyu，YIN Lianhua，HUANG Jia，LIU Zhizhen

2021, 24(12): 1470-1475. DOI: 10.12114/j.issn.1007-9572.2020.00.641

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Background　Alzheimer's disease is accompanied by cognitive decline in preclinical stage，but it is not clear at which stage the significant changes in different cognitive domains appear.Objective　To explore the characteristics of cognitive function changes in different stages of preclinical Alzheimer's disease，to provide evidence for early identification and intervention of cognitive impairment.Methods　Elderly subjects were recruited to participate in cognitive function screening at the Health Management Center，the Second Affiliated Hospital of Fujian Traditional Chinese Medical University from April to June 2019，among whom 34 were found with normal cognitive function（NC group），29 with subjective cognitive decline（SCD group），and 34 with mild cognitive impairment（MCI group） were included for neuropsychological tests，which included Fuzhou version of Montreal Cognitive Assessment（MoCA-F），Lawton Instrumental Activities of Daily Living scale （Lawton-IADL），Geriatric Depression Scale-15（GDS-15），Boston Naming Test（BNT），Rey Auditory Verbal Learning Test（RAVLT），Stroop Color and Word Test （SCWT）.Results　There was no significant difference in the mean score of Lawton-IADL or GDS-15 among the groups（P>0.05）.The mean MoCA score differed significantly across the groups（P<0.001），in particular，MCI group had lower mean MoCA score than other groups（P<0.05）.The mean scores of BNT，RAVLT immediate recall and RAVLT delayed recall varied significantly across the groups（P<0.001），in particular，they were much lower in MCI group were all lower than those of NC and SCD groups （P<0.05）.There was no significant difference in the number of words read correctly in three groups（P>0.05）.The time required to name color，time needed to read words，time needed to name color-words，number of color named correctly and number of color-words named correctly varied significantly across the groups（P<0.05）.Compared with NC group，MCI group took longer time to name color，name color-words and read words，and had less number of correctly named color（P<0.05），and SCD group took longer time to read words，and had less number of correctly named color-words（P<0.05）.MCI group had the least number of correctly named color-words （P<0.05）.Conclusion　Attention and executive function decreased significantly in SCD stage，while language ability and memory function decreased significantly in MCI stage，suggesting that the decline of different cognitive domains may occur in different stages of Alzheimer's disease in preclinical stage.Therefore，clinicians should pay necessary attention to attention and executive function in SCD stage and to language ability and memory function in MCI stage.

Effects of Euthyroid Sick Syndrome on the Long-term Prognosis of Patients with Chronic Heart Failure　

SHI Genling，FANG Hui，DAI Xixi，GAO Mingxi，SU Gong

2021, 24(12): 1476-1481. DOI: 10.12114/j.issn.1007-9572.2021.00.120

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Background　Abnormal metabolism of thyroid hormones is involved in the pathological processes of chronic heart failure （CHF）.However，there are few studies on the long-term prognosis of CHF patients with euthyroid sick syndrome （ESS） in China.Objective　To study the effects of ESS on long-term prognosis of CHF patients.Methods　This study included 304 CHF patients，who were hospitalized in Department of Cardiology，Wusong Hospital of Zhongshan Hospital，Fudan University from January 2017 to June 2019.The general information and laboratory indicators were compared between those with T3 level<1.01 nmol/L and/or FT3 level<3.28 nmol/L（ESS group） and those with T3 level of 1.01-2.48 nmol/L and FT3 level of 3.28-6.47 nmol/L（normal thyroid function group）.Post-discharge follow-up was conducted until June 2020 with all-cause death （including death due to heart failure and non-cardiac death）as the primary endpoint，and readmission due to heart failure as the secondary endpoint.Thyroid hormones 〔T3，FT3，thyroxine （T4），free T4 （FT4），and thyroid stimulating hormone （TSH）〕，B-type natriuretic peptide （BNP），and left ventricular ejection fraction （LVEF）of the survivors were compared with those of the deceased due to all causes，the deceased due to heart failure，and the deceased due to noncardiac causes.The readmission rate due to heart failure，heart failure mortality rate，and all-cause mortality rate between the ESS and normal thyroid function groups were compared，and Kaplan-Meier survival curves were plotted.Cox regression analysis was used to identify the factors associated with heart failure death and all-cause death.Results　There were 164 patients in the ESS group and 140 patients in the normal thyroid function group.The distribution of NYHA class showed significant difference between the two groups （P<0.05）.The mean levels of T3，FT3，FT4，TSH，albumin，and hemoglobin，and LVEF were lower，and mean levels of BNP，C-reactive protein，and creatinine were higher in the ESS group （P<0.05）.In a median follow-up period of 25.7 （interquartile range 14.2） months，there were 46 all-cause deaths （32 due to heart failure，and 14 due to noncardiac causes） and 258 survivors（115 were readmitted at least once for heart failure）.The survivors showed higher mean levels of T3，FT3 and LVEF and lower mean level of BNP compared with the deceased due to all causes，or the deceased due to heart failure （P<0.05）.Those with ESS had higher heart failure readmission rate，heart failure mortality rate，and all-cause mortality rate than those with normal thyroid function（P<0.05）.Kaplan-Meier survival analysis showed that the heart failure mortality rate and all-cause mortality rate of the ESS group were higher than those in the normal thyroid function group （P<0.016）.Cox regression analysis showed that age 〔HR=1.056，95%CI（1.009，1.105）〕，FT3 〔HR=0.564，95%CI（0.325，0.976）〕，hemoglobin 〔HR=0.955，95%CI（0.932，0.980）〕，and LVEF〔HR=0.980，95%CI（0.961，1.000）〕 were associated with heart failure death in CHF patients （P<0.05），and age 〔HR=1.055，95%CI（1.019，1.093）〕，hemoglobin〔HR=0.964，95%CI（0.944，0.984）〕，and LVEF 〔HR=0.979，95%CI（0.963，0.994）〕 were associated with all-cause death （P<0.05）.Conclusion　CHF patients with ESS had poor renal and liver function.Their heart-failure mortality rate and all-cause mortality rate were higher，and their prognosis was poorer than those of CHF patients without ESS.T3 and FT3 levels reflected the severity and prognosis of CHF patients.

Relationship between Serum BMP4 Level and Bone Density in Patients with Type 2 Diabetes Mellitus　

DU Cen，AO Na，YU Jie，YANG Jing，GENG Baochuan，DU Jian

2021, 24(12): 1482-1486. DOI: 10.12114/j.issn.1007-9572.2020.00.583

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Background　BMP4 is a major factor which can promote bone formation and influence insulin secretion.However，few studies have been done regarding the relationship between bone density and serum BMP4 level in type 2 diabetes mellitus （T2DM） patients.Objective　To explore the association between bone density and serum BMP4 level in T2DM patients.Methods　A prospective design was used.T2DM inpatients （n=128） from No.1 Department of Endocrinology and Metabolism，the Fourth Affiliated Hospital of China Medical University were enrolled during January to December 2017.Clinical data were collected，including demographic data，routine laboratory parameters，serum BMP4 detected using ELISA，and bone density （66 with normal and 62 with reduced bone density）.Spearman rank correlation analysis was used to analyze the correlation of serum BMP4 with other indices.Logistic regression was used to determine variables associated with osteopenia.Results　Compared with patients with normal bone density，those with reduced bone density had higher percentage of women，greater average age and longer average duration of T2DM，and lower average BMI，waist circumference as well as BMP4 （P<0.05），but similar average levels of fasting blood glucose，fasting insulin，fasting C-peptide，HbA1c，TG，TC，LDL，HDL，uric acid，and HOMA-IR （P>0.05）.The level of BMP4 had negative correlation with age （rs=-0.262，P=0.003） and positive correlation with BMI （rs=0.205，P=0.020）.Logistic regression analysis showed that BMP4 was independently associated with reduced bone density 〔OR=0.364，95%CI（0.214，0.619），P<0.05〕.Conclusion　The level of BMP4 in serum was significantly decreased in T2DM patients with reduced bone density.Low BMP4 was significantly correlated with advanced age and low BMI.BMP4 was an independent predicted factor of bone density.

#br# Non-motor Symptoms in Early Parkinson's Disease with Three Different Motor Subtypes　

LOU Yue，QIAO Song，WANG Yanwen，CAI Miao，ZHUANG Liying，LIU Xiaoli

2021, 24(12): 1487-1493. DOI: 10.12114/j.issn.1007-9572.2021.00.020

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Background　Parkinson's disease（PD） is a common neurodegenerative disease in the elderly with high incidence，prevalence and morbidity.Patients with PD have variable clinical presentations，including motor and non-motor symptoms.According to motor symptoms，PD can be divided into different subtypes，with subtype-specific pathogenic factors and pathophysiological processes.However，only a few studies have focused on non-motor symptoms of PD，especially early PD.Objective　To explore the relationship between non-motor symptoms and motor subtypes of early PD by analyzing non-motor symptoms such as cognitive function，frontal lobe function，mood and sleep status，and autonomic function by motor subtypes in early PD patients.Methods　One hundred and sixteen neurology outpatients and inpatients with early PD from Zhejiang Hospital were included between January 2017 to March 2020 and divided into tremor-dominant（TD），postural instability/gait disorder（PIGD），and mixed（IT） groups according to the Movement Disorder Society-Unified Parkinson's Disease Rating Scale.The clinical data，and Motor disorders society-the unified Parkinson's disease rating scale，measurement results of Non-Motor Symptom Scale，Mini-Mental State Examination，Frontal Assessment Battery，Geriatric Depression Scale，Apathy Evaluation Scale，Parkinson's Disease Sleep Scale and Scales for Outcomes in Parkinson's Disease-Autonomic were compared between the three groups.Results　There were 76 cases in TD group, 32 cases in PIGD group and 8 cases in IT group.There were significant differences in frequency and severity of non-motor symptoms among three groups（P<0.05）.The assessed frontal lobe function，depression，apathy and cardiovascular autonomic function of patients between the three groups showed significant differences（P<0.05）.Conclusion　Non-motor symptoms are common in PD，which can appear in the early stage.The non-motor symptoms of PIGD and IT subtypes are more severe than those of TD subtype.The precise motor classification of early PD may facilitate effective assessment of the patient's status and prognosis in clinical practice，as well as the formulation of an appropriate treatment regimen.

Peripheral Blood Leukocytes in Patients with Functional Dyspepsia　

LI Nijiao，YAO Shukun，XU Weihua，ZHANG Yanli

2021, 24(12): 1494-1499. DOI: 10.12114/j.issn.1007-9572.2021.00.119

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Background　Functional dyspepsia （FD） is a common and frequently-occurring digestive disease in China.Previous studies paid little attention to the clinically measured peripheral blood indicators of patients.Objective　To observe and analyze the differences of peripheral blood leukocytes between FD patients and normal healthy people.Methods　We enrolled 172 cases from China-Japan Friendship Hospital from 2016 through 2018，including 87 outpatients with a definite diagnosis of FD from Department of Spleen and Stomach Diseases，and 45 normal health people（consisting of workers and physical examinees in this hospital）.We collected and compared the values and rates of abnormalities of peripheral blood leukocyte count，neutrophil count，neutrophil percentage，eosinophil count between the groups，and conducted a sex-based analysis of white blood cells between the groups.Results　The proportion of women in FD group was higher than that in control group（P<0.05）.Abnormal leukocyte counts were found in 15 FD patients and one control，which were slightly lower than the normal reference range.Abnormal neutrophil percentage was found in 16 FD patients and one control，which was also slightly lower than the normal reference range.Abnormal percentage of neutrophils was detected in four FD patients（decreased slightly in one and elevated slightly in three） and three controls（slightly decreased in two and slightly elevated in one）.Abnormal eosinophil count was found in two FD patients and one control，all elevated slightly.FD patients had higher rate of abnormalities and lower average level of white blood cell count（P<0.05）.Moreover，they also had higher rate of abnormalities and lower average level of neutrophil count（P<0.05）.The average levels of leukocyte and neutrophil counts in female FD patients were significantly lower than those of female controls（P<0.05）.Conclusion　PD patients，especially female PD patients，may be more prone to abnormalities and decline in leukocyte and neutrophil counts.

Prevalence and Influencing Factors of Comprehensive Disability in the Elderly in Henan Province　

ZHU Chunyan，GUO Qing，TIAN Qingfeng，LIU Xiaoguang，ZHANG Qian

2021, 24(12): 1500-1505. DOI: 10.12114/j.issn.1007-9572.2021.00.169

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Background　The 14th Five-Year Plan period （2021—2025） is a rapid stage of aging，and a crucial development period of aging-related industries and elderly care system in China.Henan Province has a large elderly population with urgent demand for elderly care services.Objective　To investigate the prevalence and influencing factors of comprehensive disability in the elderly in Henan Province.Methods　This survey was implemented from January to September 2019.By use of multi-stage stratified cluster random sampling，adults aged 60 and above were selected from Henan Province for a survey.They were asked to fill in questionnaires Demographic Information Form developed by our research team and the Ability Assessment for Older Adults（MZ/T039-2013） onsite.For those who could not write，investigators did that for them after acquiring relevant information via a detailed interview.Ordinal and multinomial logistic regressions were used to identify factors associated with disability.Results　Altogether，5 570 of the 6 014 cases who gave effective responses to the survey were finally enrolled.Among them，the prevalence of intact comprehensive ability，and different levels of comprehensive disability was 49.55%（2 760/5 570），and 50.45%（2 810/5 570），respectively.To be specific，the prevalence of mild，moderate and severe disability was 41.14% （2 291/5 570），6.10%（340/5 570） and 3.21%（179/5 570），respectively.The prevalence of disability in activity of daily living，mental status，sensory and communication，and social involvement was 20.45% （1 139/5 570），35.89% （1 999/5 570），23.34% （1 300/5 570），and 19.48% （1 085/5 570），respectively.The level of comprehensive disability varied significantly by sex，age，place of residence，education level，living status，income，developmental physical or mental disability，dementia prevalence，mental illness prevalence and the prevalence of accidental events within 30 days prior to the survey （P<0.05）.Logistic regression analyses found that age〔60~ years old：OR=0.115，95%CI（0.075，0.177）；70~ years old：OR=0.154，95%CI（0.101，0.236）；80~ years old：OR=0.323，95%CI（0.209，0.498）〕，education level〔Illiterate / semi illiterate：OR=2.911，95%CI（2.337，3.626）；primary school：OR=1.873，95%CI（1.519，2.310）；junior middle school：OR=1.545，95%CI（1.244，1.918）〕，living status〔live alone：OR=0.521，95%CI（0.373，0.727）；living with spouse：OR=0.452，95%CI（0.338，0.604）；living with children：OR=0.534，95%CI（0.396，0.719）〕，income〔0~：OR=2.306，95%CI（1.172，4.539）；4 001~：OR=2.939，95%CI（1.340，6.444）〕，prevalence of developmental physical or mental disability〔OR=0.257，95%CI（0.214，0.310）〕，dementia prevalence〔OR=0.030，95%CI（0.022，0.041）〕，mental illness prevalence 〔OR=0.190，95%CI（0.126，0.286）〕and the prevalence of accidental events within 30 days prior to the survey〔OR=0.163，95%CI（0.134，0.198）〕 were associated with the level of comprehensive disability （P<0.05）.Conclusion　The prevalence of comprehensive disability in older adults in Henan Province was over than 50%，and mild comprehensive disability made up the largest percentage.Age，education level，living status，income，developmental physical or mental disability，dementia，mental illness，and accidents within the past 30 days influenced the level of comprehensive disability.

A Systematic Meta-synthesis of Qualitative Research on Factors Influencing Pre-diabetics' Attitudes toward Pre-diabetes and Lifestyle Changes　

LI Rui，LIU Fangli，CHEN Xia，WANG Ying

2021, 24(12): 1506-1511. DOI: 10.12114/j.issn.1007-9572.2021.00.004

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Background　Studies at home and abroad have shown that effective intervention can reduce the risk of type 2 diabetes in pre-diabetics.Therefore，timely detection of pre-diabetes population and giving them effective management and intervention are the key to reducing the prevalence of diabetes.Objective　To systematically review and synthesize qualitative research on factors affecting the attitudes toward prediabetes and lifestyle of patients with prediabetes，providing evidence for hospitals，communities and families to offer continuing care for this population.Methods　Qualitative studies in English about factors associated with pre-diabetics' attitudes toward prediabetes and lifestyle were searched in databases of PubMed，EMBase，Cochrane Library and Scopus，and those in Chinese were searched in databases of CNKI，Wanfang Data and VIP，from inception to June 2020.Literature screening and data extraction were performed by two researchers independently.Quality assessment was conducted using the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses.Meta-synthesis was carried out to synthesize the results.Results　A total of 8 studies with B level were included.34 themes derived from repeated review were grouped according to their similarities to form 9 categories，which were then synthesized into two findings:（1） The attitudes to prediabetes in pre-diabetics were between two extremes:caring about the disease too much and too little.（2） Prediabetes patients encountered various facilitators or obstacles to healthy life promotion in the process of changing lifestyles.Conclusion　To enhance the attention to prediabetes and actively promote lifestyle changes in pre-diabetics，related departments and professionals should strengthen the public education of prediabetes，and encourage people at high risk of diabetes to screen diabetes.Moreover，medical workers should develop good physician-patient relationships，improve their knowledge about diabetes，and guide pre-diabetics to develop a healthy lifestyle，as well as provide them with targeted diabetes education and healthy life programs.

Differential Analysis of Ultrasonographic and Intraoperative Characteristics between Focal Subacute Granulomatous Thyroiditis and Papillary Thyroid Carcinoma　

WEN Ya，LIU Jingjing，LIU Liping，YAN Xiaohui，LI Xiaoyu，XIN Yuwei，BI Yanjing

2021, 24(12): 1512-1516. DOI: 10.12114/j.issn.1007-9572.2021.00.006

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Background　Since the ultrasonographic findings of both focal subacute granulomatous thyroiditis（FSGT） and papillary thyroid carcinoma（PTC） have much in common，which implies that clinical misdiagnosis could happen and that may result in unnecessary surgeries upon patients.Objective　This study is aimed at enhancing the sonographers' differential diagnosis ability in recognizing FSGT through differentially analyzing the ultrasonographic appearance between FSGT and PTC.Methods　A retrospective study was conducted.Participants were recruited from First Hospital of Shanxi Medical University，including 18 with postoperatively pathology-confirmed FSGT（23 thyroid nodules in total） treated between January 2013 and July 2019，and 63 with PTC confirmed by repeated postoperative pathology tests （70 thyroid nodules in total） treated from February 2017 to October 2019.Characteristics of routine ultrasonography were collected，including echoes，internal structure of nodules，homogeneity of echo intensity，nodule margin，Adler grade of blood flow in thyroid nodules，anteroposterior-transverse ratio，and punctate hyperechogenic foci.Besides，intraoperative nodule conditions were also collected，including adhesion or invasion of the nodule capsule，nodule texture，and the relationship between the nodule and peripheral thyroid glands.Results　There were no significant differences in echoes，homogeneity of echo intensity，Adler grade of blood flow between FSGT and PTC nodules（P>0.05）.The prevalence of anteroposterior-transverse ratio ≤1 was higher and that of punctate hyperechogenic foci was lower in FSGT nodules（P<0.05）.There were no significant differences in adhesion or invasion of the nodule capsule，and the nodule texture（P>0.05），FSGT nodules had higher prevalence of having a more evident boundary with surrounding thyroid glands（P=0.003）.Conclusion　Although FSGT and PTC possess similar ultrasonographic characteristics，but FSGT nodules may have higher prevalence of anteroposterior-transverse ratio ≤1 and lower prevalence of punctate hyperechogenic foci.Therefore，a comprehensive analysis should be implemented during clinical work to exclude the possibility of painless FSGT，and fine needle aspiration is indispensable to prevent patients from misdiagnosis and unnecessary surgeries.

Liver Carcinoma-related Mortality and Potential Years of Life Lost among Residents in Pudong New Area of Shanghai between 2002 and 2019　

CHEN Yichen，QU Xiaobin，SUN Lianghong，LI Xiaopan，CHEN Hanyi，CHEN Hua，ZHOU Yi，XIAO Shaotan

2021, 24(12): 1517-1522. DOI: 10.12114/j.issn.1007-9572.2021.00.116

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Background　Liver carcinoma is a common digestive malignancy worldwide.There is still lack of epidemiological data of liver carcinoma-related deaths of residents in Pudong New Area.Objective　To explore liver carcinoma-related mortality and potential years of life lost（PYLL） among residents in Pudong New Area of Shanghai between 2002 and 2019，to provide a reference for the development of targeted interventions.Methods　Data of people who died of liver carcinoma （ICD-10 C22） during 2002—2019 were collected from Pudong New Area' Residents Death Surveillance Database with death causes classified by the ICD-10.The crude mortality rate，age-standardized mortality rate，PYLL，rate of PYLL，average PYLL，age-standardized PYLL，and age-standardized PYLL rate were calculated and used to analyze the deaths and PYLL from liver carcinoma.The tendency of mortality and PYLL were estimated by annual percent change （APC）.Results　During 2002—2019，12 522 cases died of liver carcinoma in Pudong New Area，with 25.38/100 000 and 12.29/100 000 as the average annual crude mortality rate and average annual standardized mortality rate，respectively.Both the crude mortality rate and the age-standardized mortality rate of liver carcinoma declined over the years （APC=-1.88%，Z=-12.468，P<0.001；APC=-4.71%，Z=-10.601，P<0.001）.And these two indicators also showed a downward trend either among males or females （P<0.001）.The crude mortality of liver carcinoma declined over years for those aged 15-59 and those aged 60-79 （P<0.001），but kept stable for those over 80 years old （P=0.053）.The PYLL of liver carcinoma was 98 580 years，the PYLL rate was 2.00‰，the average PYLL was 7.87 years per person，age-standardized PYLL was 61 767 years and age-standardized PYLL rate was 1.25‰，respectively.The PYLL rate，age-standardized PYLL rate and average PYLL due to liver carcinoma on total showed a downward trend during 2002 to 2019（P<0.001）.However，the trend of average PYLL kept stable between 2002 and 2010 （P=0.853）.The PYLL，PYLL rate，average PYLL，age-standardized PYLL，and age-standardized PYLL rate of liver carcinoma were 81 126 years，3.29‰，9.20 years per person，50 225 years and 2.04‰，respectively，among males，and were 17 454 years，0.71‰，4.72 years per person，10 942 years and 0.44‰，respectively，among females.All the above-mentioned 5 indicators of males were higher.Conclusion　The crude mortality rate and age-standardized mortality rate of liver carcinoma in Pudong New Area showed a tendency to descend during 2002—2019，but still caused severe life loss.More attention should be paid to the harm of liver carcinoma to males and the aged population over 80 years old.So interventions should be delivered according to the conditions of different populations：priority should be given to improving liver carcinoma-related behavioral risk factors to reduce the harm of this disease in males，and should be given to hospice care and supportive care to improving survival status in aged liver carcinoma patients.

Age-specific Prevalence and Risk Factors of Impaired Fasting Glucose：an Analysis Based on Chronic Disease Surveillance Data in Zhenjiang City from 2011 to 2017　

GU Xiaoyong，JIANG Fangping，WANG Hongyu，XU Lu，HE Jiajia

2021, 24(12): 1523-1533. DOI: 10.12114/j.issn.1007-9572.2021.00.083

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Background　Available studies mainly focus on the epidemiological indicators of diabetes，but inadequately evaluate the prevention and treatment effect for diabetes as well as its prevalence using a time-trend analysis.Moreover，there is few studies about age-specific prevalence and risk factors of impaired fasting glucose（IFG）.Objective　To analyze age-specific prevalence and risk factors of IFG and the development trend in Zhenjiang City from 2011 to 2017 using the chronic disease surveillance data.Methods　This study was conducted from June 2011 to December 2017.We retrospectively analyzed the chronic disease surveillance data from 2011 to 2017 of Zhenjiang City，which were obtained via questionnaire survey，physical examination and laboratory examination.Age-specific and standardized prevalence as well as risk factors of IFG and their trend during the period were analyzed.Results　A total of 29 400 testees to the questionnaire were extracted，and 130 of them（0.46%）were excluded，other 28 408 cases（96.63%）were finally enrolled，including 3 953，3 482，4 259，4 270，4 203，4 039，and 4 202 cases for 2011，2012，2013，2014，2015，2016，and 2017，respectively.The prevalence of IFG showed a downward trend in male residents aged 45-59 from 2011 to 2017〔annual percent change（APC）=-6.92，95%CI（-12.50，-1.00），P<0.05〕，as well as in male residents aged 60 or over from 2014 to 2017〔APC=-15.71，95%CI（-26.50，-3.30），P<0.05〕.The overall standardized prevalence of IFG showed a downward trend in all of the residents〔APC=-3.18，95%CI（-5.90，-0.40），P<0.05〕，as well as in all of the male residents〔APC=-5.26，95%CI（-9.50，-0.80），P<0.05〕. The standardized prevalence of IFG also showed a downward trend in male residents aged 60 or over from 2014 to 2017〔APC=-16.23，95%CI（-28.20，-2.30），P<0.05〕.During 2011 to 2017，there were no significant differences in prevalence rates of smoking and passive smoking，as well as vegetable intake frequency at least 4 days per week（P>0.05）.The prevalence rates of drinking，good and very good sleep quality，basically unchanged body weight within the year prior to the survey，overweight，systolic blood pressure less than 130 mm Hg，and diastolic blood pressure less than 85 mm Hg，having breakfast at least 5 days per week，having fruits at least 4 days per week showed an upward trend（P<0.05），while those of time spending in specific sedentary behaviors less than 4 hours per day，obesity and central obesity showed a downward trend（P<0.05）.The prevalence rate of IFG related risk factors showed significant differences in different age groups.Conclusion　The prevalence and risk factors of IFG were partly under control in Zhenjiang City from 2011 to 2017，especially in male residents aged 60 or over，indicating that the community interventions for IFG have obtained initial achievements.In the delivery of related interventions further，priority should be given to young and middle-aged people，and the interventions should be changed timely by age group，IFG prevalence and risk factors at a point of time .

Relations of Body Adiposity Index and Normal Weight Obesity with Metabolic Syndrome and Its Components：a Cross-sectional Study Based on Community Residents Living in Shenhe District，Shenyang City　

LIU Yuyan，LI Yongfang，HE Jing，MA Ping，YU Luyang，SUN Guifan

2021, 24(12): 1534-1540. DOI: 10.12114/j.issn.1007-9572.2021.00.067

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Background　The prevalence rate of metabolic syndrome（MS）is relatively high in Northern China. Body adiposity index（BAI），a new indicator for estimating body fat，and normal weight obesity（NWO）have been proved to be correlated with MS and its risk factors. However，there is few reports about relations of BAI and NWO with MS in Northern China. Objective　To examine the relations of BAI and NWO with MS and its components based on a survey of community residents living in Shenhe District，Shenyang City. Methods　By cluster random sampling method，we extracted 2 338 community residents who participated in local health survey from April to June，2015，in Shenhe District，Shenyang City. Anthropometric and metabolic indices，as well as life behavior factors were analyzed. Multivariate Logistic regression analysis was used to analyze the relations of BAI with MS and its components. Results　After adjusting for age，smoking and alcohol use，multivariate Logistic regression analysis results showed that，BAI was significantly related to MS，central obesity and elevated TG in male community residents（P<0.001），and was significantly related to MS，central obesity，elevated blood pressure，elevated FBG as well as elevated TG in female community residents（P<0.05）. In male community residents，compared to those with normal weight and BAI≥26.1，those with normal weight and BAI<26.1 showed lower risk of MS，central obesity，and elevated TG，those with overweight and BAI≥26.1 showed higher risk of central obesity，those with obesity and BAI<26.1 showed higher risk of elevated blood pressure，and those with obesity and BAI≥26.1 showed higher risk of MS（P<0.05）. In female community residents，compared to those with normal weight and BAI≥29.2，those with normal weight and BAI<29.2 showed lower risk of MS，central obesity and elevated TG，those with overweight and BAI<29.2 showed higher risk of elevated blood pressure and lower HDL-C，those with overweight and BAI≥29.2 showed higher risk of MS，central obesity and elevated blood pressure，those with obesity and BAI<29.2 showed higher risk of lower HDL-C，those with obesity and BAI≥29.2 showed higher risk of MS，central obesity，elevated blood pressure，elevated FBG and elevated TG（P<0.05）. Conclusion　The MS prevalence rate is relatively high in this group of participants〔which is 50.4%（386/766）and 46.6%（733/1 572） in meles and females，respectively〕，which is associated with BAI. The risk of MS was higher in residents with NWO（evaluated by BMI and BAI）than that of those without，but the risk was similar in those with obesity and overweight. Regular evaluation of BAI may be a good method for monitoring obesity and preventing MS.

Hospice Care Resource Utilization Related to Cancer Management and Hospice Care Physicians and Nurses' Occupational Satisfaction：a Survey from Community Healthcare Institutions in Shanghai's Central Districts　

YANG Sen，ZHAO Huaxin，NIU Xiaomin，CHEN Chen，ZHANG Wenjing，GE Xuhua3，LU Yuan3，MA Le，SHI Xiaoxiao,YU Dehua

2021, 24(12): 1541-1545. DOI: 10.12114/j.issn.1007-9572.2021.00.138

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Background　Hospice care has been implemented in Shanghai for over 30 years，and currently it can be accessed from all the community health centers（CHCs）（n=246） in the city.Actions taken in these years by Shanghai such as pilot projects promotion，development of standards for hospice care and hospice care-related trainings for medical workers，have promoted the sustainable，standardized and efficient development of hospice care.Objective　To investigate hospice care resource use related to cancer management and hospice care physicians and nurses' occupational satisfaction based on a survey in community healthcare settings in Shanghai's central districts Methods　This survey was conducted from March to September 2019.From seven central districts（Huangpu District，Xuhui District，Yangpu District，Putuo District，Jing'an District，Changning District and Hongkou District） selected by simple random sampling，14 CHCs delivering hospice care as the pilot institutions were extracted by stratified sampling，from which 42 hospice care physicians and nurses were sampled by use of simple random sampling.Data about hospice care resource use，such as occupancy rate of hospice beds，average length of hospice care per capita，average medical expense per capita and average daily medical expense per capita in the hospice care center were collected from the 2018 health statistics and financial statements of these CHCs.A self-developed questionnaire named Hospice Care Physicians and Nurses' Occupational Satisfaction in Shanghai's Pilot Institutions for Hospice Care，involving general demographics，occupational satisfaction（evaluated in terms of salary and welfare，career development，professional identity，turnover intention，peer relationships，job satisfaction） and associated factors，was used to survey the participants.Results　In 2018，the occupancy rate of hospice beds，average length of hospice care per capita，average medical expense per capita and average daily medical expense per capita in the hospice care center were （48.42±2.34）%，（41.8±3.5） days，（7 632.8±234.7） yuan，（182.6±22.6） yuan，respectively.The average length of home hospice care per capita，average home medical expense per capita and average home daily medical expense per capita were （56.2±7.5） days，（1 371.3±186.4） yuan，and （24.4±4.2） yuan，respectively.Physicians and nurses showed low satisfaction with salary and welfare and career development，but high satisfaction with peer relationships and professional identity in delivering institution-based hospice care.They showed similar satisfaction with delivering home hospice care.The main factors associated with the delivery of institution-based hospice care by physicians and nurses were：the contradiction between heavy workload and low salary，the delivery of hospice care relying on the institution's own operating subsidies without enough special funds，high level of negative emotions and great mental burdens caused by long-term caring dying patients.The major factors associated with the delivery of home hospice care by physicians and nurses were：too much trivial details in care but low payment，insufficient number of hospice care practitioners，and insufficient attentions to home hospice care from all walks of life.Conclusion　The institution-based and home hospice care services delivered by CHCs in central districts of Shanghai may effectively reduce the social and family burden，but there are aspects need to be improved：low occupancy rate of hospice beds，low payment and occupational satisfaction of hospice care physicians and nurses，and unsatisfied referrals for cancer patients with hospice care between medical institutions.

Use of Essential Medicines for Diabetes in Different Levels of Hospitals during the Implementation of Hierarchical Medical System　

ZHANG Xiaomin，CHEN Xiang，CHEN Jiang，BAO Yuyan，YE Aiju，HONG Bing

2021, 24(12): 1546-1551. DOI: 10.12114/j.issn.1007-9572.2021.00.028

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Background　Due to increasing diabetes prevalence year by year，diabetic prevention and treatment have become extremely severe challenges to China，and the associated hierarchical diabetes management is a key part of the ongoing development of hierarchical diagnosis and treatment. Whether diabetes medication services in primary hospitals in which essential medicines make up the largest proportion of medicines can appropriately link up the diabetes medication services in higher level referral hospitals is an important issue that may directly affect the improvement of diabetes prevention and treatment ability and uniformity of diabetic treatments in primary hospitals. Objective　To study the connection of diabetes medication services in different levels of hospitals under the implementation of the hierarchical medical system，and to explore the impact of the implementation of the national essential medicine system on the supply guarantee system of drugs for chronic disease prevention and treatment. Methods　A total of 9 hospitals were selected from Zhejiang，Anhui，and Shaanxi provinces（a provincial tertiary hospital，a county secondary hospital，and a primary hospital were selected from each province）. Drug purchase data were collected from China Medical Economic Information Network of Chinese Pharmaceutical Association from 2016 to 2018. The connection of medication services among three levels of hospitals was studied by comparatively analyzing the forms，specifications，DDDs and costs of antidiabetic drugs and essential antidiabetic drugs and related trend of changes. Results　Overall，it was found that the forms and specifications of essential antidiabetic drugs accounted for 25.58%（33/129） of those of antidiabetic drugs in hospitals in these provinces，and the proportions of DDDs in hospitals of different levels in 2018 were significantly different（P<0.01）. The number of essential antidiabetic drugs of different forms and specifications in terms of DDDs listed in the top 10 was the most in Anhui's hospitals（7） and the least in Shaanxi's hospitals（3）．Comparisons by the level of hospital among provinces showed that the hospital of Anhui had the highest proportion of DDDs and costs of essential antidiabetic drugs（64.08% and 41.49%） at the tertiary level as well as at the primary level（38.11% and 28.77%）. Zhejiang's secondary hospital had the highest proportion of DDDs and costs of essential antidiabetic drugs（40.63% and 35.00%） among the three secondary hospitals. Compared with the three-year growth rate of drug use frequency and sum of money of essential drugs and non essential drugs in different levels of hospitals，except for the growth rate of drug use frequency in Shaanxi Province（P>0.05），the differences of other indicators were statistically significant in Zhejiang Province and Anhui Province（P<0.01）. Conclusion　Our study suggests that the use of antidiabetic drugs differed significantly by region as well as the level of hospitals，the connection of diabetic medication services among different levels of hospitals was unsatisfied，and the essential antidiabetic drugs in primary hospitals could not meet the needs of chronic disease patients，which need to improve urgently.

Survey on the Use of Extended Prescriptions in Chronically Ill Patients in the Community　

NIE Lianlian，MAO Changqing，YANG Xueguang，MIAO Changjun

2021, 24(12): 1552-1555. DOI: 10.12114/j.issn.1007-9572.2021.00.139

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Background　The extended prescription service has been implemented since the extended prescription-related policy was specifically proposed during the comprehensive reform of community healthcare launched in Shanghai in 2015.However，there is a lack of study on the use of extended prescriptions in community-living chronic disease patients.Objective　To explore the use of extended prescriptions and influencing factors in community-living chronic disease patients，to provide a reference for optimizing this kind of services.Methods　A retrospective design was used.By use of cluster sampling，treatment data of chronic disease patients who had received extended prescriptions services from Zhujing Community Health Center of Jinshan District，Shanghai between 2017 and 2018 were extracted from the Health Information System of Jinshan District，Shanghai，and their general demographic information（sex，age，education level and marital status），disease history and medication （number of drug varieties） were obtained from the Residents' Health Records Management System.The use of extended prescriptions services and influencing factors（including problems） in these patients were analyzed.Results　There were 714 chronic disease patients who used extended prescriptions in Zhujing Community Health Center，accounting for 2.19% of the total patients（n=32 666） using prescription services during the two years，most of whom〔83.19%（594/714）〕 were 60 years old or older，and most of their visits were for treating common chronic diseases〔81.55%（707/867）〕，83.05% （593/714） of them had good adherence to extended prescriptions.The percentage of patients with good adherence to medication varied significantly by age，education level，marital status，type of disease，and medication（number of drug varieties）（P<0.05）.Of the total extended prescriptions，the problematic ones accounted for 12.50% （25/200），mainly included nonstandardized prescriptions〔without clinical diagnosis or with incomplete clinical diagnosis（10，5.00%），one treatment course longer than 30 days（6，3.00%），inappropriate drugs for symptoms（5，2.50%）〕 and inappropriate prescriptions〔inappropriate dosage（2，1.00%），inappropriate dosage form or route of administration（2，1.00%）〕．Conclusion　The prevalence of using extended prescriptions in this group is still relatively low.To improve this，it is suggested to strengthen the governmental support and guidance on extended prescription services.

Diagnostic and Therapeutic Analysis of Gitelman Syndrome with Severe Hyponatremia　

MA Fuhui，WANG Xinling，WANG Jing，SONG Xiangxin，GUO Yanying

2021, 24(12): 1556-1559. DOI: 10.12114/j.issn.1007-9572.2020.00.643

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The patient encountered by us had onset symptoms of intermittent limb weakness，accompanied by cough，sputum，and intermittent fever.His laboratory test revealed hypokalemia，hypomagnesemia and low urinary calcium，RASS system activity increased，with severe hyponatremia，lung infection at the same time，he was clinically diagnosed with Gitelman syndrome with SIADH.After being treated by anti-infection，water restriction，sodium and potassium supplementation，his weakness and electrolyte levels except for hypomagnesemia were improved significantly.SLC12A3 gene was detected with D486N monoheterozygous mutation，which confirmed the clinical diagnosis.This case suggests that when severe hypokalemia with hyponatremia occurs，the causes should be actively sought for identification and treatment.To avoid a delayed diagnosis，enough attentions should be paid to considering a variety of causes for diseases that can not be explained by only one factor clinically.

Reflection on the Diagnosis and Treatment of a Case of Cushing Syndrome　

LI Feng，ZENG Xuemei

2021, 24(12): 1559-1563. DOI: 10.12114/j.issn.1007-9572.2021.00.002

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Cushing syndrome （CS） is a condition that is most often caused by abnormally high levels of glucocorticoid secreted by adrenal glands due to various etiologies，which can affect every system of the body，and cause a variety of complications，seriously affecting the quality of life and life span.However，due to complex and various clinical manifestations，CS is prone to missed diagnosis and misdiagnosis.We reported a case of CS caused by adrenocortical adenoma，in which the diagnostic and therapeutic process was detailed，in particular，the reasons for delayed diagnosis were analyzed thoroughly，such as lack of adequate understanding of multiple symptoms of CS，and vigilance for secondary hypertension as well as a comprehensive assessment of the patient's age，sex and physique，and paying insufficient attention to the diagnostic role of routine blood test in CS.Then we proposed that primary care physicians should make efforts to recognize diseases with diverse clinical manifestations，and improve techniques for consultations and comprehensive examinations based on a patient-centered approach to enhance the possibility of making an early diagnosis.Moreover，a series of policy recommendations were put forward to improve the quality of primary health services so that patients with complex symptoms can be diagnosed and treated as soon as possible.

Recent Advances in Home Care Assessment Tools for Stroke Patients　

HE Xingyue，HAO Jiaqi，YANG Hui，CAO Huili

2021, 24(12): 1564-1569. DOI: 10.12114/j.issn.1007-9572.2021.00.107

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Recent studies about home care，a link in continuous care，are increasing in stroke patients as an important type of intermediate care.Community-based home care for stroke patients is developing，focusing on home care assessment systems，patient discharge preparation services，and the development and application of family functions，and so on.However，there are relatively few studies on assessment tools for home care.We introduced the reasons for assessing home care for stroke patients，appropriate assessment time，and specific available assessment tools，aiming to provide the community nurse with a simple and effective tool with high accuracy and specificity for assessing home care for stroke patients to promote the effectiveness of home care，and to offer a theoretical basis for the development of appropriate home care assessment tools.

Advances in the Study of Factors and Treatment of Secondary Daytime Somnolence after Stroke and Its Influence on Prognosis　

WANG Wenyi，CHEN Guang

2021, 24(12): 1570-1574. DOI: 10.12114/j.issn.1007-9572.2021.00.057

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As a ubiquitous sleep disorder，Excessive Daytime Sleepiness（EDS） has become a hot topic in clinical research in recent years due to its close relationship with cardiovascular and cerebrovascular diseases.EDS is very common in stroke patients，it can reduce the life quality of stroke patients，affect cognitive function，and have an important impact on stroke rehabilitation and prognosis.However，compared with other stroke complications，it has not attracted enough attention in clinical practice.The papers reviews the related research progress on the influencing factors and treatment of EDS after stroke and the impact on prognosis in recent years，with a view to clinicians，patients and family members having a thorough and comprehensive understanding and proper response to EDS.

New Advances in the Effect of Continuous and High-intensity Interval Trainings on Blood Glucose Regulation in Type 2 Diabetes　

YAN Zengyin，YAN Pingping，QIN Chunli，LUO Jiong

2021, 24(12): 1575-1580. DOI: 10.12114/j.issn.1007-9572.2021.00.135

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Regular exercise may help to improve blood glucose control，prevent the incidence or reduce the risk of diabetes-related cardiovascular disease in type 2 diabetics.We reviewed the improvement in glycemic control achieved by aerobic exercise，especially the regulation of glycemic level by continuous and high-intensity interval trainings，and summarized that high-intensity interval training regulates the glucose metabolism in skeletal muscle，and reduces fasting blood glucose and glycosylated hemoglobin；moderate-intensity aerobic exercise three times a week（more than 150 minutes in total） is recognized to be the optimal scheme to improve the symptoms of type 2 diabetes，and better effect could be achieved by higher training frequency and greater amount of training within the bearable range；resistance training can enhance insulin effect，but whether it combined with aerobic exercise or high-intensity interval training can yield better effect，which needs to be verified by further studies.

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