April 2020, Volume 23，No12 Abstracts（A）
Author：尹鹏 Source：CGP Published： [03-30] views： 141
Research on the Service Mode of Home Care Medicine in China YAO Nengliang1，2
1.School of Health Care Management/NHC Key Laboratory of Health Economics and Policy Research，Shandong University，Jinan 250012，China
2.School of Medicine，University of Virginia，Charlottesville 22908，USA
【Abstract】 A hospital-centered health care system does not serve the needs of aging population，and fragile and old patients need home-centered medical care.There are very limited number of home care programs in China，and these programs provide skilled nursing，primary care，and therapy services at home，while nurses are the main staff.Four different healthcare modes are provided in home care services，including home bed services represented by community health service centers，door-to-door services represented by public hospitals in transition period，integrated services represented by hospital groups and simple home-based medical services represented by private medical services.These medical institutions provide home-based medical services with different purposes and income patterns，but they all meet the needs of the elderly and the weak.This paper described the current service models of home-based health care in China and the challenges they face in their development process.
【Key words】 Home care；Door-to-door medical care；Home care services；Aging；Community health services
Challenges of Home-based Medical Care in China：a Telephone Interview from the Perspectives of Home Care Providers CHEN Tao1，YAO Nengliang1*，SU Mingzhu1，NONG Sheng2，BAI Meng1，MA Ziyuan1
1.School of Health Care Management/NHC Key Laboratory of Health Economics and Policy Research，Shandong University，Jinan 250012，China
2.Youjiang Medical University for Nationalities，Baise 533000，China
*Corresponding author：YAO Nengliang，Professor，Doctoral supervisor；E-mail：email@example.com
【Abstract】 Background Home-based medical care is a good way to provide older，weak and disability populations with accessible health care in an aging society at abroad.China is promoting the emerging home-based medical care，but many problems during the process need to be solved.Objective This study was to intensively explore the challenges of home-based clinical care in progressing in China from the perspectives of home care providers，offering new ideas for achieving the goals of building a healthy China and for proactively coping with the aging society.Methods A qualitative study was carried out from June 18, 2018 to July 7, 2018 with a phenomenology approach.By use of purposive sampling，14 medical workers with an experience of delivering home care and researchers with an interest in home care were selected from those who participated in the Third International Training on Home Care，and received an in-depth semi-structured telephone interview.The Colaizzi's method was used to analyze the interview data and summarize themes.Results Two major recurring themes of foremost importance were summarized as follows：（1）Problems in the development of home-based medical care：high risks of quality and safety，and insufficient capabilities of providers together with inadequate technology equipments to offer services to meet people's needs of home-based care.（2）External challenges：insufficient supports from laws and statutes，low economic security，and negative impact of the social environment.Conclusion China is facing many internal and external challenges in the development of home-based medical care.To address these challenges，governmental economic and law supports for home-based medical care should be increased，and home-based medical care providers should enhance their professional capabilities to advance the quality of home-based medical care.
【Key words】 Home care services；Home-based medical care；Door-to-door care；Aged；Qualitative research
Citespace-based Visual Analysis of Overseas Research Frontiers and Hot Spots about Home-based Care WAN Meijuan1，SONG Yang2，SUN Xinglan1，WANG Fen1，TAN Yibing3*
1.School of Nursing，Guangzhou University of Chinese Medicine，Guangzhou 510000，China
2.The Second Clinical College，Guangzhou University of Chinese Medicine，Guangzhou 510000，China
3.School of Nursing，Guangzhou University of Chinese Medicine，Guangzhou 510000，China
*Corresponding author：TAN Yibing，Associate professor；E-mail：firstname.lastname@example.org
【Abstract】 Background In China，a country with huge elderly population，accelerated population aging and heavy burden caused by disabilities and chronic diseases，there is a lack of top-level design to cope with aging and the strategic planning is relatively backward.Moreover，hospital-centered medical system can not meet people's healthcare needs.Furthermore，home-based care is still backward and develops relatively slowly in contrast to rapid growth of elderly population，population with disabilities and chronic disease population.Objective To analyze the overseas research frontiers on home-based care in the past 10 years，to identify the research hotspots and frontiers as well as prospect of home-based care.Methods On August 14，2019，using "home-based care" as the subject heading，the database of Web of Science Core Collection was searched for studies regarding home-based care published from 2010 to August 14，2019.Web of Science- and CiteSpace-based analyses，and co-citation analysis of the included studies，as well as co-occurrence analysis of the keywords were performed.Results Overall，
3 216 studies were included，1 311（40.8%） of them were published in the United States，accounting for the largest proportion of the total.The studies showed a trend of annual increase during this period.The top 3 research fields were health care services（549 studies），public environment & occupational health（420 studies），and geriatrics（409 studies）.5 co-citation clusters were derived：heart failure，qualitative study，study protocol，breast cancer patient，and home-based palliative care.Co-concurrence network analysis identified "quality of life"（325 times） as the second high-frequency keywords，next to "care"（395 times）.And "AIDS" had the strongest citation burst.The top 3 key words The top three keywords with highest centrality value were "randomized controlled trial" （0.85），"disease management" （0.73），and "home-based intervention"（0.71）.Conclusion The overseas research topics of home-based care involving multiple fields，mainly focus on quality of life in elderly people，AIDS counselling，home-based palliative care，cost，and home-based heart failure rehabilitation.In a word，overseas research on home-based care is comprehensive，showing a sound and stable as well as constant rapid development，in particular，its development models are constantly being explored.In contrast，home-based care in China is still in the exploratory phase，needing to learn advanced experiences from other countries.Literature review may find that home-based care plays an important role in improving patients' quality of life，chronic diseases rehabilitation，AIDS counseling and testing，and reducing medical cost.
【Key words】 Home care services；Home-based care；Rresearch hotspots；Research frontiers；CiteSpace；Bibliometrics
Influencing Factors of Appropriate Post-discharge Lifestyle in Coronary Stent Implantation Patients WANG Jianhui1，DONG Jianxiu1*，CHANG Wenhong1，CHEN Changxiang2，MA Yi1，ZHANG Hongxin1，HAN Jing1，ZHAO Caijie1，MA Jiahui1
1.Cardiovascualr Department，Tangshan Gongren Hospital，Tangshan 063000，China
2.College of Nursing and Rehabilitation，North China University of Science and Technology，Tangshan 063000，China
*Corresponding author：DONG Jianxiu，Nurse in charge; E-mail：email@example.com
【Abstract】 Background Unhealthy lifestyle is closely associated with the increasing prevalence and mortality of cardiovascular diseases in China.For coronary heart disease treated with coronary stent implantation，an important treatment，the maintenance of therapeutic result requires both medication and changing unhealthy lifestyle.So attention should be paid to post-discharge lifestyle and associated factors in coronary stent implantation patients，to promote the establishment and maintenance of healthy lifestyle.Objective To investigate the influencing factors of appropriate post-discharge lifestyle in coronary stent implantation patients.Methods From July to November 2017，we conducted a questionnaire-based telephone survey in a random sample of 798 coronary stent implantation patients who had been discharged for at least one year from the cardiovascular department of 3 grade A tertiary hospitals from Tangshan，Shijiazhuang and Zhangjiakou，Hebei Province（one from each city） selected by stratified multistage random sampling.The survey covered demographic data，clinical data，and appropriate lifestyle.Appropriate post-discharge lifestyle was assessed by whether following the 5 instructions（regularly monitoring blood lipid，eating heart healthy diet，controlling weight，quitting smoking，and having physical exercise），and was classified into 3 levels（following at least 4 instructions，following 2-3 instructions and following 0-1 instruction）.Multinomial Logistic regression analysis was used to explore the associated factors of appropriate post-discharge lifestyle.Results 798 questionnaires were distributed，798 valid questionnaires were collected，and the effective recovery rate was 100.0%.The prevalence rates of regularly monitoring blood lipids，eating heart healthy diet，losing weight，successful smoking cessation，and having physical exercise were 67.2%（536/798），62.2%（496/798），44.0%（351/798），56.8%（220/387），and 45.5%（363/798），respectively.And smokers still accounted for 20.9%（167/798）of the total.The prevalence rates of following at least 4 instructions，2-3 instructions，and 0-1 instruction were 48.6%（388/798），28.7%（229/798），and 22.7%（181/798），respectively.Gender〔male：OR=1.600，95%CI（1.149，2.228），P=0.005〕，age〔≤40 years old：OR=23.927，95%CI（7.980，71.664），P<0.001；41-50 years old：OR=3.307，95%CI（1.870，5.847），P<0.001〕，returning to work after coronary stent implantation〔no：OR=1.747，95%CI（1.280，2.385），P<0.001〕，number of coronary artery lesions〔single lesion：OR=1.654，95%CI（1.132，2.416），P=0.009；double branch lesions：OR=1.483，95%CI（1.033，2.132），P=0.033〕，disease-related knowledge〔lack：OR=2.340，95%CI（1.701，3.219），P<0.001〕，knowledge of cardiac rehabilitation〔knowing nothing：OR=2.691，95%CI（11.545，4.688），P<0.001；knowing a little：OR=1.745，95%CI（1.083，2.815），P=0.022〕were associated with the level of appropriate post-discharge lifestyle.Conclusion The level of appropriate pos-discharge lifestyle differs significantly across the patients，which is associated with gender，age，returning to work after coronary stent implantation，number of coronary artery lesions，disease-related knowledge，and knowledge of cardiac rehabilitation.Therefore，clinical health education of coronary heart disease，and cardiac rehabilitation for these patients，especially males，the young and middle-aged，and those with mild coronary artery disease，should be strengthened，and patients should be encouraged to return to work after discharge，and to develop and maintain a healthy lifestyle.
【Key words】 Coronary disease；Coronary artery stent implantation；Life style；Patient discharge；Root cause analysis
Modified Simple Sequential Organ Failure Assessment Score：a New Scoring System for Sepsis Screening WANG Zhengguang，YAO Jianhua*，CHEN Xiaoyan，ZHANG Kai，WANG Guobin，YAN Xiaoling
ICU，Huangshan Shoukang Hospital，Huangshan 245400，China
*Corresponding author：YAO Jianhua，Chief physician；E-mail：firstname.lastname@example.org
【Abstract】 Background Sepsis is one of the most common critical diseases encountered clinically.Early detection and active treatment are beneficial to improving patient prognosis.Due to the low sensitivity of the quick Sequential Organ Failure Assessment（qSOFA） score in sepsis screening，it is necessary to establish a sepsis screening score with high sensitivity and specificity.Objective To develop a new scoring system for sepsis screening by modifying the simple Sequential Organ Failure Assessment（sSOFA） score，namely，Modified simple Sequential Organ Failure Assessment（M-sSOFA） score，providing a reference for early detection of sepsis.Methods The inpatients from the ICU，Huangshan Shoukang Hospital and Huangshan City People's Hospital during March 2015 to February 2018 were recruited for retrospective analysis，including 206（105 with sepsis and 101 without） enrolled during March 2016 to February 2018（M-sSOFA model group），and 106（55 with sepsis and 51 without） enrolled during March 2015 to February 2016（M-sSOFA validation group）.ROC curve analysis was performed to determine the new variables（white blood cell count and oxygenation index） and diagnostic cut-off point of M-sSOFA score，and was applied to measure the accuracy of M-sSOFA score and qSOFA score in screening sepsis.Results M-sSOFA model group：the sepsis patients（62 males and 43 females） had an average age of（71.1±15.2） years，with an ICU mortality rate of 33.33%（35/105），and the non-sepsis patients（80 males and 21 females） had an average age of（62.2±15.1） years，with an ICU mortality rate of 11.88%（12/101）.The area under the ROC curve（AUC） of M-sSOFA score was biggest〔AUC= 0.806，95%CI（0.743，0.868），P<0.05〕，the sensitivity and specificity were 81.90%，and 79.21%，respectively，when diagnostic cut-off point of M-sSOFA score ≥3（WBC<4×109/L or >10×109/L and oxygen index<450 mm Hg，1 mm Hg=0.133 kPa）.White blood cell count <4×109/L or >10×109/L scored as 1 point and oxygenation index <450 mm Hg scored as 1 point were included in the final M-sSOFA scoring standard.M-sSOFA validation group：the sepsis patients（33 males and 22 females） had an average age of（70.9±14.4） years，with an average M-sSOFA score of 4（range：3，5），an average qSOFA score of 1（range：1，2），and an ICU mortality rate of 38.18%，and the non-sepsis patients（38 males and 13 females） had an average age of（60.5±16.5） years，with an average M-sSOFA score of 1（range：0，2），an average qSOFA score of 0（range：0，1），and an ICU mortality rate of 11.76%.The AUC，sensitivity，specificity and Kappa coefficient of M-sSOFA score in screening sepsis were 0.78，80.00%，76.47%，and 0.56，respectively，and these aforementioned 4 indicators for M-sSOFA score were 0.63，40.00%，86.28%，and 0.26，respectively.The difference in AUC between M-sSOFA score and qSOFA score in screening sepsis was significant（Z=2.751，P=0.006）.Conclusion M-sSOFA score，a new scoring system for rapid sepsis screening，demonstrated better predictive value for sepsis screening compared to qSOFA score，with an AUC of 0.78，80.00% sensitivity and 76.47% specificity.
【Key words】 Sepsis；Screening；Score；Quick Sequential Organ Failure Assessment；Simple Sequential Organ Failure Assessment
Risk Prediction of Cancer in Adult Population Based on Support Vector Machine versus XGboost MA Qianqian1，2，SUN Dongxun1，2，SHI Jinming1，2，HE Xianying1，2，ZHAI Yunkai1，2，3*
1.The First Affiliated Hospital of Zhengzhou University，Zhengzhou 450052，China
2.National Engineering Laboratory for Internet Medical Systems and Applications，Zhengzhou 450052，China
3.School of Management Engineering，Zhengzhou University，Zhengzhou 450001，China
*Corresponding author：ZHAI Yunkai，Professor，Doctoral supervisor；E-mail：email@example.com
【Abstract】 Background The risk prediction of cancer is of great importance for improving the health of the population and reducing the economic burden of patients.However，with the development of medical big data，traditional statistical forecasting methods are gradually unable to meet the demand，and the application of new methods such as machine learning in the field of cancer prediction is necessary.Objective To explore the application of XGboost，Support Vector Machine（SVM）and stepwise logistic regression（SLR） model in cancer risk prediction.Methods The data were collected from the China Health and Nutrition Survey（CHNS） in 2011 and 2015，targeting at urban and rural adults（≥18 years old） in 12 regions of China（including Heilongjiang，Liaoning，Hunan，Shandong，Guizhou，Jiangsu，Guangxi，Hubei，Henan，Beijing，Shanghai，and Chongqing）.After data cleansing，19 410 subjects were eventually included in the study，which were further divided into the training set and test set by a ratio of 2:1.Based on the variables screened by stepwise regression，the SLR，SVM，and XGboost prediction models were established using the training set and were verified using the test set，respectively.The area under the receiver operating characteristic（ROC） curve（AUC） was applied to evaluate the prediction performance of each model.Results Of the 19 410 subjects，262 were diagnosed with cancer（1.35%），174 of whom were included in the training set（n=12 919），and other 88 were included in the test set（n=6 491）.The accuracies of SLR，SVM and XGboost models in the test set were 72.96%〔95%CI（71.86%，74.04%）〕，99.54%〔95%CI（99.34%，99.69%）〕，70.05%〔95%CI（68.92%，71.16%）〕，respectively.The AUCs of the three models were 76.75%〔95%CI（72.35%，81.14%）〕，86.32%〔95%CI（81.64%，91.00%）〕，79.03%〔95%CI（74.96%，83.10%）〕，respectively.The AUC of SLR was significantly different from that of SVM model（Z=-2.519，P=0.012） and XGboost model（Z=-2.138，P=0.032）.The AUC of XGboost was much smaller than that of SVM（Z=2.081，P=0.037）.Conclusion In predicting the risk of cancer in adults，compared with the SLR model，SVM model shows better accuracy，sensitivity，specificity，and AUC，while the XGboost model has no significant improvement in predictive performance.Considering the advantages of the SLR in terms of easy operation and interpretability，it is recommended to use both SVM and SLR in the prediction of cancer risk.
【Key words】 Neoplasms；Health status；Stepwise Logistic regression；Support vector machine；XGboost；Forecasting
Long-term Prognostic Value of Coronary Stenosis Detected by Coronary CT Angiography YANG Quan1，YANG Yong1，YU Jianqun2，ZENG Hanjiang2，HUANG Fangyang3，CHEN Mao3*
1.Cardiovascular Department，Sichuan Provincial Fourth People's Hospital，Chengdu 610016，China
2.Department of Radiology，West China Hospital，Sichuan University，Chengdu 610041，China
3.Cardiovascular Department，West China Hospital，Sichuan University，Chengdu 610041，China
*Corresponding author：CHEN Mao，Professor；E-mail：firstname.lastname@example.org
【Abstract】 Background Coronary CT angiography（CCTA） is a non-invasive method for evaluating coronary artery stenosis，but its long-term prognostic value has rarely been reported in China.Objective To evaluate the clinical value of coronary stenosis detected by CCTA in predicting long-term prognosis of patients.Methods This is a retrospective cohort study.Consecutive inpatients who underwent CCTA in West China Hospital，Sichuan University from January 1，2012 to September 30，2012 were analyzed.In accordance with the stenosis degree was scored by the CAD-RADS introduced in 2016，they were divided into plaque-free group，non-obstructive plaque group and obstructive plaque group.The primary end point was all-cause death，and the secondary end points were cardiac death，nonfatal myocardial infarction and elective revascularization.The following up completed from August 1, 2017 to October 10, 2017.Results The study eventually included 705 patients with an average follow-up of（5.0±0.9） years，including 295（41.8%） without plaque，410（58.2%） with non-obstructive plaques，and 221（31.3%） with obstructive plaques.5-year all-cause mortality（19.0%） in obstructive plaque group was significantly higher than that in plaque-free group（5.8%） and non-obstructive plaque group（7.4%）（χ2=21.88，11.62，P<0.001）.Cox proportional hazard model showed that age，ACS，and obstructive stenosis（CAD-RADS≥3） was a risk factor for 5-year all-cause mortality（P<0.05）.The 5-year cardiac mortality in the obstructive plaque group（7.7%） was significantly higher than that in the plaque-free group（0.7%） and non-obstructive plaque group（1.6%）（χ2=17.53，8.18，P<0.001）.Cox proportional risk model showed that age，acute coronary syndrome，and obstructive stenosis（cad-rads score ≥） were the influencing factors of 5-year cardiac death（P<0.05）.The 5-year selective revascularization rate in the obstructive plaque group（12.7%） was significantly higher than that in the plaque-free group（2.0%） and the non-obstructive plaque group（4.8%）（χ2=23.64，7.76，P<0.001）.The 5-year non-fatal myocardial infarction rate in the obstructive plaque group（7.7%） was higher than that in the plaque-free group（1.4%） and the non-obstructive plaque group（1.6%）（χ2=13.18,8.18，P<0.001）.There were no significant differences in 5-year all-cause death，cardiac death，selective revascularization，and non-fatal myocardial infarction rate between the non-obstructive plaque group and the plaque-free group（P>0.05）.Conclusion The longer-term prognosis of patients with severe coronary artery stenosis assessed by CCTA was worse，whose 5-year all-cause mortality，and cardiac mortality were associated with obstructive plaques.Compared with those with non-obstructive plaques or without plaques，patients with obstructive plaques had lower all-cause mortality，cardiac mortality，non-fatal myocardial infarction rate and selective revascularization rate.The long-term prognosis was similar between those with non-obstructive plaques and those without plaques.
【Key words】 Coronary artery disease；Coronary stenosis；Coronary angiography；Tomography，spiral computed；Stenosis degree；Prognosis
Echocardiographic Evaluation of the Left Ventricular Remodeling and Function in End Stage Renal Disease Patients with Preserved Left Ventricular Ejection Fraction ZHANG Zhihua1，MO Weichun2，ZHENG Fengya1，HUANG Leijun1，GONG Hui3*
1.Department of Echocardiography，Jinshan Hospital of Fudan University，Shanghai 200540，China
2.Department of Emergency，Jinshan Hospital of Fudan University，Shanghai 200540，China
3.Department of Cardiology，Jinshan Hospital of Fudan University，Shanghai 200540，China
*Corresponding author：GONG Hui，Chief physician； E-mail：email@example.com
【Abstract】 Background Cardiovascular diseases continue to be a leading cause of death in ESRD.The basic pathology may be the changes of cardiac structure and function.In daily clinical practice，more attention is often paid to heart failure，particularly when left ventricular ejection fraction（LVEF） is abnormal，while many other important cardiac parameters are ignored.Objective To assess the left ventricular remodeling and function in ESRD patients with preserved LVEF by using echocardiography.Methods Participants were selected from Jinshan Hospital of Fudan University from January 2016 to June 2018，including 121 ESRD patients receiving the initial dialysis in this hospital and with preserved LVEF during the follow-up period（case group），and 50 age- and sex-matched physical examinees with normal results of physical examination，electrocardiogram and routine echocardiography（control group）.Intergroup comparisons were made in terms of general data，aortic diameter （AOd），parameters of chamber size（LAd，LVEDd，LVESd，LAV，LVEDV，LVESV，gLVEDV，gLVESV）and their values after body surface area（BSA） correction，left ventricular configuration （IVST，LVPWT，LVM，LVMI and RWT），systolic function parameters 〔LVFS, LVEF, gLVEF and peak systolic mitral annular velocity（S'）〕，global left ventricular function （LV Tei index），diastolic function parameters 〔peak early diastolic E-wave velocity（E peak）， peak late diastolic A-wave velocity（A peak），E/A，deceleration time （DT），iso-volumic relaxation time （IVRT），peak early diastolic mitral annular velocity（E'），peak late diastolic mitral annular velocity （A'），E'/A' and E/E'〕.The left ventricular configuration and the status of the gLVEF were analyzed in ESRD patients，and were further analyzed in those with diastolic dysfunction.Results The case group showed lower mean weight，BMI，BSA, higher mean systolic blood pressure （SBP），diastolic blood pressure （DBP） and pulse pressure difference （DP） compared with the control group（P<0.05）.The case group demonstrated greater mean AOd，AOd/BSA，LAd，LAd/BSA，LVEDd，LVEDd/BSA，LVESd，LVESd/BSA，LAV，LAVI，LVEDV，LVEDV/BSA，LVESV，LVESV/BSA，gLVEDV，gLVEDV/BSA，gLVESV，and gLVESV/BSA，and thicker mean IVST，LVPWT，and RWT，LVM，LVMI as well as less mean LVFS，LVEF and gLVEF compared with the control group （P<0.05）.In case group，left ventricular configuration was normal in 17 cases （14.0%），abnormal in 104 cases （86.0%），mainly centrifugal hypertrophy in 55 cases and centrifugal hypertrophy in 48 cases；gLVEF was abnormal in 39 cases （32.2%） and normal in 82 cases （67.8%）.Compared with the control group，case group had faster mean E peak and A peak，lower mean E/A，greater mean DT，IVRT，and LV Tei index，slower mean S'（s），E'（s），E'（l），E'/A'（s），and E'/A' （l），and higher mean A'（l），and E/E'（av） （P<0.05）.In case group，the left ventricular diastolic function was normal in 5 （4.1%），and diastolic dysfunction in 116 （95.9%）.And those with diastolic dysfunction included 104 （86.0%） with abnormal left ventricular configuration and 39 （32.2%） with abnormal gLVEF.Of the ESRD patients，14 were found with normal left ventricular configuration and gLVEF，3 with normal left ventricular configuration and abnormal gLVEF，68 with abnormal left ventricular configuration and normal gLVEF，and 36 with abnormal left ventricular configuration and gLVEF.Conclusion There were left ventricular remodeling characterized by dilation of cardiac chambers，thickened ventricular wall and cardiac systolic and diastolic dysfunction in ESRD patients with preserved LVEF.And the LV diastolic dysfunction was prior to the systolic dysfunction and left ventricular remodeling.So comprehensively evaluating left ventricular remodeling and left ventricular diastolic function in ESRD patients with preserved LVEF counts for much，and is not allowed to neglect in clinical work.
【Key words】 Nephrosis；Stroke volume；Ventricular remodeling；Ventricular function，left；Echocardiography；Case-control studies
Impact of Plantar Perception Training on the Balance Ability and the Risk of Falls in the Elderly with a History of Falls LIU Kai1*，CHEN Ying2，GAO Zhao1，LYU Jingmei1，HUANG Yijun1
1.Healthcare Center/Geriatric Center，Hainan General Hospital，Haikou 570311，China
2.Clinical Laboratory，Hainan General Hospital，Haikou 570311，China
*Corresponding author：LIU Kai，Associate chief physician；E-mail：firstname.lastname@example.org
【Abstract】 Background Falls have become the leading cause of death among elderly people over the age of 65 in China，which are associated with over 50% of the injuries requiring hospital treatment in this group.Plantar perception training can improve balance ability and may be of value in reducing falls.Objective To explore the effect of plantar perception training on the balance ability and risk of falls in the elderly with a history of falls，with a view to providing a basis for reducing falls in the elderly.Methods From May 2017 to May 2018，62 out of the elderly patients over the age of 60 with an experience of at least one fall within 6 months before 2018-06-01 were recruited from Geriatrics Center，Hainan General Hospital，and were randomly divided into the experimental group and control group with 31 in each.All of them received the same plantar perception training of the same duration from rehabilitation department except that the controls were not required to distinguish the hardness levels of five sponge pads.General information，balance test results〔pre- and post-intervention eye opening，center-of-pressure（COP）total trajectory length with eyes closed，timed up and go（TUG）test〕，and fall risk assessment（FES）results were collected and compared between the groups.Results In the experimental group，the scores of plantar perception training on the 7th，8th，9th，and 10th days of training were all lower than those on the 1st day（P<0.05）.In eyes-open conditions，there was no interaction between the training method and time on the COP total trajectory length（P>0.05）.Training duration produced significant main effect on the COP total trajectory length（P<0.05），while training duration did not（P>0.05）.There was an interaction between training method and time on COP total trajectory length and TUG results（P<0.05）.Both training method and time exerted significant main effects on COP total trajectory length and TUG results（P<0.05）.The COP total trajectory length decreased in both groups after training（P<0.05）.In eyes-closed conditions，the COP total trajectory length decreased in both groups after training（P<0.05）.Compared with the control group，the mean COP total trajectory length was longer before training but it was shorter after training in the experimental group（P<0.05）.The time used to complete the TUG test decreased in both groups after training（P<0.05）.The experimental group used shorter mean time to complete the TUG test either before or after training（P<0.05）.There was an interaction between the training method and time on the FES score（P<0.05）.Both the training method and time had significant main effects on the FES score（P<0.05）.The mean FES score increased in both groups after training（P<0.05）.Although the mean FES score was lower before training in the experimental group in comparison with the control group，it became higher after training（P<0.05）.Conclusion Plantar perception training helps to improve the balance ability in elderly people，thus the risk of falls may be reduced.
【Key words】 Accidental falls；Aged；Plantar perception training；Balance ability；Treatment outcome
Comparative Study of Clinical Atomization Effect of Pressure Jet Atomization Pumps WANG Huanying1，XU Wangmei1，WU Ying1，SUN Huifen2*，LI Fan1*
1.Songjiang Central Affiliated Hospital of Nanjing Medical University，Shanghai 201600，China
2.Songjiang Yongfeng Community Health Center，Shanghai 201600，China
*Corresponding author：SUN Huifen，Attending physician；E-mail：Lvzhou_shf@163.com
LI Fan，Chief physician；E-mail：email@example.com
【Abstract】 Background Atomization inhalation therapy is an important treatment for diseases of respiratory system.The common atomization inhalation devices include jet atomization pump，ultrasonic atomization pump and vibrating mesh technology，among which jet atomization pump has the highest utilization rate.There are many brands of jet atomization pumps，but there is a lack of unified use standards，and there are few reports on them.Objective To compare the atomization time and residual volume after atomization of different jet-pressure atomization pumps.Methods This study was conducted from March 15 to March 21，2019 in the classroom of Department of Respiratory and Critical Care.All atomization pumps and atomizers were tested under the same confined conditions in accordance with the standards of their respective brand specifications，and each group atomized 10 times.The three pressure jet atomization pumps of a，b and c and their corresponding atomizers of a1，b1，and c1 were paired，which were divided into aa1，bbl，cc1，ab1，ac1，ba1，bc1，ca1 and cb1 groups.The atomization time, residual dosage and average atomization rate of 10 ml 0.9% sodium chloride solution. The atomization time, residual dosage and average atomization rate of 4 ml 0.9% sodium chloride solution in aa1, bb1 and cc1 groups were compared. The residual dosage of 10 ml and 4 ml 0.9% sodium chloride solution in aa1, bb1 and cc1 groups were compared.Results The atomization time of 10 ml 0.9% sodium chloride solution in ab1 group was longer than that of groups of aa1，ac1，ba1，bb1，bc1，ca1，cb1，cc1（P<0.05）.The volume after atomization of 10 ml 0.9% sodium chloride solution in aa1 group was more than that of groups of ab1，ac1，ba1，bb1，bc1，ca1 ，cb1 and cc1（P<0.05）.The average atomization rate of 10 ml 0.9% sodium chloride solution in bb1 group was higher than that of groups aa1，ab1，ac1，ba1，bc1，ca1，cb1，cc1（P<0.05）.The atomization time of 4 ml 0.9% sodium chloride solution in aa1 group was longer than that in bb1 group and cc1 group（P<0.05）.The residual volume after atomization of 4 ml 0.9% sodium chloride solution in aa1 group was more than that in bb1 group and cc1 group（P<0.05）.The average atomization rate of 4 ml 0.9% sodium chloride solution in bb1 group was higher than that in aa1 group and cc1 group（P<0.05）.The residual volume after atomization of 4 ml 0.9% sodium chloride solution was less than that of 10 ml 0.9% sodium chloride solution after atomization in bb1 group（P<0.05）.Conclusion There are great differences in atomization time and residual volume after atomization between different atomization pumps and atomizers.Suitable atomization pump and its supporting atomizer should be selected for atomization treatment of patients.Reasonable arrangement of each atomization amount and atomization times is necessary to obtain the maximum therapeutic effect.Each manufacturer should mark the output pressure，output flow rate，residual volume after atomization，atomization rate and other parameters of atomizing pumps and atomizers in specifications so as to facilitate clinical selection.
【Key words】 Respiratory system；Pulmonary disease，chronic obstructive；Asthma；Nebulizers and vaporizers；Comparative effectiveness research
Clinical Efficacy of Conventional Intravenous and Intrathecal Drug Therapies in Acute Neuromyelitis Optica Spectrum Disorders QIAO Yanyan1*，LIU Bin2，LU Yan1
1.Department of Neurology，Xinxiang Central Hospital，Xinxiang 453000，China
2.Magnetic Resonance Imaging Department，Xinxiang Central Hospital，Xinxiang 453000，China
* Corresponding author:QIAO Yanyan，Attending physician；E-mail：firstname.lastname@example.org
【Abstract】 Background Neuromyelitis optica spectrum disorder（NMOSD） is a demyelinating disease invading the optic nerve，spinal cord and brain.Although NMOSD has been isolated from multiple sclerosis（MS），there are differences as well as overlapping or similarities in pathogenic mechanism，gene susceptibility and treatment strategies of the two.In recent years，intrathecal drug therapy has achieved good results in the treatment of MS，but its therapeutic effect on NMOSD is not clear.It is necessary to further clarify this.Objective To observe the efficacy of conventional intravenous combined intrathecal drug therapy in the treatment of acute NMOSD.Methods A total of 104 inpatients with acute NMOSD from Department of Neurology，Xinxiang Central Hospital were enrolled from January 2014 to June 2016，and were randomized into the control group（n=32） and observation group（n=72）.The observation group was further stratified into observation subgroup 1（n=37） and observation subgroup 2（n=35） by intervention method.All of the participants received conventional intravenous therapy with one or two drugs，observation subgroup 1 and subgroup 2 additionally received conventional intravenous with dexamethasone（5.0 mg once every day） and methotrexate（2.5 mg once every day），dexamethasone（5.0 mg once every day） or methotrexate（2.5 mg once every day），respectively.All of them were given a post-discharge follow-up of 24 months after being treated for at least 4 weeks.Sex，age，neurological impairment status on admission and at discharge〔assessed by the Expanded Disability Status Scale（EDSS） and some of its subscales〕，independent living skills on admission and at discharge 〔assessed by the Activities of Daily Living（ADL） Scale〕 of all participants，and number of intrathecal injections of those in the observation group were collected.Results Compared with the control group，the observation group showed a lower mean EDSS score at discharge，and a lower difference value between mean EDSS scores on admission and at discharge（P<0.01）.The observation subgroup 1 demonstrated a greater difference value between mean EDSS scores on admission and at discharge（P<0.05），and a lower mean EDSS score at discharge compared with observation subgroup 2（P<0.05）.The recurrence rate of the observation group was lower than that of the control group during 13-18,19-24 months after discharge（P<0.05）.Conclusion Compared with intravenous drug therapy alone，intravenous and intrathecal drug therapies have more obvious advantages in improving motor function recovery，reducing disability level and long-term recurrence rate.In particular，intrathecal injection of dexamethasone or methotrexate is inferior to the combination use of these two.
【Key words】 Neuromyelitis optica；Injections，spinal；Treatment outcome；Dexamethasone；Methotrexate
Precise Preoperative Planning Based on PACS for the Treatment of Vertebral Fragility Fractures with Percutaneous Kyphoplasty WEN LI，WANG Shengli，GE Zhanyong*
Department of Orthopedics，Tianjin Jinnan Hospital，Tianjin 300350，China
*Corresponding author：GE Zhanyong，Attending physician；E-mail：email@example.com
【Abstract】 Background To ensure the safety of operation，C-arm fluoroscopy is often performed many times in the process of percutaneous kyphoplasty（PKP）for vertebral fragility fractures，which may impair the health of both the patient and doctor due to exposure to high-dose radiation.Therefore，to study how to reduce the amount of X-ray radiation in vertebroplasty can ensure the health of patients and doctors from radiation-induced impairment.Objective To study the effect of PKP on vertebral fragility fractures with precise preoperative planning based on picture archiving and communication system（PACS），with a view to reducing the number of intraoperative fluoroscopy times，and the amount of radiation，as well as shortening the operation duration.Methods From March 2018 to June 2019，58 patients with vertebral fragility fractures from Tianjin Jinnan Hospital were selected，and 29 of them undergoing PKP with precise preoperative planning based on PACS，and other 29 undergoing PKP with conventional approach were assigned to the experimental group，and control group，respectively.Preoperative and postoperative VAS score，postoperative anterior edge and central height of the vertebral body，duration of operation，number of intraoperative fluoroscopy examinations and complications were recorded and compared between the two groups.Results There were no significant differences in mean preoperative and postoperative VAS score，mean postoperative anterior edge height and central height of the vertebral body between the two groups（P>0.05）.The experimental group had much shorter mean duration of operation and less number of fluoroscopy examinations（P<0.05）.The mean VAS score decreased significantly in both groups after operation（P<0.05）.There was no significant difference in the incidence of complications between the two groups（P>0.05）.Conclusion Implementing PKP with precise preoperative planning based on the PACS may simplify the treatment procedure，shorten the duration of operation，reduce the number of fluoroscopy examinations，and the radiation dose.This method is safe and effective，and can be popularized clinically.
【Key words】 Fractures，bone；Vertebral fragility fractures；Kyphoplasty；Precise preoperative planning；Picture archiving and communication system；Treatment outcome
Construction of Incentive Mechanism for Family Doctor Contracted Services Based on Comprehensive Incentive Model WANG Meinan，ZHAO Panpan，WANG Yiting，LIN Zhenping，QIAN Dongfu*
Institute of Healthy Jiangsu Development/Research Center for General Practice/School of Health Policy and Management，Nanjing Medical University，Nanjing 210029，China
*Corresponding author：QIAN Dongfu，Professor；E-mail：firstname.lastname@example.org
【Abstract】 This paper sorts out the incentive mechanism of family doctor contracted services at home and abroad，analyzes the problems existing in the incentive mechanism of domestic family doctor contracted services，and finds that the incentive mechanism is insufficient in theoretical research.On the basis of comprehensively analyzing the comprehensive incentive model，this paper constructs a family doctor contacted service incentive model based on comprehensive incentive model.It is proposed a combination of material incentives and spiritual incentives，internal incentives and external incentives，positive incentives and negative incentives，individual incentives and team incentives，and the improvement of supporting measures and other incentive strategies.
【Key words】 Health policy；Comprehensive incentive model；General practitioners；Signing service；Incentive mechanism
Development of a Community Health Promotion Model Based on Integrating Physical Activity and Medical Technologies WANG Shiqiang1，2，3，LI Dan1，SHENG Xiangmei1，XIAO Gang1，NIE Yingjun3，WU Juhua2*
1.Physical Education College of Hunan University of Technology，Zhuzhou 412000，China
2.School of Sport，Guangxi University of Science and Technology，Liuzhou 545006，China
3.Wuhan Sports University，Wuhan 430079，China
*Corresponding author：WU Juhua，Associate professor；E-mail：email@example.com
【Abstract】 The increasing incidence of aging and chronic diseases has become a major social challenge faced by China.The achievement of Healthy China goals urgently needs to change the previous health promotion models that overly depend on medical care，and to promote the formation of a disease management and health management services model by integrating physical activity and medical technologies.However，the integration of physical activity and medical technologies is in the theoretical exploration stage，and the practical pathway is not clear.Moreover，there is no available feasible model for reference or following.Therefore，on the basis of theoretical analysis and field investigation，this study puts forward a health promotion model of "medical institutions-sports institutions-community institutions" with medical institutions and sports institutions as the advantages of resources，and community as the basic environment.The organization structure，operation mechanism and implementation process of the model are described in detail and analyzed and demonstrated，aiming to provide a feasible path choice for the integration of physical activity and medical technologies，explore a set of replicable and popularizable community work model，and explore a new way for the integration of physical activity and medical technologies and non-medical health intervention.
【Key words】 Sports and medical integration；Integrative medicine；Physical education and training；Community medicine；Health promotion；Mode construction
Research on Two-way Referral Cognition of Doctors and Patients in Medical Treatment Partnership System in Chongqing LUO Zhaoyang，LIU Li*
School of Public Health and Management，Chongqing Medical University，Chongqing 400016，China
*Corresponding author：LIU Li，Researcher；E-mail：firstname.lastname@example.org
【Abstract】 Background The medical treatment partnership system is one of the effective ways to promote rational distribution of medical resources and improve hierarchical diagnosis and treatment.As of 2018，Chongqing has achieved comprehensive coverage of the medical treatment partnership system.The medical treatment alliance of the First Affiliated Hospital of Chongqing Medical University was established in March 2011 and has achieved some progress over the past six years.This paper takes the medical treatment partnership system as a sample to study the operation of two-way referral among doctors and patients in the system，so as to provide policy reference for improving the hierarchical diagnosis and treatment pattern in Chongqing.Objective To investigate the cognitive status of two-way referral，the problems existing in two-way referral，and to explore its solutions.Methods From September to November 2017 and from August to October 2017，a random sampling survey was used to investigate the medical staff and inpatients of six medical institutions in the medical treatment partnership system of First Affiliated Hospital of Chongqing Medical University.Self-designed questionnaire included topics such as basic information of medical staff and patients，knowledge of two-way referral，implementation of two-way referral by medical staff and relevant factors，two-way referral of patients and influencing factors，reorganization of smooth two-way referral and the implementation of two-way referral among medical staff and the authors.Results The response rate of questionnaire among health care providers was 88.3% （309/350）．A total of 288 （93.2%） health care professionals were aware of the two-way referral.The medical staff with different professional titles and source hospitals had significant difference in knowing the two-way referral （P<0.05）．There were 282 （91.3%） health care professionals who had provided referral services to patients during their work；among them，there were 151（53.5%） two-way referrals，62（22.0%） were upward referral visits，and 69（24.5%） downward referrals.Factors that promoted the downward referral of medical staff in core hospitals mainly included stable disease condition，and patients in the rehabilitation or recovery period.Factors that should be considered when promoting up-referral of patients by medical personnel in hosted county hospitals was mainly the need of the patient.Factors that hindered the downward referral of medical personnel in core hospitals were mainly patient dissatisfaction with the technical level of primary care institutions.Factors that hindered the downward referral of health care professionals in hosted county hospitals were the fact that higher level hospitals believed that subordinate hospitals had insufficient capability.There was no statistically significant difference in the recognition rate of two-way referral among the medical personnel of core hospitals and hosted county hospitals （χ2= 0.090，P=0.764）．The recognition rate of two-way referral by healthcare professionals was 57.9%（179 cases）．There was statistically significant difference in the recognition of two-way referral between the medical personnel of core hospitals and county hospitals（χ2=4.742，P<0.05）．The patient response rate to a valid questionnaire was 85.7%（257/300）．Two-way referral was known in 182 patients（70.8%）．There were significant differences in the awareness of bilateral referral among patients with different degrees of literature（χ2=8.555，P<0.05）．There are 83 patients（32.3%） who had a referral experience.The main factor that promoted the patient's upward referral was the patient's condition needs，and the main factor that hindered the patient's upward referral was the high cost of diagnosis and treatment.The main factor contributing to the downward referral was that the condition was already in the rehabilitation period，and no need to continue treatment，and the main factor preventing the downward referral was dissatisfaction with medical technique level in primary care institutions.The recognition rate of smooth two-way referral was 98.8%（79 cases） in core hospitals and 89.3%（158 cases） in county hospitals，and the difference was not statistically significant（χ2=0.011，P=0.918）．The recognition rate of bilateral referral was 42.5%（34 cases） in core hospitals and 33.3%（59 cases） in county hospitals，and the difference was statistically significant（χ2=-1.484，P=0.138）．Conclusion The cognition of two-way referral of doctors and patients in a medical association in Chongqing is generally high，the upward referral is easy and the downward referral is difficult.The recognition of doctors and patients in the medical association are both low, and the service ability of basic medical institutions needs to be improved.We should improve the service ability of primary care institutions，increase guidance，supervision and incentive of two-way referral，so as to ensure the smooth referral.
【Key words】 Medical treatment partnership system；Two-way referral；Cognition；Research；Chongqing
Reflection on the Implementation of Community-based Bi-directional Referrals in the Construction of Regional Medical Consortium SU Jin，XU Liping*，YI Chuntao，DING Hongjuan，ZUO Wenying，GUO Feina
Xuhui District Fenglin Community Health Center，Shanghai 200030，China
*Corresponding author：XU Liping，Associate chief physician；E-mail：email@example.com
【Abstract】 Background The construction of medical consortium is an important move for deepening the reform of medical and healthcare system in China.Medical association plays a pivotal role in promoting healthcare resource sharing，bi-directional referrals and building an orderly treatment order.Exploring a reasonable and effective bi-directional referral mode is essential for the achievement of orderly healthcare-seeking pattern and for the promotion of highly efficient use of medical and health resources.Objective To investigate the role of community-based bi-directional referrals in the construction of regional medical consortium based on the analysis of multiple patterns of bi-directional referrals implemented in Xuhui District Fenglin Community Health Center（XDFCHC）.Methods Data were collected from XDFCHC，including percentages of community-based outpatient referrals（consisting of electronic referrals based on an integrated platform and referrals based on the printed form with physician manual signature for referral，and a general practitioner-specialist cloud platform），ward referrals（mainly referred to an oriented hospital，namely，Orthopeadic Surgery，the Sixth People's Hospital Affiliated to Shanghai Jiaotong University） implemented in 2013—2018，and outpatient referrals via the general practitioner-specialist cloud platform implemented in 2017—2018，top 3 secondary and tertiary hospitals that patients were transferred to and referrals via the general practitioner-specialist cloud platform.Results There were 19 493 referrals during 2013 to 2018 in total.To be specific，there were 13 704 community-based upward referrals from outpatient department，accounting for 70.3%，including 1 262（9.2%） electronic referrals via an integrated platform，12 386（90.4%） referrals based on the printed form with physician manual signature，and 56（0.4%） referrals via the general practitioner-specialist cloud platform，and there were 573（2.9%） upward referrals from the ward，and 5 216（26.8%） downward referrals to the ward.From 2013 to 2018，there was a significant difference in the rates of upward referrals from consisting of electronic referrals based on an integrated platform and referrals based on the printed form with physician manual signature for referral，and a general practitioner-specialist cloud platform，and the ward，and downward referrals to the ward（P<0.001）.The rates of upward referrals via the general practitioner-specialist cloud platform differed significantly across 2017 to 2018（P=0.001）.From 2013 to 2018，there were 8 591 cases were transferred to the top three hospitals，included the second and third level hospitals，based on the printed form with physician manual signature.The top 3 transferred tertiary hospitals were Zhongshan Hospital Affiliated to Fudan University〔3 330 referrals（38.8%）〕，Longhua Hospital，Shanghai University of Traditional Chinese Medicine〔3 544 referrals（41.3%）〕，and Mental Health Center Affiliated to Shanghai Jiaotong University School of Medicine〔1 216 referrals（14.2%）〕.The top 3 transferred secondary hospitals were Xuhui Hospital，Zhongshan Hospital Affiliated to Fudan University〔216 referrals（2.5%）〕，Xuhui Dental Disease Prevention and Treatment Institute〔186 referrals（2.1%）〕 and Shanghai Eighth People's Hospital〔99 referrals（1.1%）〕．From 2013 to 2018，there were 5 789 ward referrals.The top 3 transferred tertiary hospitals were the Sixth People's Hospital Affiliated to Shanghai Jiaotong University（277 referrals），Zhongshan Hospital Affiliated to Fudan University（138 referrals），and Longhua Hospital，Shanghai University of Traditional Chinese Medicine（70 referrals），and the transferred secondary hospital was Xuhui Hospital，Zhongshan Hospital Affiliated to Fudan University（88 referrals）.From 2017 to 2018，365 bi-directional referrals via the Xuhui featured general practitioner-specialist cloud platform were implemented，including 309（84.9%） online consultations，11（2.7%） examination appointments，40 specialist appointments（11.0%），5 admission appointments（1.4%）.Conclusion Multiple patterns of bi-directional referrals within the regional medical consortium may improve the efficiency of community-based referrals.Bi-directional referrals in healthcare institutions in the regional medical consortium near to the patient's home provide geographical convenience for seeking healthcare.Online counseling and group consultations via the featured general practitioner-specialist cloud platform can reduce the times of actual healthcare seeking，and improve the effectiveness of referrals.Upward referrals outnumber downward referrals within the regional medical consortium.However，the handover between general practitioners and specialists in higher level hospitals is not accurate due to downward referrals without electronic records although upward referrals with.To strengthen the handover，electronic records for downward referrals should be automatically recorded by informatization means.And the development of a point-to-point community-based referral pattern is an important means for the handover between general practitioners and specialists.
【Key words】 Community health centers；Community health services；Referral and consultation；Patient transfer；Medical association；Shanghai
Associated Factors for Choice of Medical Institutions for Treatment in Chronic Disease Patients during the Implementation of Hierarchical Medical System：a Survey in Xuzhou LI Haiyang*，JIANG Jinxing，ZHAO Qiyu，JIANG Jia
Department of Clinical Medicine，Xuzhou Medical University，Xuzhou 221004，China
*Corresponding author：LI Haiyang，Associate professor；E-mail：firstname.lastname@example.org
【Abstract】 Background The implementation of hierarchical medical system is an important way to improve the use efficiency of health resources，better the performance of medical institutions，and solve the problem of "It is difficult and expensive to see a doctor" among the residents in China.However，its implementation effect may be affected by the choice of medical institutions for treatment among gradually increased chronic disease patients.Objective To investigate the awareness of hierarchical medical system，and choice and associated factors of medical institutions for treatment among chronic disease patients in Xuhzhou，providing evidence for the development of the pattern of treating acute and chronic diseases separately.Methods From July to August 2017，by stratified cluster sampling，600 chronic disease patients from Xuzhou were recruited to participate a face-to-face survey to fill a self-administered questionnaire covering demographic data，awareness of hierarchical medical system and choice of medial institutions for treatment.Multivariate Logistic regression was used to explore the influencing factors of choice of medical institutions for treatment.Results The survey obtained a response rate of 89.0%（534/600）.Among the respondents，41.9%（224/534） knew the hierarchical medical system，and 76.6%（409/534）approved the implementation of the hierarchical medical system to solve the problem of "ppris difficult and expensive to see a doctor".In terms of the medical institution visited for latest treatment，287 respondents（53.7%） chose a primary healthcare institution，and other 247（46.3%） chose a general hospital.Place of residence〔OR=2.142，95%CI（1.331，3.448）〕，average monthly income〔3 000-4 999 yuan：OR=4.489，95%CI（2.165，9.311）；≥5 000 yuan：OR=5.773，95%CI（2.216，15.037）〕，time used to get to the nearest primary healthcare institution from home on foot 〔≥30 min：OR=3.421，95%CI（1.685，6.947）〕，time used to get to the nearest general hospital from home by bus or car〔30-59 min：OR=0.480，95%CI（0.255，0.906）；≥60 min：OR=0.244，95%CI（0.126，0.472）〕，disease severity〔 moderate：OR=1.799，95%CI（1.053，3.071）；severe：OR=2.559，95%CI（1.400，4.679）〕，awareness level of the hierarchical medical system〔awareness：OR=0.288，95%CI（0.186，0.445）〕 and approval of the implementation of the hierarchical medical system〔approval：OR=0.311，95%CI（0.188，0.513）〕were associated factors for the choice of medical institutions for treatment.Conclusion The prevalence of seeking healthcare in primary healthcare institutions is unsatisfactory in chronic disease patients from Xuzhou，which is associated with place of residence，average monthly income，time used to get to the nearest primary healthcare institution from home on foot，time used to get to the nearest general hospital from home by bus or car，disease severity，awareness level of the hierarchical medical system and approval of the implementation of the hierarchical medical system.In view of this，health administrative departments should strengthen the development of general practitioners，standardize the diagnosis and treatment procedure for chronic diseases，to promote the development of the pattern of treating acute and chronic diseases separately.
【Key words】 Chronic disease；Hierarchical medical services；Health services；Choice of medical treatment；Root cause analysis
Dizziness to Be Investigated：an Experience of the Diagnosis and Treatment of Cervical Spondylotic Myelopathy FU Jinchao，REN Wen，REN Jingjing*
Department of General Practice，the First Affiliated Hospital，College of Medicine，Zhejiang University，Hangzhou 310003，China
*Corresponding author：REN Jingjing，Chief physician；E-mail：email@example.com
【Abstract】 Cervical spondylosis is one of the common diseases at general practice clinics.With the change of lifestyles，the incidence of cervical spondylosis has been on the rise and there are more and more young patients.This article touched upon a case of a patient with severe cervical spondylotic myelopathy（CSM）.Based on the RICE inquiry of general practitioners，medical check-up and imaging examination，the diagnosis of the disease was clarified.Then orthopaedic specialists completed a consultation session to determine a therapeutic regimen mainly based on surgery.Lastly，the patient recovered after hospitalization and clinical follow-up.By summarizing the key diagnostic points of CSM，more general practitioners can instantly diagnose diseases at the first time，so that more CSM patients can receive proper treatment，and rehabilitation early.
【Key words】 Cervical vertebrae；Cervical spondylosis；General practice；General practitioners；RICE consultation；Referral
Clinical Analysis of Ten Cases with Exogenous Insulin Autoimmune Syndrome YUN Sufang1，ZHAO Yanxue2，YAN Zhaoli1*
1.Department of Endocrinology，Affiliated Hospital of Inner Mongolia Medical University，Hohhot 010059，China
2.Graduate School，Inner Mongolia Medical University，Hohhot 010050，China
*Corresponding author：YAN Zhaoli，Professor，Chief physician；E-mail：firstname.lastname@example.org
【Abstract】 Objective To investigate the clinical characteristics of exogenous insulin autoimmune syndrome（EIAS），to understand clinical diagnosis and treatment process and its characteristics of EIAS in combination with literature，and to improve clinicians' skills in diagnosis and treatment of the disease.Methods From January 2010 to March 2019，ten patients with EIAS diagnosed in the Department of Endocrinology of Affiliated Hospital of Inner Mongolia Medical University were selected.A retrospective summary of the patient's general condition，laboratory examination，treatment and prognosis was made.Results There were 5 males and 5 females aged 35-83 years with diabetes mellitus of 7-23 years.The onset of hypoglycemia was mostly fasting hypoglycemia.All cases had a long history of insulin therapy.The combined immune diseases were eczema-like rash in one case，psoriasis in one case.Antibody test results showed that serum islet cell antibody （ICA），antibody of glutamic acid decarboxylase （GAD） were negative，insulin autoantibody （IAA） was positive in ten cases.At the same time，the serum insulin levels were significantly increased and inconsistent with C-peptide level.Eight patients stopped insulin treatment，six of whom changed to oral hypoglycemic drugs，one was given intravenous infusion of Methylpredation because of coma after hypoglycemia and one changed diet.The other two patients were replaced with the insulin dosage form and added with Butanpine at the same time.No hypoglycemia occurred in ten patients from 2 weeks to 5 months after treatment.Conclusion Diabetic patients with long-term insulin use have recurrent episodes，severe spontaneous hypoglycemia，and significantly increased insulin levels，which are inconsistent with C-peptide level.When IAA is positive，the diagnosis of EIAS should be considered.They should stop using insulin，or change insulin dosage form，and severe patients should be given glucocorticoid therapy.Patients with EIAS have a good prognosis.
【Key words】 Exogenous insulin autoimmune syndrome；Immunological；Insulin；Autoantibodies
Advances in Research on the Role of NLR in Cardiovascular Diseases QIU Le，LIU Qizhi*
Department of Cardiology 2，the Second Affiliated Hospital of Dalian Medical University，Dalian 116027，China
*Corresponding author：LIU Qizhi，Chief physician，Professor；E-mail：email@example.com
【Abstract】 Neutrophil-to-lymphocyte-ratio（NLR） is a novel inflammatory marker，which is closely related to tumor，sepsis，acute pancreatitis and other diseases.Recent studies have found that NLR is involved in the occurrence and development of cardiovascular diseases and has important predictive value for a variety of cardiovascular diseases.This article introduces the research progress of NLR in cardiovascular diseases，including coronary heart disease，heart failure，hypertension，arrhythmia and heart valve disease，NLR can predict the near and long term mortality and major adverse cardiovascular events in patients with coronary heart disease.Higher NLR is associated with an increased risk of short-term readmissions and long-term mortality in patients with acute decompensated heart failure.NLR is a predictor of diastolic dysfunction and all-cause mortality in patients with hypertension.NLR has a good predictive value for new onset of atrial fibrillation and recurrence after radiofrequency ablation.NLR has a prognostic value for patients undergoing transcatheter aortic valve replacement.NLR has many advantages in community and grass-roots medical institutions due to its low price，immediate access，and repeatable detection，in order to provide a new direction for the diagnosis and treatment of cardiovascular diseases.
【Key words】 Cardiovascular diseases；Neutrophil-to-lymphocyte-ratio；Inflammatory maker；Review