January 2020, Volume 23,No.3 Abstracts(A)

 Current Situation and Prospect of Chronic Obstructive Pulmonary Disease Community Management in China CHEN Mingmin1,YE Kangli2,XU Zhijie3,REN Jingjing2*
1.Zhejiang University School of Medicine,Hangzhou 310058,China
2.Department of General Practice,the First Affiliated Hospital,Zhejiang University,Hangzhou 310003,China
3.Department of General Practice,Sir Run Run Shaw Hospital,Affiliated to Zhejiang University School of Medicine,Hangzhou 310016,China
*Corresponding author:REN Jingjing,Chief physician;
【Abstract】 Chronic obstructive pulmonary disease(COPD) has been the third most common chronic disease in China,bringing heavy economy burden to us.However,the primary healthcare management of COPD is still limited,and great improvement is needed.For example,the early screening rate and diagnosis rate of COPD are low,health education is not in place,equipment and drugs are insufficient,drug use is not standard,and the diagnosis and treatment ability of community doctors is poor.In this review,we summarize the current status of the primary healthcare management of COPD,and expound the problems of the primary healthcare management of COPD,and put forward the possible better primary mode of healthcare management,such as general practitioner team management model,hospital-community-family-individual hierarchical diagnosis and treatment model,internet-based patient management model,in order to improve the prognosis and life quality of patients with COPD.
【Key words】 Pulmonary disease,chronic obstructive;Community management;Community medicine;Mode-exporing
Review of Screening Methods for Chronic Obstructive Pulmonary Disease in Primary Care PAN Zihan1,CHI Chunhua1*,ZHENG Jiaqiang2,3
1.Department of General Practice,Peking University First Hospital,Beijing 100034,China
2.Institute of Applied Health Research,University of Birmingham,Birmingham B15 2TT,UK
3.General Practice Development and Research Center,Peking University Health Science Center,Beijing 100191,China
*Corresponding author:CHI Chunhua,Chief physician,Professor,Doctoral supervisor;
【Abstract】 Chronic obstructive pulmonary disease(COPD) has become one of the diseases seriously affecting public health.The latest study showed that the prevalence of COPD amongst 40 years or older people was 13.7% in China,and estimated that there were 99 million COPD patients in China.However,how to identify such huge population and manage them is a big challenge in China now.Meanwhile,regarding of which screening methods are suitable for primary care has been one of the top questions for research globally in recent years.Currently,screening tools which have been studied more often include screening questionnaires,devices to test peak expiratory flow and microspirometers,and so on.There are also various screening modes,either using the tool alone or in combination.As primary care institutions are important places to manage COPD,this article summarizes the methods of COPD screening in primary care around the world,and discusses the problems and challenges of COPD screening in China's primary care,aiming at providing references for further studying of COPD screening methods suitable for primary care settings in China.
【Key words】 Pulmonary disease,chronic obstructive;Screening methods;Questionnaire;Expiratory peak flow meters;Microspirometers;Primary care;Current status
Review of Risk Factors Screening of Postpartum Depression and Its Interventions LI Yuhong
Nursing College of Anhui Medical University,Hefei 230601,China
【Abstract】 Postpartum depression has severe harms and effect on women themselves,their offspring,families and the society.The high incidence of postpartum depression has gradually attracted the attention of mental health service workers,and it has also become a hot topic in the field of mental health.Starting from the screening,diagnosis and epidemiological characteristics of postpartum depression,this paper mainly introduces and comments on the risk factors,screening tools,and current status of its intervention research at home and abroad.This paper puts forward the current direction of intervention research of postpartum depression in China,in order to provide ideas and enlightenment for the prevention of postpartum depression in women.
【Key words】 Depression,postpartum;Risk factors;Preventive intervention;Review
Establishment of General Practice Department in General Hospitals:a Survey QIU Yan,LIU Ying,REN Wen,QIN Hongli,REN Jingjing*
Department of General Practice,the First Affiliated Hospital,Zhejiang University,Hangzhou 310003,China
*Corresponding author:REN Jingjing,Chief physician;
【Abstract】 Background According to the issue in 2018,general hospitals determined as a standardized residency training base need to set up general practice department in accordance with the requirements in the document.However,to most heads of the department planned to be established,it is a great challenge to establish and manage the general practice department.Objective To survey the establishment of general practice department in general hospitals in China,providing a reference for general hospitals that have not yet built the department.Methods Participants were heads of the general practice department in general hospitals who were recruited from attendees of a general practice conference conducted in China in 2018.A WeChat survey with a self-designed questionnaire was carried out in September 2018,which covered the aspects of basic information of heads of the general practice department,establishment status of general practice department,attitudes toward general practice ward establishment,support for general practice department establishment,and so son.Results Altogether,41 cases handed in responsive questionnaires.Of the 41 hospitals owning general practice department that the respondents come from,23 are in Zhejiang Province,other 18 are in other regions;most(75.6%) were grade A tertiary hospitals;68.3% have established general practice department independently;90.2% have set up the general practice clinic;73.2% had an independent general practice ward;68.3% had successful cooperation between general practice department and other specialties;95.1% had fixed community training base for general practice.Moreover,although the leaders of most (80.5%) hospitals attached importance to general practice development,41.5% of the hospitals had not carried out any general practice research.Furthermore,51.2% of the hospitals developed independent economic indicators for the operation of general practice department.The heads for general practice department in 70.7%(29/41)of the hospitals firmly supported the setting up of the general practice ward.Either the general practice ward was operated independently or not was not associated with perceptions of the necessity of establishing the ward among the heads of the ward(P>0.05).In addition,general practice development achieved strong or relatively strong support from 70.7% of the hospitals,and 75.6% of the provincial or municipal health commissions.Conclusion Most general hospitals have independently established general practice department,and also set up general practice clinic and general practice ward as well as fixed community training base meeting the national criteria.Outpatient teaching is the major pattern of general practice teaching.Some hospitals with general practice ward could carry out featured inpatient teaching.
【Key words】 General practice;Comprehensive hospital;Hospital department;Questionnaires;Data collection
Associations between HbA1c Glycation Index and Risk of Chronic Complications of Diabetes Mellitus ZHONG Yuling1,FAN Haozhi2,ZHANG Ru1,WANG Hongliang3,ZHANG Wei4,TIAN Ting5,WANG Qingqing6,ZHANG Liuxin1,WANG Jie1*
1.School of Nursing,Nanjing Medical University,Nanjing 211166,China
2.The First Affiliated Hospital with Nanjing Medical University,Nanjing 210029,China
3.Gulou District Mofan West Road Community Health Center,Nanjing 210013,China
4.Shanghai Cancer Institute,Shanghai 200032,China
5.Jiangsu Provincial Center for Disease Control and Prevention,Nanjing 210009,China
6.Nanjing Brain Hospital Affiliated to Nanjing Medical University,Nanjing 210029,China
*Corresponding author:WANG Jie,Associate professor,Master supervisor;
【Abstract】 Background HbA1c glycation index(HGI) is a simply and conveniently measured indicator that reflects the level of glycosylated hemoglobin.Its associations with microvascular and macrovascular complications of diabetes have been reported in foreign studies,but have not been well studied in Asian.Objective To investigate the value of HGI in predicting chronic complications of diabetes by examining its associations with multiple chronic complications of diabetes(diabetic nephropathy,diabetic retinopathy,diabetic foot,diabetic neuropathy) in populations from a community of Nanjing,China.Methods Clinical data of 644 diabetic patients who received services from a diabetes management project of a community hospital,Nanjing from April 2015 to January 2018 were collected.Based on the calculated HGI level,they were divided into low HGI group(tertile 1:HGI≤-0.313%),medium HGI group(tertile 2:-0.313%<HGI≤0.160%),and high HGI group(tertile 3:HGI>0.160%).Association of HGI and the risk of chronic complications of diabetes was estimated.Results As the sample size of diabetic foot (only 8 cases) was too small,so only the prevalence rates of other three complications were incorporated in the multivariate Logistic regression model as dependent variables.After adjusting for age,sex,history of alcohol consumption,type of diabetes,BMI,hypertension,hyperlipidemia,coronary heart disease,and HbA1c,Logistic regression analysis showed that high HGI group had a significantly increased risk of chronic diabetic complications〔adjusted OR=2.576,95%CI(1.077,6.164),P=0.033〕,and showed an even higher risk of diabetic nephropathy〔adjusted OR=3.402,95%CI(1.070,10.817),P=0.038〕 compared with low HGI group.But no significant associations of HGI with the risk of diabetic retinopathy and diabetic neuropathy were found(P>0.05).Conclusion The patients with high HGI may be more likely to develop chronic diabetic complications,especially diabetic nephropathy.HGI measurement is expected to be used for personalized assessment and prediction of diabetic nephropathy in diabetic patients in clinic practice.
【Key words】 Diabetes mellitus;Diabetes complications;Hemoglobin A,glycosylated;Hemoglobin glycation index;Diabetic nephropathies
Relationship between Ejection Fraction and the Efficacy and Prognosis of Low-dose Spironolactone in the Treatment of Ejection Fraction-preserving Heart Failure KANG Rui1*,CHEN Ke2,XIE Xiule1,XU Jie1
1.Department Ⅱ of Cardiology,Xinyang Central Hospital,Xinyang 464000,China
2.Ward Ⅱ of Cardiac Arrhythmia,Fuwai Central China Cardiovascular Hospital,Zhengzhou 450000,China
*Corresponding author:KANG Rui,Attending physician;
【Abstract】 Background Ejection fraction-preserving heart failure(HFpEF)is a highly heterogeneous disease involving multiple systems with mild symptoms,but its morbidity and mortality are high and traditional drugs are not effective.Spironolactone is a diuretic commonly used in the treatment of chronic heart failure and has a potassium-sparing effect.Recently,it has been found to play an important role in antiventricular remodeling,which may be related to the patient's left ventricular ejection fraction(LVEF).Objective To investigate the relationship between ejection fraction and the efficacy and prognosis of low-dose spironolactone in the treatment of HFpEF and to provide evidence for clinical treatment of HFpEF.Methods A total of 187 patients with HFpEF diagnosed in the DepartmentⅡ of Cardiology,Xinyang Central Hospital,Henan Province were enrolled from January 2014 to January 2016.Baseline data of patients were collected and they were divided into LVEF 45%-49% group(36 cases),LVEF 50%-54% group(42 cases),LVEF 55%-59% group(49 cases),LVEF≥60% group(60 cases)according to LVEF.All patients were treated with 25 mg of spironolactone for one week on the basis of the original treatment plan at the start of the study.If hyperkalemia were not found in patients,then they would continue to be administered at a dose of 25 mg once daily for 180 days.The efficacy was tested at 3 months after drug withdrawal.The patients were followed up for 30 months and the main endpoint events including death from heart failure,heart failure rehospitalization,and all-cause death in each group were counted.Results In December 2016,one patient in LVEF 50%-54% group was lost to follow-up due to work reasons.In June 2017,one patient in LVEF≥60% group was lost to follow up due to invalid contact.The incidence of myocardial infarction in LVEF 50%-54% group was lower than that in LVEF 45%-49% group,while the incidence of hypertension,diabetes,and the utilization ratio of diuretics were higher than those in LVEF 45%-49% group(P<0.05);the proportion of women,age and the incidence of hypertension,diabetes,and the utilization ratio of diuretics in LVEF 55%-59% group were higher than those in LVEF 45%-49% group,but the diastolic blood pressure,myocardial infarction,and the utilization ratio of angiotensin-converting enzyme inhibition(ACEI)/angiotensinⅡ receptor antagonist(ARB)were lower than those in LVEF 45%-49% group(P<0.05);the proportion of women and the incidence of hypertension,diabetes in LVEF 55%-59% group were higher than those in LVEF 50%-54% group,while the diastolic blood pressure,the incidence of myocardial infarction,the utilization ratio of ACEI/ARB and diuretics were lower than those in LVEF 50%-54% group(P<0.05);the proportion of women,age,Body Mass Index(BMI)and the incidence of hypertension,diabetes in LVEF≥60% group were higher than those in LVEF 45%-49% and 50%-54% group,but the diastolic blood pressure,heart rate,estimated glomerular filtration rate(eGFR),hospitalization due to heart failure within one year,incidence of myocardial infarction and the utilization ratio of ACEI/ARB were lower than those in LVEF 45%-49% and 50%-54% group(P<0.05);the utilization ratio of diuretics in LVEF≥60% group was higher than that of LVEF 45%-49% group(P<0.05)and the proportion of women,age,incidence of diabetes were higher than those in LVEF 55%-59% group,and the heart rate,hospitalization due to heart failure within one year and the utilization ratio of ACEI/ARB were lower than those in LVEF 55%-59% group(P<0.05).The efficacy of LVEF 45%-49% group was better than that in LVEF 55%-59% group and LVEF ≥60% group(P<0.05).The efficacy decreased with increasing LVEF(χ2trend=9.049,P=0.003).LVEF was negatively correlated with efficacy(rs=-0.222,P=0.002).The incidence of primary end point events in LVEF 55%-59% group was higher than that in LVEF 45%-49% and 50%-54% group(P<0.05);the incidence of primary end point events in LVEF≥60% group was higher than that in LVEF 45%-49%,50%-54% and 55%-59% groups(P<0.05).The incidence of re-hospitalization due to heart failure in LVEF 55%-59% group was higher than that in LVEF 45%-49% and 50%-54% group(P<0.05).The incidence of re-hospitalization of heart failure in LVEF≥60% group was higher than that in LVEF 45%-49%,50%-54% and 55%-59% groups(P<0.05).Multivariate Cox regression analysis showed that LVEF,gender,age,history of hypertension,and New York Heart Association(NYHA)classification were the influencing factors of the main endpoints of HFpEF patients(P<0.05),and the LVEF,age,eGFR,and history of myocardial infarction,hypertension and diabetes were the influencing factors of heart failure rehospitalization in patients with HFpEF(P<0.05).Conclusion Patients with HFpEF who have lower LVEF(≤54%)had better efficacy with Spironolactone and lower incidence of major endpoint events and re-hospitalization.
【Key words】 Heart failure;Stroke volume;Spironolactone;Treatment outcome;Prognosis;Left ventricular ejection fraction;Ejection fraction-preserving heart failure
Predictive Value of Psychological Scale Combined with Clinical Data for Non-specific Chest Pain before Coronary Angiography DING Feng1,GUO Lin1,LIU Xi1,ZHAO Xingsheng1*,Siqingaowa1,ZHANG Jie2
1.Department of Cardiology,Mongolia Autonomous People's Hospital,Hohhot 010017,China
2.Department of Endocrinology,Hohhot First Hospital,Hohhot 010020,China
*Corresponding author:ZHAO Xingsheng,Professor,Chief physician;
【Abstract】 Background Non-specific chest pain (NSCP) refers to the patients with chest pain and negative coronary angiography but without identified clear causes of physical disease after repeated examination.Identification of it mainly relies on coronary angiography due to no other effective methods.But coronary angiography is invasive and expensive.We attempted identify NSCP before coronary angiography by studying its characteristics.Objective To identify NSCP before coronary angiography by comparing the clinical data and psychological status of ischemic chest pain (ICP) and NSCP in patients with suspected coronary heart disease and angina pectoris,and evaluating the value of multi-factor prediction model with psychological factors included in distinguishing NSCP from ICP.Methods 239 subjects (78.4%) who completed the above three scales were included in this study.There were 136 cases in NSCP group and 103 cases in ICP group.We enrolled the patients suspected with coronary heart disease and angina pectoris with paroxysmal chest pain as the chief complaint from Cardiac Center,Mongolia Autonomous People's Hospital from July 2016 to March 2017.All of them had indications for coronary angiography and underwent it for the first time.According to coronary angiography and ECG results,we divided them into NSCP group and ICP group,and compared the clinical data as well as mean scores of Somatic Symptom Scale(SSS),Patient Health Questionnaire-9(PHQ-9) and General Anxiety Disorder-7(GAD-7) between the groups.We used multivariate Logistic regression to explore the influencing factors of NSCP,and performed an ROC curve analysis to examine the value of each indicator and the combined predictive variable P in identifying NSCP.Results  239 subjects (78.4%) who completed the above three scales were included in this study.Compared with ICP group,NSCP group had younger mean age,lower percentages of ever smokers and diabetes history,and lower mean TC,but had higher percentages of women and unemployed,and hypertension history (P<0.05).Moreover,NSCP group showed higher mean scores of SSS,PHQ-9 and GAD-7(P<0.05).Logistic regression analysis showed that gender,age,TG,SSS score,PHQ-9 score were the influencing factors of NSCP(OR=0.935,0.235,0.376,1.522,1.204,P<0.05).And the AUC of the aforementioned indices in identifying NSCP was 0.527,0.625,0.564,0.873,0.637,respectively.The AUC of the combined variable P reached 0.921,with≥0.344 as the cut-off value,the sensitivity and specificity of diagnosing NSCP were 0.882 and 0.837,respectively.Conclusion Female,younger age,decreased TG,severe somatic symptoms and depression are high risk factors for NSCP.Among them,SSS has the highest diagnostic accuracy for NSCP.But the combination of multiple indicators can yield even higher accuracy,and can detect NSCP earlier and noninvasively.
【Key words】 Chest pain;Non-specific chest pain;Coronary artery disease;Coronary angiography;Somatoform disorders;Self-rating scale;Multi-factors digital model
Association between Metabolic Syndrome and the Level of High-sensitivity C-reactive Protein in Patients with Schizophrenia YAO Xianhu1,XIA Lei2,LI Wenzheng3,ZHU Mei4,TAO Degang1,LIU Huanzhong2*
1.Department of Psychiatry,Maanshan Fourth People's Hospital,Maanshan 243000,China
2.Department of Psychiatry,Chaohu Hospital of Anhui Medical University,Hefei 238000,China
3.Department of Psychiatry,Hefei Fourth People's Hospital,Hefei 230022,China
4.Clinical Laboratory,Chaohu Hospital of Anhui Medical University,Hefei 238000,China
*Corresponding author:LIU Huanzhong,Chief physician,Doctoral supervisor;
【Abstract】 Background Body immunity is related closely with metabolic abnormalities.Inflammation is involved in the maintenance of homeostasis in multiple metabolic organs and the occurrence of metabolic diseases.However,there are few reports on the relationship between inflammation and metabolic abnormalities in schizophrenia.Objective To explore the association between metabolic syndrome(MS) and the level of high-sensitivity C-reactive protein(hs-CRP) in patients with schizophrenia.Methods This study was based on a cross-sectional design.Inpatients who had schizophrenia for at least 5 years were recruited from Department of Psychiatry,Maanshan Fourth People's Hospital,Chaohu Hospital of Anhui Medical University,and Hefei Fourth People's Hospital during May to December,2018.Among them,those with MS(MS was determined by the recommended diagnostic criteria by the Chinese Diabetes Society) and without were compared in terms of clinical data.The associations of hs-CRP with MS and its components were examined.Results Altogether,322 cases were finally included.The prevalence of MS in all the participants was 16.5%(53/322),and that in male and female participants was 13.6%(26/191),and 20.6%(27/131),respectively.The mean age,and hs-CRP level,as well as the prevalence of abnormal elevated CRP levels(hs-CRP,≥3 mg/L) were higher in those with MS,while the negative symptoms were more severe in those without MS(P<0.05).Correlation analysis showed the level of hs-CRP was positively associated with BMI(r=0.22,P<0.001),systolic blood pressure(r=0.14,P=0.014),diastolic blood pressure(r=0.13,P=0.021),fasting plasma glucose(r=0.14,P=0.014),and triglyceride(r=0.15,P=0.006),and positively associated with high-density lipoprotein cholesterol(P<0.05).Multivariate logistic regression analysis showed older age(OR=1.029,P<0.05) and elevated lg(hs-CRP) level(OR=1.750,P<0.01) were independent risk factors,and higher negative symptoms score(OR=0.957,P<0.05) was a protective factor for MS.Furthermore,the analysis showed patients with elevated CRP levels(≥3 mg/L) had 2.305 times higher risk for MS〔OR=2.305,95%CI(1.186,4.481),P=0.014〕.Conclusion Microinflammatory state is closely associated with obesity,hypertension,hyperglycemia,and dyslipidemia in schizophrenia patients.Elevated peripheral inflammatory markers such as hs-CRP,to some extent,reflect the higher risk of MS.So measurement of plasma hs-CRP level in patients with schizophrenia is beneficial to better assess their metabolic risk profile.
【Key words】 Schizophrenia;Metabolic syndrome X;C-reactive protein;Hypersensitive C-reactive protein;Inflammation
Application of Multimodality Imaging Scoring in Evaluation of Endometrial Receptivity in Patients with Recurrent Spontaneous Abortion JIAO Yan1,2,SHUI Xujuan2,YU Caicha2,HU Chunhong1*
1.Department of Radiology,the First Affiliated Hospital of Soochow University,Suzhou 215006,China
2.Obstetrical and Gynecological Ultrasound Department,Wenzhou People's Hospital,Wenzhou 325000,China
*Corresponding author:HU Chunhong,Professor,Doctor supervisor;
【Abstract】 Background The effective evaluation of abnormal endometrial receptivity has important clinical value for the diagnosis and treatment of recurrent spontaneous abortion(RSA).The quantitative evaluation of endometrial receptivity using multimodality imaging scoring might become a highly practical and feasible method facilitating,the diagnosis and treatment of RSA.Objective To evaluate the value and feasibility of multimodality imaging scoring in the evaluation of endometrial receptivity in RSA patients.Methods 78 RSA patients(RSA group) and 80 women of childbearing age with delivery history and without spontaneous abortion history(control group) from Wenzhou People's Hospital were enrolled from January to December 2018.Intergroup comparisons were made in terms of mean age,BMI and hormone levels,and multimodality imaging score developed by additive summation of the evaluation scores of mid-luteal phase(7-9 days after ovulation) endometrial parameters(endometrial thickness,morphology type and movement examined by two-dimensional gray-scale ultrasound,endometrial-subendometrial blood flow distribution examined by two-dimensional color Doppler ultrasound,and endometrial volume and blood flow examined by three-dimensional ultrasound).Results Both groups had no significant differences in mean age,BMI,and levels of estradiol,progesterone,testosterone,luteinizing hormone,prolactin and follicle-stimulating hormone(P>0.05).RSA group showed lower mean multimodality imaging score than the control group〔(10.3±2.8) vs(14.3±1.5),P<0.05〕.Conclusion The multimodality imaging score is reduced in RSA patients.The multimodality imaging scoring,can be used to evaluate endometrial receptivity of RSA effectively.This method can minimize the differences in subjective judgments made by different operators,which is more objective and has important clinical application value.
【Key words】 Endometrial receptivity;Abortion,spontaneous;Ultrasonography;Ultrasonic multimode;Quantitative scores
Relationship between Depression and Suicidal Ideation in Pregnant Women and Its Risk Factors YANG Wenjiao1,CHEN Yu1*,XIAO Chaoqun2,CHEN Weichen1,GAO Yuanmin1,WANG Jing1
1.School of Nursing,Southern Medical University,Guangzhou 510515,China
2.Department of Obstetrics and Gynecology,Nanfang Hospital,Southern Medical University,Guangzhou 510515,China
*Corresponding author:CHEN Yu,Associate professor;
【Abstract】 Background Antenatal depression is one of the common stress reactions in pregnancy with a high incidence,which affects the health of women and newborns,and the family's quality of life.In extreme cases,self-injury and suicidal ideation and behavior may occur.The research on the depression and suicide ideation of pregnant women has important clinical value of preventing adverse perinatal events and improving perinatal health care.Objective To explore the relationship between depression and suicidal ideation in pregnant women and its risk factors.Methods A total of 448 pregnant women in Nanfang Hospital and Nanhai Hospital of Southern Medical University in Guangdong Province were investigated with the Patient Health Questionnaire(PHQ-9),Social Support Rating Scale(SSRS),Simple Coping Style Questionnaire(SCSQ),Eysenck Personality Questionnaire-Revised Short Scale for Chinese(EPQ-RSC) and Basic Data Questionnaire from January to April in 2018.Spearman rank correlation was used to analyze the relationship between depression and suicidal ideation.Binary Logistic regression was used to analyze the relationship among antenatal depression,suicidal ideation and psychosocial factors.Results The incidence of depression and suicide ideation in pregnant women were 47.8% and 6.9% respectively and there was a positive correlation between them(rs=0.250,P<0.001).The binary Logistic regression analysis showed that unemployment or being housewives,the family income is less than 3 000 yuan,and high score of psychophysical dimension were risk factors for the depression in pregnant women(OR=1.568,1.860,1.539,P<0.05).While the risk factors of suicidal ideation in pregnant women were living in rural area,low level of social support,high score of internal and external dimension and introverted personality(OR=2.703,12.148,5.374,15.550,P<0.05).Conclusion Antenatal depression is positively correlated with suicidal ideation.We should pay attention to screening for serious psychological problems during pregnancy period of a woman,and focus on pregnant women who are unemployed or housewives(without stable occupations),live in rural areas,and have low monthly household income,low level of social support,negative coping styles,high scores in internal and external dimension and psychophysical dimension.
【Key words】 Depressive disorder;Pregnancy;Suicidal ideation;Risk factors
Serum Tenascin-C and Abdominal Aortic Calcification in Peritoneal Dialysis Patients LIU Yuan,SUI Xiaoni,WANG Anyang,WANG Junnan,REN Caixia,WAN Meiyan*
Department of Nephrology,Qingdao Municipal Hospital of Qingdao University,Qingdao 266011,China
*Corresponding author:WAN Meiyan,Chief physician;
【Abstract】 Background Atherosclerotic cardiovascular disease(CVD) is the leading cause of disability and death in patients with end-stage renal disease(ESRD).In recent years,a large number of studies have found that vascular calcification is a key risk factor for CVD in patients with ESRD.Studies on animals and at cell level have found that tenascin-C(TN-C) is involved in the mechanism of vascular calcification,but clinical studies are relatively rare.Objective  To investigate the serum tenosin-C(TN-C) level,abdominal aortic calcification and related factors in patients with peritoneal dialysis (PD),and to analyze their correlation in this population.Methods Eighty patients with continuous ambulatory peritoneal dialysis(CAPD) for more than 3 months in Qingdao Municipal Hospital were selected from September 2017 to October 2018.Their clinical data were collected.The levels of serum TN-C were detected by enzyme-linked immunosorbent assay (ELISA).Abdomen lateral plain was used as a criterion to determine the abdominal aortic calcification.The abdominal aortic calcification score(AACs) was calculated.According to the median TN-C level,the patients were divided into low TN-C group and high TN-C group.According to AACs,the patients were divided into the non- and mild calcification group (0≤AACs≤4 points) and the moderate-to-severe calcification group(>4 points).Logistic regression analysis was used to determine the risk factor of abdominal aortic calcification and TN-C in PD patients.The receiver operating characteristics(ROC) analysis was applied to evaluate the predict value of TN-C in abdominal aortic calcification.Results In this study,the median serum TN-C level was 63.27(60.78,66.56)μg/L,and 40 patients were in the low TN-C group,40 patients in the high TN-C group.There were 66 patients(82.5%) with abdominal aortic calcification,38 patients were in the non- and mild calcification group and 42 patients in the moderate-to-severe calcification group.The dialysis age of patients in the high TN-C group was greater than that in the low TN-C group (P<0.01).The age and dialysis age of patients in the moderate-to-severe calcification group were older than those in the non- and mild calcification group.The proportion of primary diabetic nephropathy in the moderate-to-severe calcification group was higher than that in the non- and mild calcification group(P<0.05).Parathyroid hormone(PTH),serum Ca,TN-C and AACs were higher in the high TN-C group than those in the low TN-C group (P<0.05).PTH,serum phosphorus,alkaline phosphatase(ALP),TN-C,and AACs were higher in the moderate-to-severe calcification group than those in the non-and mild calcification group (P<0.05).TN-C was positively correlated with age,dialysis age,PTH,serum Ca,and AACs levels(rs=0.29、0.41、0.54、0.35、0.73,P<0.01),and negatively correlated with albumin (Alb) levels (rs=-0.23,P<0.05).Logistic regression analysis showed that high serum PTH level〔OR=1.003,95%CI(1.000,1.005),P<0.05〕and high AACs〔OR=1.148,95%CI(1.029,1.282),P<0.05〕 were independent risk factors for high serum TN-C.Abdominal aortic calcification was positively correlated with age,dialysis age,PTH,ALP,serum phosphorus,serum Ca,and TNC levels(rs=0.34、0.39、0.49、0.22、0.25、0.38、0.73,P<0.05),and negatively correlated with Alb level(rs=-0.23,P<0.05).Logistic regression analysis showed that high serum TN-C level〔OR=1.605,95%CI(1.156,2.228),P<0.01〕,senior age〔OR=1.072,95%CI(1.006,1.143),P<0.05〕and high serum phosphate level〔OR=10.407,95%CI(1.480,73.197),P<0.05〕were independent risk factors for moderate-to-severe calcification of the abdominal aorta.ROC-AUC of serum TN-C for moderate to severe abdominal aortic calcification was 0.856,cut-off value 63.87 μg/L,sensitivity 71.4%,and specificity 94.7%.Conclusion The high serum TN-C is positively associated with abdominal aortic calcification.Serum TN-C may play an important role in the initiation and progression mechanism of abdominal aortic calcification in PD patients.
【Key words】 Peritoneal dialysis,continuous ambulatory;Tenascin-C;Vascular calcification
Mediating Effect of Perceived Stress between Self-acceptance and Postpartum Depression among Puerperas LIAO Peipei1,2,LI Yuhong1*,WANG Fengying3,ZHANG Liu1
1.Nursing School,Anhui Medical University,Hefei 230601,China
2.Lianyungang Maternal and Child Health Care Hospital,Lianyungang 222000,China
3.The First Affiliated Hospital of Anhui Medical University,Hefei 230022,China
*Corresponding author:LI Yuhong,Associate professor;
【Abstract】 Background Increased perceived stress may be associated with higher risk of postpartum depression in puerperas.Although high self-acceptance level can reduce the possibility of developing postpartum depression,there are no studies concerning the effect of perceived stress on the relationship between self-acceptance and postpartum depression.Objective To investigate the relationships of perceived stress with self-acceptance and postpartum depression,and the mediating role of the former in the association between the latter two.Methods By use of convenience sampling,300 hospitalized puerperas were recruited from Obstetrics Department,The First Affiliated Hospital of Anhui Medical University during September 2014 to October 2015.The Self-Acceptance Questionnaire(SAQ) was used to evaluate self-acceptance status.The Perceived Stress Scale(PSS) was used to appraise the perceived stress status.The Edinburgh Postnatal Depression Scale(EPDS) was used to examine postpartum depression.Pearson correlation analysis was adopted to analyze the relationships of the three.Bootstrap analysis was performed to measure the mediation effect of perceived stress on the relationship between self-acceptance and postpartum depression.Results The mean scores of SAQ,PSS,and EPDS obtained by the puerperas were(44.2±4.7)(range,31-59),(28.4±3.0)(range,22-40),and(12.5±3.1)(range,5-21),respectively.The incidence of postpartum depression(defined as EPDS score >10) was 39.7%.Self-acceptance level was positively correlated with perceived stress(r=0.206,P<0.01),but negatively correlated with postpartum depression level(r=-0.366,P<0.01).Perceived stress level was positively correlated with postpartum depression level(r=0.185,P<0.05).Perceived stress had mediating effect in the relationship between self-acceptance and postpartum depression.And the effect size was 73.51%.Conclusion Self-acceptance had an indirect effect on postpartum depression by the mediating role of perceived stress.Perceived stress mediated the relationship between self-acceptance and postpartum depression.
【Key words】 Depression,postpartum;Self-acceptance;Perceived stress;Parturition;Mediating effect
Influencing Factors of Community Hypertension Contract Patients Participating in Chronic Disease Health Management JIANG Changyong,YANG Mei,HU Wei*
Jinyang Community Health Service Center of Wuhou District,Chengdu 610041,China
*Corresponding author:HU Wei,Public health physician;
【Abstract】 Background At present,in the health management of chronic diseases at the grass-roots level,the overall participation of patients is not high or they are passive(or even forced)to accept health management,and the quality of management is unsatisfactory.Objective To explore the influencing factors of community hypertension contract patients participating in the chronic disease health management,so as to provide reference for adjusting the health management service means and activating the patients' participation in health management intervention pathway in the next stage of family doctor contract chronic disease health management work,so as to improve the dynamic and potential of patients' participation in health management and enhance the quality of chronic disease management in primary medical institutions.Methods From September 2018 to March 2019,three comparable institutions were selected from 13 community health service centers in Wuhou District of Chengdu City by stratified sampling method,namely Jinyang,huonan and Huaxing community health service centers.In the system of hypertension contract patients,120 patients were randomly selected according to the number of patients' files.The self-made Questionnaire about the Current Situation of Hypertension Contract Patients Participating in Chronic Disease Health Management and Influencing Factors was used to investigate the respondents.The questionnaire mainly includes the basic information of hypertension contract patients and the possible influencing factors of patients' participation in chronic disease health management.Results A total of 360 questionnaires were sent out and 349 effective questionnaires were recovered,with an effective recovery rate of 96.9%.There was no significant difference in the willingness of patients of different genders to participate in chronic disease health management(P>0.05).There were statistically significant differences in the willingness of patients with different age,course of hypertension,marital status,living style,family per capita monthly income,children's situation,special family situation,hypertension diagnosis and classification,current work status,anxiety level,situation of health bulletin boards in the community,situation of health lectures in the community,situation of health education leaflets received by patients,situation of theme parks/streets in the jurisdiction,situation of fitness rooms or sports venues in the jurisdiction,awareness of hypertension,health satisfaction and hypertension treatment expectations to participate in chronic disease health management(P<0.05).Conclusion The influencing factors of hypertension contract patients' participation in chronic disease health management are age,course of hypertension,diagnosis and grading of hypertension,current working condition,anxiety level,personal and family factors(marital status,living style,monthly income per capita of family,children's situation,special family situation),community health supporting factors(health propaganda column in the community,health promotion in the community),health lectures,health education leaflets received by patients,theme parks/streets in the jurisdiction,fitness rooms or sports venues in the jurisdiction,personal health literacy level(awareness of hypertension,health satisfaction,hypertension treatment expectations).In order to activate the initiative of patients and improve the quality of chronic disease management,on the one hand,basic medical institutions need to improve the health literacy of patients by health education,on the other hand,they need the support of all sectors of society,including social security,community construction and medical service delivery system.
【Key words】 Hypertension;Chronic disease;Contracted services of family doctors;Health management;Patient participation;Patient engagement;Root cause analysis
Effect of Health Literacy on Self-management Behaviors in Patients with Hypertension XIE Kuifang,WANG Yuqing,ZANG Xiaoying*
School of Nursing,Tianjin Medical University,Tianjin 300070,China
*Corresponding author:ZANG Xiaoying,Associate professor;
【Abstract】 Background According to the guideline for high blood pressure updated in 2017 by the American Heart Association,more people may be diagnosed with hypertension.High self-management level can better delay the progression of hypertension and prevent hypertension-related complications.Health literacy,an important factor involving in self-management,but its effect on self-management behaviors in hypertension patients has not come to a conclusion.Objective To explore the effect of health literacy on self-management behaviors in patients with hypertension.Methods By use of convenience sampling,hypertension patients were recruited from 3 grade A tertiary general hospitals(Beichen District Hospital of TCM,Tianjin Third Central Hospital,The Second Hospital of Tianjin Medical University),and 4 community health institutions(Wenchang Community Health Center,Sixindao Community Health Station,Machangdao Community Health Center and Xinxing Community Health Center) from July to August 2018.A self-designed general information questionnaire was used to collect the basic data of the patients,including gender,age,height,body weight,place of residence,marital status,household size,course of hypertension,medication treatment,first diagnosis institution,first healthcare-seeking behavior,adherence to drug treatment,main reasons for adjusting drug treatment,drug adjustment following the advice from healthcare workers).The Chinese version of the Health Literacy Management Scale(HeLMS-C),translated and adapted by SUN Haolin based on the HeLMS-C originally developed by Professor Jordan and others from The University of Melbourne,was used to assess the health literary level.Hypertension Patients Self-Management Behavior Rating Scale(HPSMBRS) was used to evaluate self-management behaviors.The relationships of HeLMS-C and its domains with self-management level were analyzed.And the impact of impact of health literacy on self-management behaviors was explored.Results A total of 250 patients participated in the survey,and 248 of them(99.2%) responded effectively.The mean total score of the HeLMS-C was(90.8±10.1).And the mean scores for 4 domains from high to low were(93.6±12.3) for patient attitudes towards their health,(90.5±11.2) for being proactive and using health information,(90.2±15.4) for socioeconomic considerations,and(89.9±13.3) for communication with health professionals,respectively.The mean total score of HPSMBRS was(73.7±14.2).And the mean scores for 6 domains from high to low were(78.4±22.1) for medication management,(77.6±16.7) for emotional management,(74.6±17.3) for rest and work management,(73.7±15.6) for diet management,(67.4±20.9) for condition monitoring,and(64.9±21.9) for exercise management,respectively.The mean total score of HPSMBRS differed significantly by age,place of residence,household size,occupation,prevalence of drinking,history of hypertension,diagnostic institution,first healthcare-seeking behavior,adherence to drug treatment,main reasons for adjusting drug treatment,and drug adjustment status following the advice from healthcare workers(P<0.05).The self-management level was positively associated with the total score of HeLMS-C,and the scores of domains of communication with health professionals,patient attitudes towards their health,and socioeconomic considerations(P<0.05),but had no linear association with being proactive and using health information(P>0.05).Hierarchical multiple regression analysis found that health literacy level contributed 12.7% to the changes in self-management behaviors,in particular,patient attitudes towards their health,and socioeconomic considerations were associated with the changes in self-management behaviors(P<0.05).Conclusion The self-management level of patients with hypertension in Tianjin is moderate.The overall level is mainly affected by factors such as the place of residence,household size,adherence to drug treatment,patient attitudes towards their health,and socioeconomic considerations.To improve the self-management level in such patients,attention should be paid to the improvement of health literacy.
【Key words】 Hypertension;Health literacy;Self-management behavior;Root cause analysis
Influencing Factors of Healthcare Seeking Behavior of Hypertension Patients:an Analysis Based on Anderson's Model MAO Qi1,YU Yi1,LIU Xiaoqiang2,XUE Chengbing2,XU Aijun1*
1.School of Health Economics and Management,Nanjing University of Chinese Medicine,Nanjing 210000,China
2.Jiangsu Health Statistics Information Center,Nanjing 210000,China
*Corresponding author:XU Aijun,Professor;
【Abstract】 Background Hypertension and other chronic diseases have become an important public health problem in China.To understand the behavior of patients with hypertension and its influencing factors is conducive to guiding patients to seek medical treatment orderly and improving the quality of life and health.Objective To explore the influencing factors of healthcare seeking behaviors in hypertension patients using Anderson's model,providing data reference for promoting active and effective use of medical and health services in this group.Methods From August to October 2018,we collected data from the Jiangsu part of the Sixth National Health Services Survey in China,and enrolled 1 953 hypertension patients(≥15 years old)from Jiangsu people who participated in the survey.Using the framework of modified Anderson's model,we explored the influence of contextual characteristics,population characteristics and health behaviors on healthcare-seeking behaviors of hypertension patients.Results The two-week visiting rate in these hypertension patients was 18.69%(365/1 953).Multivariate Logistic regression analysis showed that:time required to arrive at the nearest medical institution from home〔6-10 min:OR=1.448,95%CI(1.045,2.005);≥11 min:OR=1.143,95%CI(0.814,1.606)〕,urban and rural distribution〔OR=0.604,95%CI(0.449,0.813)〕,annual household income per capita〔medium income:OR=0.979,95%CI(0.674,1.421);high income:OR=1.387,95%CI(1.049,1.832)〕,insurance participation 〔basic medical insurance for urban employees:OR=0.502,95%CI(0.200,1.260);basic medical insurance for urban and rural residents:OR=0.705,95%CI(0.529,0.938)〕,self-perceived severity of disease〔general:OR=0.469,95%CI(0.317,0.694);not serious:OR=0.519,95%CI(0.394,0.683)〕 were influencing factors of healthcare seeking behaviors in patients with hypertension(P<0.05).Conclusion Contextual characteristic(time taken to the nearest medical institution from home)and population characteristics(urban and rural distribution,annual household income per capita,insurance participation,self-perceived severity of disease)affect healthcare seeking behaviors in hypertensive patients to different degrees.Therefore,relevant departments should improve the accessibility of medical services and the medical insurance system,focus on the medical services needs of elderly and low-income hypertensive patients,and strengthen the education of hypertension prevention to enhance the health awareness of hypertension patients.
【Key words】 Hypertension;Healthcare seeking behavior;Anderson's model;Utilization of health services;Health services research
Predictive Value Analysis of Framingham Hypertension Risk Prediction Model in Xinjiang Kazakh Herdsmen XU Yuezhen1,2,WANG Jiawei1,LIU Jinbao2,FAN Qiongling1,LUO Yuanyuan1,ZHAN Huaifeng3,WANG Hongjun4,CHEN Rui1,TAO Ning2,YOU Shuping1*
1.School of Nursing,Xinjiang Medical University,Urumqi 830011,China
2.College of Public Health,Xinjiang Medical University,Urumqi 830011,China
3.Shuixigou Central Hospital,Urumqi 830000,China
4.Xiaoquzi Township Hospital,Urumqi 830000,China
*Corresponding author:YOU Shuping,Professor,Master supervisor;
【Abstract】 Background The incidence of hypertension among Kazakh herdsmen in Xinjiang is high,so it is important to find effective methods to assess the risk of hypertension among Kazakh herdsmen and to intervene reasonably to prevent the occurrence of hypertension.Objective To evaluate the accuracy and applicability of Framingham hypertension risk prediction model (hereinafter referred to as Framingham model)in predicting hypertension among Kazakh herdsmen in Xinjiang,in order to provide a reference for the establishment of risk prediction model for hypertension among Kazakh herdsmen in Xinjiang.Methods In January 2008,5 327 Kazakh herdsmen in the Nanshan Pastoral Area of Urumqi County in Xinjiang were selected as research objects by stratified cluster random sampling method to establish the Nanshan dynamic cohort.Baseline data(including questionnaire and physical examination form)were collected,and research objects were followed up every 2 years for 3 times until November 2018,and the outcome event was the development of hypertension.The research objects were randomly divided into model queue(60% Kazakh herdsmen,3 196 cases)and validation queue(40% Kazakh herdsmen,2 131 cases).According to the same method and predictive factors of the Framingham model,the model queue was adjusted and analyzed by the multi-factor Weibull regression analysis,that is,the adjusted model queue was the Framingham model in this study.The discriminatory power and ability of calibration were used to verify the predictive ability of the above Framingham model adjusted according to the data of this study to verify the risk of hypertension in the validation queue.Results As of November 2018,there were 1,985 cases of hypertension among Kazakh herdsmen.A total of 16 897 person-years were followed up,and the incidence of hypertension was 11.75 cases per 100 person-years〔95%CI(11.27/100 person-years,12.24/100 person-years)〕.In validation queue,269 and 562 patients developed hypertension after two and four years of follow-up,respectively.The AUC of the adjusted Framingham model and the original Framingham model for verifying whether hypertension occurred in the validation queue after two years of follow-up were AUC adjusted Framingham model =0.647〔95%CI(0.624,0.670)〕and AUC original Framingham model =0.594〔95%CI(0.571,0.617)〕,and the difference was statistically significant(χ2=5.085,P<0.05).The AUC of the adjusted Framingham model and the original Framingham model for verifying whether hypertension occurred after four years of follow-up in the validation queue were AUC adjusted Framingham model=0.609〔95%CI(0.590,0.628)〕and AUC original Framingham model=0.588〔95%CI(0.569,0.607)〕,and the difference was statistically significant(χ2=3.448,P<0.001).In the adjusted Framingham model and the original Framingham model,the incidence of hypertension in the validation queue was compared with the actual incidence after two years of follow-up,and the Hosmer-lemeshow χ2
(H-L χ2)test values were 697.68(P<0.05)and 802.40(P<0.05),respectively.In the adjusted Framingham model and the original Framingham model,the incidence of hypertension in the validation queue was compared with the actual incidence after four years of follow-up and the H-L χ2 test values were 682.61(P<0.05)and 832.82(P<0.05),respectively.Conclusion The Framingham model has poor ability to distinguish and calibrate the risk of hypertension among Kazak herdsmen in Xinjiang,and it can not predict the risk of hypertension well.It is necessary to build a more suitable hypertension risk prediction model for this population.
【Key words】 Hypertension;Kazakh;Framingham hypertension risk prediction model;Fitting;Xinjiang;Herdsman
General Practitioners' Understanding and Experience of the Leicester Assessment Package in Community:Qualitative Study HAO Lixiao1,JIA Jianguo2,3*,CHEN Lifen2,WANG Ting4
1.Department of Geriatrics,Xuanwu Hospital Capital Medical University,Beijing 100053,China
2.Department of Education,Xuanwu Hospital Capital Medical University,Beijing 100053,China
3.Department of General Surgery,Xuanwu Hospital Capital Medical University,Beijing 100053,China
4.School of General Practice and Continuing Education,Capital Medical University,Beijing 100069,China
*Corresponding author:JIA Jianguo,Professor,Chief physician;
【Abstract】 Background The “New World of Community Health-Community Health and Primary Care Management Training Program” is a key training program for general practitioners(GPs)promoted by the country.The program provides centralized training for 8 GPs in Beijing community through the use of the assessment kit of the Leicester Assessment Scale(LAP)by Hong Kong teachers.It's training effectiveness has important guiding significance for the development of similar programs in the future.Objective To understand the views of GPs in community on LAP,and to provide a reference for the subsequent use of this assessment package in clinical practice.Methods Eight GPs who had participated in the program were interviewed by the focus group interview method from January to March in 2018.Results Five themes were extracted regarding the training feedback,including the approval of training program,the practicality of training content,the diversity of training forms,the influence of training teachers,and the promotion of training program.Regarding the change brought by the training program,two themes were extracted,including the change of concept and the transformation of clinical consultation and teaching methods.Conclusion As an evaluation package in the evaluation system of GPs in clinical practice,LAP has been unanimously recognized by the participants for its practicability and diversity,and can be further promoted and applied in practice.
【Key words】 Community health services;General practitioners;Leicester Assessment Package;Qualitative study
British Journal of General Practice 论文摘要汇编
Evaluation of Position Transition Training Effects on General Practitioners Based on Reaction Level of Kirkpatrick Model QIN Hongli,LIU Ying,REN Jingjing*
Department of General Medicine,the First Affiliated Hospital,Zhejiang University,Hangzhou 310003,China
*Corresponding author:REN Jingjing,Chief physician;
【Abstract】 Background To enrich the team of general practitioners(GPs) and promote the implementation of hierarchical diagnosis and treatment system,position transition training,which is the transitional training form for GPs,was launched nationwide in 2010.In 2017,the First Affiliated Hospital of Zhejiang University began to undertake some training tasks.Objective By evaluating the effects of position transition training on GPs in the First Affiliated Hospital of Zhejiang University based on reaction level of Kirkpatrick model,we aim to gain a full understanding of subjective feelings of the trainees and to find problems in time,finally to provide a reference for the future training.Methods Nine doctors who were trained from September 2017 to August 2018 in the First Affiliated Hospital,Zhejiang University were selected.In June 2018,a questionnaire link was sent to the trainees through the Wechat,and each trainee completed the questionnaire on the Internet.The questionnaire included the basic situation of the trainees,and the evaluation of the transition training base,self-improvement situation,and the current transition training methods.Results Nine valid questionnaires were collected.For the evaluation of the theoretical training,8/9 of the trainees expressed "satisfied" or "very satisfied" with the number of class hours and the teaching level;7/9 of them were "satisfied" or "very satisfied" with the curriculum content.For the evaluation of the clinical training base,more than half of trainees were "satisfied" or "very satisfied" with the length of clinical training (7/9) and its contents(8/9),and all of them were "satisfied" or "very satisfied" with the quality of teaching.For the mastery of general practice theory,all of trainees thought their understanding of general medicine and doctor-patient communication ability had "moderate improvement" or "great improvement";8/9 of them chose "moderate improvement" or "great improvement" for the appropriate technology in general practice.For the evaluation of the clinical comprehensive ability,8/9 of the trainees said that their ability of outpatient consultation had "moderate improvement" or "great improvement".For the evaluation of practical ability in general practice,all the trainees indicated that they had "moderate improvement" or "great improvement" in the diagnosis and treatment of common diseases and the teaching ability of general practice.All the trainees had participated in the teaching activities of general medicine in the First Affiliated Hospital of Zhejiang University,and thought that these teaching activities had improved their comprehensive ability 〔Outpatient consultation ability (9/9),self-study ability (9/9),teaching ability in outpatient clinic (8/9) et al〕.For the overall training effects,5/9 of trainees indicated "satisfied " and 4/9 of them were "very satisfied".For the “Aspects of the GP's position transition training system that need improvement”,7/9 of trainees suggested that the salaries of trainees should be reasonably increased;5/9 of them proposed that training methods should be more flexible and diverse,and meanwhile,they hoped to strengthen the training of clinical skills.And 5/9 of trainees had the contradiction between work and study.All the trainees expressed their willingness to register as GPs after the training,and 8/9 of them were willing to participate in the training that could strengthen GPs' ability in the future.Conclusion The trainees generally have a good evaluation of the training and have improved their comprehensive ability through the training.But at the same time,we find some problems such as the difference in the requirements,lace of flexible training programs,the contradiction between work and study,and the weak organizational management et al.
【Key words】 General practitioner;Position transition training;Kirkpatrick model;Evaluation of reaction layer;Cross-sectional studies


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