According to the Guideline for the Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease （2021 revision），different levels of medical institutions undertake different tasks in the stratified diagnosis and treatment of chronic obstructive pulmonary disease （hereinafter referred to as COPD）. General practitioners are main force responsible for prevention of COPD. General practitioners use questionnaire surveys and popularize the application of simple lung function to implement early screening of COPD；implement drug treatment for stable maintenance treatment through patient education，supervision and regular follow-up；participate in the overall management of COPD by guiding and verifying the correct use of inhaled drugs，improving compliance，implementing respiratory rehabilitation treatment，etc. With reference to the revised guideline，general practitioners are expectedto participate in the overall management of COPD to improve the medical level of COPD in primary care institutions.

As main health service providers in primary care, general practitioners (GPs) undertake the responsibility of gatekeepers for residents' health. Vigorously training GPs will contribute to the transformation of the healthcare delivery model, and the addressing of the issue related to difficult and high cost of getting medical treatment in China. However, the number of qualified GPs is insufficient in China, and low income is a major factor associated with the willingness of medical students to work as a GP. How to take actions to recruit, retain and appropriately employ GPs in primary care is a problem that needs to be addressed urgently in the development of China's primary care workforce. To provide evidence for the improvement of China's payment system for GPs, we collected the information related to the payment for GPs in the United Kingdom, the United States, Australia, and China by reviewing relevant studies and relevant official websites of the four countries, and performed an inter-county comparative analysis of the information in terms of income source, income level, payment methods, payment composition, and performance appraisal. We found that the four countries have the following aspects in common: all of them own a payment system for GPs and an assessment system for service quality and effectiveness of GPs, adopt a mixed payment method for GPs, and use financial incentives to promote GPs to improve the quality of their performance. In addition, the United States and China have explored methods to decentralize the management of medical insurance funds, so that the primary healthcare institutions can independently redistribute the surplus funds which has improved the proactivity of GPs at work. And Australia has set up the "coefficient of difference" and scholarships/subsidies for GPs, and carried out free trainings for improving the service capacities of GPs working in remote areas, to increase the attractiveness of working as a GP.

In view of the shortage of general practitioners (GPs) and limited community healthcare resources, it is urgently necessary for community health institutions to find accurate and scientific incentive methods to retain GPs and help them to realize their full potential, as well as promote the development of both community health institutions and GPs, thereby benefiting the health promotion of community residents.

To develop an incentive model for GPs to test the performance and effectiveness of current incentives for GPs, so as to put forward suggestions to improve the mechanisms of employing and retaining GPs.

In August 2019, we recruited 204 GPs from 11 community health centers (CHCs) in Shanghai's Fengxian District using stratified random sampling to attend an online survey using a questionnaire named General Practitioners' Perception and Evaluation of Incentive Measures developed based on our previous research results and Herzberg's motivation-hygiene theory. Then from August to September 2019, we invited directors responsible for medical care or public health issues, and medical quality control department heads from the above-mentioned 11 CHCs to attend an online survey using a questionnaire named Workload for General Practitioners in Community Health Centers of Fengxian District developed by usbased on a literature review. Then under the guidance of Herzberg's motivation-hygiene theory, we constructed a structural equation to develop an incentive model for GPs within Fengxian District with representative incentive policies, systems and initiatives related to GPs selected from the survey results as latent independent variables to measure GPs' (responders') perception and assessment of incentives, and with willingness to work, service radius, and workload of GPs as dependent variables.

The average scores for the implementation of incentive measures, and its associated influence on GPs' work status assessed by the 204 GPs were (0.77±0.14) , and (0.73±0.19) , respectively. The assessment score for implementation of incentive measures for GPs differed significantly by personal health condition and administrative position in the respondents (P<0.05) . The assessment score for the influence of implementing incentive measures on GPs' work status differed significantly by personal health condition in the respondents (P<0.05) . Spearman correlation analysis showed that GPs' work status was associated with the implementation of 25 incentive measures (one incentive measure at the subdistrict level was not included for analysis) (P<0.05) . The top three most highly correlated incentive measures were performance distribution (r_s=0.652) , performance-based salary calculation (r_s=0.621) , and wages and benefits (r_s=0.614) . Partial correlation analysis indicated that, after controlling for variables such as the regional policy environment, the street and town government, and the work unit, the assessment score for implementation of either regional, or subdistrict or institutional incentive measures for GPs, was positively correlated with the assessment score for the influence of implementation of incentive measures for GPs on GPs' work status (r=0.381, 0.387, 0.528, P<0.001) . Theaverage assessment score for willingness to work by the respondents was (0.76±0.18) points. Theassessment scores of willingness to work by the respondents differed significantly by work unit (P<0.05) . Structural equation modeling revealed that the implementation of policy incentive measures influenced GPs' workload via GPs' willingness to work. Specifically, the implementation of policy incentive measures increased GPs' willingness to work (w1=0.43) , while GPs' willingness to work decreased with the increase of weighted workload (w2=-0.156) .

The GPs in Fengxian District showed higher level of willingness to work, namely, relatively high job stability, but they had not been incentivized by policy incentives to be competitive in obtaining improved performance, indicating that although policy incentives have produced partial effects on incentivizing GPs, the effects are still unsatisfactory. In the long run, it is necessary to consider whether there will be changes in GPs' retention status due to the lack of work initiative. For GPs, besides a guarantee of stable income, incentives to get more by doing more are also needed, which may be achieved by increasing the incentive authority and proportion of community health institutions when the total amount of incentives is limited.

General practitioners are the gatekeepers when it comes to residents' healthcare. This means that the quality and quantity of their services will play a key role in improving basic medical services. The most appropriate incentive mechanism for general practitioners can improve their ability, minimize the desire to leave, and promote the stability of teams. Currently, China lacks a comprehensive and flawless practice system, and the exploration of incentives for general practitioners is still in its infancy, and there is a lack of a complete and effective practice system. This study highlights the critical importance of incentives and incentive mechanisms. It summarizes the experience of the United Kingdom, Australia, the United States, Shenzhen, Xiamen, and Shanghai with relatively mature incentive mechanisms in China and abroad. Additionally, to summarise the current problems that still exist in the incentive mechanism for general practitioners in China (single incentive approach, lack of career attraction due to the lack of obvious incentive effect, poor science of incentives leads to uneven allocation across regions, different incentive policies across regions and slow implementation) . As part of this strategy, together with the strategy of "Healthy China", innovative ideas are put forward in terms of enrolling general practice in national key clinical specialty, establishing authoritative professional academic institutions and regulatory institutions, developing a unified performance appraisal system, improving the diversified material and non-material incentive mechanisms, improving the competition and punishment mechanisms by means of information, and forming an efficient general practitioner service teams. In order to provide new research methods for investigating the incentive system of primary general practitioners in China.

Background　There are no effective treatments for dementia，a disease with a heavy burden，which is becoming increasingly prevalent among the rapidly growing aging population. As a pre-stage of dementia，mild cognitive impairment（MCI）has attracted wide attention，but the screening for it using scales has not been popularized due to various scale limitations. So it is very important to find a simple tool suitable for screening for MCI in primary care. Objective　To explore the value of the Chinese version of the General Practitioner Assessment of Cognition（GPCOG-C） in screening for MCI in primary care. Methods　By use of simple random sampling and systematic sampling，860 cases were selected from 4 962 physical examinees（≥ 60 years old）in Shanghai to attend a questionnaire survey conducted from May to July 2020 by unified trained college student volunteers using a demographic questionnaire developed by our research group，four MCI assessment scales〔Montreal Cognitive Assessment Basic（MoCA-B），Activities of Daily Living（ADL） Scale，Dementia Rating Scale（CDR）and GPCOG-C〕. MCI was diagnosed using the criteria proposed by Petersen et al. Participants with MCI were matched 1:1 to those with normal cognitive function randomly in terms of age，sex，and years of education using SPSS software to run a comparative analysis. ROC curve of the GPCOG-C in screening for MCI was plotted to examine its cut-off threshold，sensitivity，specificity，positive and negative predictive values. Spearman's rank correlation analysis was used to measure the reliability of the GPCOG-C. The internal consistency of the scale was measured by Cronbach's α. Results　Altogether，812 cases completed the survey，and 192 of them（24.27%） were assessed to have MCI. 187 MCI cases（MCI group） and 187 matched cases of normal cognitive function（control group）were finally included. Compared with the criteria for MCI defined by Petersen et al，the gold standard，the GPCOG-C was found by ROC analysis to have a maximal Youden index of 0.43. When the cut-off threshold was determined as 12 points，the sensitivity，specificity，positive predictive value and negative predictive value of the GPCOG-C were 70.05%，69.52%，69.68% and 69.89%，respectively. The control group had higher mean scores of MoCA-B and GPCOG（P<0.05）. The mean time used for completing the MOCA-B differed significantly between the groups（P<0.05），but that used for completing the GPCOG-C did not（P>0.05）. MCI group had statistically significantly lower mean scores of time orientation，clock drawing，message，memory（first name，last name，city，road，house number），patient part，informed part and total score（P<0.05）. The inter-item correlation analysis of the GPCOG-C showed that the correlation between clock drawing and memory（last name） was negative and the correlation between clock drawing and informant section was negative. Other items were positively correlated to a certain extent，and the correlation coefficient r ranged 0.021 to 0.836. The Cronbach's α of GPCOG-C was 0.78. The mean time used for completing the MoCA-B was longer than that used for completing the GPCOG-C in all participants（P<0.001）. And the mean total GPCOG-C score was positively correlated with the mean MoCA-B score（rs=0.484，P<0.001）. Conclusion　The reliability and validity of the GPCOG-C have proved to be reasonable，suggesting that it may used for the screening for MCI in primary care.

Background　The position-specific competencies evaluation for general practitioners（GPs），the gatekeepers of residents' health，has gradually obtained the attention of scholars in general practice. Objective　To understand recent advances in the development of position-specific competencies evaluation system for Chinese GPs，to provide a basis for scientific evaluation of their position-specific competencies. Methods　From September 15 to 25，2020，we searched studies on the development of position-specific competencies evaluation system for Chinese GPs in databases of CNKI，CQVIP and Wanfang. Using advanced retrieval to construct retrieval strategy "（post competency+competency model+competency） * （general practitioner+general practitioner+family doctor+primary medical and health personnel）*（evaluation+evaluation+index+tool）"，with "Chinese abstract" or "title" as the search criteria，the matching method is "accurate matching"，and the retrieval time limit is "publication time is unlimited-up to September 2020". Bibliographical and content analyses were used to analyze the eligible studies. Results　A total of 763 studies were found and 31 of them were finally included，including 27 journal articles in Chinese，and four dissertations. A total of nine methods were used for developing the system，and the most frequently used was literature research〔71.0%（22/31）〕，followed by qualitative interview〔45.2%（14/31）〕，questionnaire survey〔45.2%（14/31）〕，and Delphi method〔45.2%（14/31）〕. The WONCA tree was the most commonly used framework，22.6%（7/31） of the studies used it for developing items. The numbers of items of the systems are various，ranging from 14 to 113. Seven studies reported their developed systems containing more than 40 items. These systems are comprehensive，generally meeting current requirements for evaluating Chinese GPs' position-specific competencies. Conclusion　Although there have been many academic studies on the development of position-specific competency evaluation systems for Chinese GPs，little was reported about application of these tools. Further research can focus on the practical use and improvement of these systems.

The last 10 years of new healthcare reform to date is a positive stage of active and rapid exploration of human resource development of general practitioners（GPs） in China．At present，the number of GPs in China is significantly growing and the GP training has made positive progress．However，there are still some aspects that need further and continuous improvement．Based on brief review of history of the last decade and current situation of the workforceof Chinese general practice，this paper analyses the existing problems of its human resource development and gives some specific recommendations．The authors believe that identifying orientation of primary care human resource，the quality and performance management of GPs，the number and quality gaps of GPs between urban and rural areas and across regions，the structure of general practice supervisors and mentors，and medical-educational dual abilities of trainers，the discipline and academic construction of general practice，and the quality and innovation of human resource development and services of general practiceare the key concerns for further development of general practice in China． Exploring general practice in the early stage of medical education for students，comprehensive measures for the sustainable and healthy human resource development of GPs in China may consider to take the needs of multiple dimensions as the orientation to establish the blueprint and roadmap of general practice education in order to pay full attention． To strengthen the discipline academic constructionand leadership and mentor development，to enhance scientific research in areas of general practice，and to support the training of clinical supervisorsof general practiceare including but not limited to the recommendations．

With the transformation of the role of pharmacists, the model and content of pharmacy services in primary care delivered by them have changed significantly, and they may play a greater role in the collaboration with general practitioner teams. This paper elaborated the content and model of collaboration between primary care pharmacists and general practitioner teams globally, analyzed the current effects of collaboration on improving clinical outcomes of patients, saving medical expenses and standardizing rational use of medicines, and summarized the challenges and barriers to collaboration, including general practitioners' low willingness to collaborate, patients' lack of confidence in the professional competence of primary pharmacists, barriers to role conversion of primary care pharmacists, additional medical costs, and imperfect infrastructure, etc. In view of the above barriers, this paper proposed five coping strategies, including clearly defining the responsibility of pharmacists in general practitioner teams, developing the incentive system and improving the management of fund, enhancing the training for community pharmacists and constructing the position-specific competencies evaluation system, strengthening the communication and mutual trust between general practitioners and pharmacists, and optimizing the pattern of collaboration. All of these provide theoretical reference and strategic support for the development of the collaboration between primary care pharmacists and general practitioners teams in China.

Background　At present，chronic obstructive pulmonary disease （COPD for short），as a preventable and controllable chronic disease，has become one of the most prominent public health and medical problems in our country，and the prevention and treatment of COPD in grassroots community is particularly important.Understanding the cognitive ability and current status of community general practitioners on COPD can provide a better scientific basis for the prevention and treatment of respiratory diseases in grassroots level.Objective　To investigate the status quo of cognition of COPD among general practitioners in community health service institutions in Beijing， and analyze the influencing factors to provide scientific basis for the prevention and treatment of respiratory diseases at the grassroots level.Methods　From September 28 to October 4 in 2020，a survey was conducted on the frontline general practitioners in 34 community health service centers and 159 community health service stations in Beijing. Self-designed questionnaire，after joint demonstration，the final draft of the questionnaire formed through star technology platform was published on the WeChat work group.The content of the questionnaire includes the basic information and the approaches to update and learn professional knowledge and general practitioners，the ways to carry out patient education of general practitioners，the knowledge test of COPD prevention and treatment ability（60 points or more is a pass，60 points or less is not enough）. The different demographic characteristics，approaches to obtaining professional knowledge，and the way to conduct patient education of the community health service organization and the situation about the passing of COPD prevention and control ability test of general practitioners were analyzed.And the binary Logistic regression was used to analyze the influencing factors of the prevention and control ability test of general practitioners.Results　A total of 1 226 questionnaires were distributed，and 1 226 valid questionnaires were returned.The recovery rate was 100.0%.（1）The total average score of the general practitioner's COPD knowledge test was （45.5±18.5） points，with 987 failing doctors and 239 passing doctors（pass rate 19.5%）.Among them，the passing rate of female doctors was higher than that of males（P<0.05）.The difference in the passing rate of doctors with different academic qualifications is statistically significant（P<0.05）；among them，the passing rate of doctors with master degree and above is higher than the doctors with bachelor degree，college degree，technical secondary school education and below，and the passing rate of doctors with bachelor degree is higher than doctors with college degree，technical secondary school education and below.The difference in the passing rate of doctors with different professional titles was statistically significant（P<0.05）；among them，the passing rate of doctors with senior and intermediate titles was higher than the passing rate of doctors with junior titles（P<0.05）.（2）The passing rate of general practitioners who had passed the COPD prevention and control ability knowledge test at the community health service center/community health service station by listening to the lectures by outside experts and the experts organized by the medical association was higher than the general practitioners without listening to the lectures by experts outside the hospital and the experts organized by the medical society on the spot（P<0.05）.（3）General practitioners who carried out patient education and education had a higher pass rate than those who did not carry out patient education（P<0.05）；general practitioners who disseminate health education manuals，health education lectures and health consultations to teach patients had a higher pass rate than general practitioners without distributing health education manuals，health education lectures and health consultations to teach patients.（4）The results of binary Logistic regression analysis showed that gender，educational background，and professional title were the influencing factors of general practitioners' passing knowledge test of COPD prevention and treatment （P<0.05）.Conclusion　The general practitioners in Beijing community health service institutions have insufficient knowledge of COPD，and further training and assessment in this area need to be further strengthened；emphasis should be placed on strengthening community male，low-educated and low-professional title grade practitioners in COPD knowledge training；among the approaches to obtain professional knowledge of COPD，it is more effective to listen to the lectures by experts outside the hospital at the community health service center/community health service station and the experts organized by the medical society on the spot；the general practitioner's cognitive level of COPD can be also improved through the distributing COPD health education manuals，conducting health education lectures and health consultations for patient education.

The recent updates of guidelines for the management of gout have gradually promoted the standardization of gout diagnosis and treatment. What's more，the newly released 2020 American College of Rheumatology Guideline for the Management of Gout has made some vague concepts to be clear. As general practitioners play a vital role in the management of gout，a common and frequently-occurring disease，we interpreted the 2020 American College of Rheumatology Guideline for the Management of Gout from their perspective，and compared it to the latest Chinese guideline for the management of gout，offering proposal ideas to help general practitioners with the diagnosis and treatment of gout.

Background　At present，general practitioners（GPs） in China are facing many problems，such as heavy work tasks，low social recognition，and imperfect salary incentive mechanism，which make them prone to job burnout.Analyzing the factors associated with job burnout in GPs can provide a basis for stabilizing the workforce of GPs，and improving the quality of care at primary care level.Objective　To investigate the prevalence of job burnout of GPs in China and explore its influencing factors.Methods　Multistage stratified random sampling was used to conduct a questionnaire survey in 3 244 GPs with at least one year of full-time work experience in community health centers from the eastern，central，and western China between October，2017 and February，2018.The questionnaire is consisted of two parts：the first part is the sociodemographic information and the second part is the job burnout scale.Burnout was measured using the revised version of the Chinesized 22-item Maslach Burnout Inventory-Human Services Survey，including emotional exhaustion（EE），depersonalization（DP） and low personal accomplishment（PA）．Associated factors with burnout and its subscales among GPs were estimated using a stepwise binary Logistic regression model.Results　A total of 3 236（99.75%） of the GPs returned responsive questionnaires.The survey results showed that the prevalence of high EE，high DP and low PA among the respondents was 43.17%（1 397/3 236），22.93%（742/3 236） and 41.19%（1 333/3 236），respectively.Stepwise binary Logistic regression analysis revealed that location，educational level，working hours per day，and overtime were associated with high EE（P<0.05）．Location，sex，years of working as a GP，and income level were associated with high DP（P<0.05）．Location，age，and working hours per day were associated with low PA （P<0.05）．Conclusion　The prevalence of burnout among Chinese GPs is high，which is more often manifested as EE and low PA.The associated factors for burnout are complex and various.Actions such as optimizing the working hours，reducing the work intensity，increasing the wages，and attaching importance to the career prospect are needed to relieve the burnout of GPs.

Skills for communicating with patients are one kind of core ability that general practitioners（GPs） must possess，ensuring the improvement of services quality provided by GPs. The systematic，simple and practical doctor-patient communication models developed by foreign countries based on a large amount of research experience have been widely used in medical education，and proved to be crucial for improving doctors' skills for communicating with patients.In contrast，in China，GPs show relatively poor abilities in communicating with patients，which may be caused by insufficient awareness of training this ability in medical students influenced by the traditional biomedical model，and unsatisfied quality of such trainings due to lack of relevant teaching materials for medical students with different majors at different learning stages，and lack of relevant theoretical studies. As systematic，simple，and practical curriculum is the key to ensure the quality of training GPs' skills for communicating with patients，we detailedly analyzed the recommended major doctor-patient communication models in foreign countries（patient-centered communication，Calgary-Cambridge Guide，SEGUE Framework，Four Habits Model，Kalamazoo Essential Elements communication Checklist-Adapted），aiming at providing a reference for developing course contents of doctor-patient communication skills for GPs in China.

Sexual health is an important component of human health. Ignoring, misunderstanding and having misconceptions of sexual health will greatly impair people's quality of life. Owing to the concept of holistic health in general medicine, influence of biopsychosocial model of health, and family as a vital unit of care, and adherence to protecting patient privacy as a professional responsibility, general practitioners (GPs) have obvious advantages in offering sexual health services. However, more efforts are needed to strengthen the promotion of sexual healthcare knowledge popularization, sexual health screening, and sexual problem diagnosis and treatment in primary care of China. To provide support for Chinese GPs to deliver sexual health services, Department of General Medicine, the University of Hong Kong-Shenzhen Hospital, has pioneered in providing sexual health services and exploring new service delivery models using actions such as constructing a sexual health service team and a genital examination skills workshop, carrying out the consultation about sexual history, and developing a standard diagnostic and therapeutic procedure for sexualproblems.

Background　The development of general practitioners'（GPs'） competence assessment systems has become mature in foreign countries. However，in China，GPs' competence has been assessed mainly by healthcare institutions themselves. Due to different standards and evaluation methods of various institutions，the authority and objectivity of the assessment results cannot be guaranteed. Therefore，it is necessary to establish a unified standard in line with the current development of general practice. Objective　To develop a tiered GPs' competence assessment system using the Delphi method，and based on this，to develop a theory-skill-humanity（TSH） cube model，to improve the GPs' competence assessment more accurately and objectively via promoting the homogenous progress. Methods　From April to May 2019，using literature review and group discussion，we developed a preliminary framework of a three-tiered GPs' competence assessment system consisting of 3 first-tier indices（general practice theory，skills and humanity），44 second-tier indices and 44 third-tier indices. Then we developed the GPs' competence assessment system after revising the framework according to the results analysis data of a two-round Delphi survey with 28 experts conducted from July 1 to September 10，2019. We analyzed the experts' basic personal information，suggestions for the framework，and their positive，authoritative and Kendall's concordance coefficients as well as consensus level in the survey. Results　The familiarity and judgment coefficients were 0.900 and 0.936，respectively，in the first round of survey，and were 0.948 and 0.952，respectively，in the second round.The authority coefficient in the first and second round expert consultation was 0.918 and 0.952，respectively，which were both above 0.70. The importance and accessibility coefficients were 0.471 and 0.409，respectively，for the first round of survey，and were 0.363 and 0.386，respectively，for the second round. The final GPs' competence assessment system includes three domains（general practice theory，clinical skills and humanity），and 43 assessment items. In accordance with this system and previous patents，the TSH model was developed.Conclusion　 Our GPs lusmpetence assessment system developed based on the results of email-based surveys with high expertsent sytive and authoritative coefficients and consensus，includes three first-tier indices，43 second-tier indices and 43 third-tier indices，which is scientific，reliable and reliable verified statistically.

Family systems theory is a characteristic theory in general practice, which suggests that in the process of diagnosis and management of a patient, besides physiological problems, general practitioners should pay attention to the influence of family factors on the disease development and treatment as well as rehabilitation of the patient. We reported a case of depression treated with family therapy by the general practitioner after analyzing the impact of her family factors using biopsychosocial model and ideas of general medicine, hoping to improve general practitioners' capability of family-based disease management.

General Practitioners Should Understand The Subtype Of Essential Hypertension-Longitudinal Hypertension

NIE Liantao¹，ZHANG Fangfang¹，JING Yan¹，HUANG Juxiang¹，YAN Qiongwen¹，ZHOU Yuhan¹，

LI Shifeng¹，LI Zhongjian¹，RUAN Bingxin²

1.Department of    Electrocardiography,     the Second   Affiliated        Hospital of    Zhengzhou University,450014,China

2.Department of Electrocardiography,Nanning first people's Hospital,530022,China

^*Corresponding author:LI Zhongjian,Professor, chief technologist; E-mail: lizhongjian56@126.com 【Abstract】In clinical work and daily life，target organ damage caused by blood pressure ≥ 140/90mmHg（1mmHg=0.133kPa）usually attracts attention，but target organ damage caused by blood pressure <140/90mmHg will often be ignored.Therefore，in order to improve the innovative concept and research orientation of hypertension,the research team proposed "longitudinal hypertension".This article found that the transverse hypertension emphasizes the “quantity” change caused by blood pressure≥140/90mmHg ， while the “longitudinal hypertension” emphasizes both "quantity" change and "quality" change of each individual through the introdution of the concept，diagnostic criteria and advantages of "longitudinal hypertension"，

similaritiesanddifferences between “longitudinal hypertension” and transverse hypertension.Therefore，as primary health caregivers，general practitioners should understand and master the essence，concept，diagnosis and treatment methods of "longitudinal hypertension".At the same time，the research team also hopes to discuss and improve the existence and application value of "longitudinal hypertension" with colleagues.

【Keywords】 general practitioner, essential hypertension, transversehypertension, longitudinal hypertension, electrocardiography, morphology

Five thousand years of traditional Chinese Medicinehas the concept and characteristics of "one person, one pulse diagnosis" and "one person, one prescription".That is to say, the method and traditional idea of syndrome differentiation and treatment according to people are in the same line with the idea of modern evidence-based medicine.In clinical work and daily life,the damage of heart, brain, kidney, eyes, ears (sudden deafness/tinnitus) and other target organs caused by blood pressure≥140/90mmHg (1mmHg=0.133 kPa) often attracts people's attention.However, the target organ damage caused by blood pressure <140/90mmHg is not recognized, understood or even valued by people, but it can also lead to the same outcomes as the target organ damage caused by blood pressure≥140/90mmHg, such as cerebral thrombosis, cerebral hemorrhage, myocardial infarction and even sudden cardiac death.Based on this, our team proposes the concept and diagnostic method of "longitudinal hypertension"(or atypical hypertension) for the first time.That is to say, the patient's blood pressure increases 20-30mmHg compared with that at the age of 18 years old, accompanied by clinical manifestations of hypertension and objective examination indications of target organ damage,which can be diagnosised "longitudinal hypertension".Why does "longitudinal hypertension" cause damage to human target organs?Because everyone's appearance, height, weight, appetite, sleep and so on are different, so the basic blood pressure (blood pressure at the age of 18years old) and blood pressure with age (adult) will bedifferent.Howto determine, judge and "customize"one person's "longitudinal hypertension"?Clinically, it can be combined with the subjective and objective indicators of patients.Subjectiveindicators-hypertension symptoms:headache,dizziness, head discomfort, blurred vision, stiff neck, fatigue, etc.Objective indicators-functional examinations (occasional blood pressure measurement, ambulatory blood pressure measurement, home self-test blood pressure measurement, cardiac function examination, etc.),electrical examinations (ECG, vectorcardiogram, Holter, etc.),morphological examinations (echocardiography, X-ray, CT, MRI, etc.) andlaboratory examinations.As an innovative idea and research direction to improve hypertension, longitudinal hypertension proposed in this paper is essentially different from transverse hypertension. For example, transverse hypertension emphasizes the change of "quantity" of blood pressure≥140/90mmHg, while longitudinal hypertension emphasizes not only the change of "quantity", but also the change of "quality" of each individual.Therefore, general practitioners should understand and master the essence, concept, diagnosis and treatment of "longitudinal hypertension", so as to contribute to the prevention and control of cardiovascular and cerebrovascular diseases in healthy China 2030.

1.What is the globally accepted blood pressure assessment method?

1.1 Blood pressure measurement At present, there are three main methods for blood pressure diagnosis, level classification and evaluation of antihypertensive effect in the world, including clinic blood pressure, ambulatory blood pressure and home self-test blood pressure. However, the European hypertension guidelines^[1] no longer recommend clinic blood pressure as the only standard for screening and diagnosis of hypertension, but pay attention to ambulatory blood pressure and home blood pressure monitoring for the detection and identification of white coat hypertension and cryptorchidism Occult hypertension. The new guidelines for hypertension in the United States^[2] also agree with this view.

1.2 Diagnostic criteria of hypertension At present, the diagnostic criteria of hypertension (Europe, China^[1、3]): (1) the diagnostic criteria of clinic blood pressure:≥140/90mmHg without using antihypertensive drugs measured three times on different days; (2) the diagnostic criteria of ambulatory blood pressure: 24h ambulatory mean blood pressure≥130/80mmHg, daytime≥ 135/85mmHg, night≥120/70mmHg (3) the diagnostic criteria of home self-test blood pressure:≥

135/85mmHg.American diagnostic criteria for hypertension: ≥ 130/80mmHg without using antihypertensive drugs measured three times on different days.The continuous adjustment and change of the diagnostic criteria for hypertension is due to the continuous understanding of the harm of hypertension. From the first generation of hypertension criteria ≥160/95mmHg to the second generation of hypertension criteria ≥140/90mmHg, and then to the new American guidelines ≥ 130/80mmHg, all lie in the prevention and control of cardiovascular and cerebrovascular events^[4].Studies have shown that blood pressure >115/75 mmHg, blood pressure growth and the risk of cardiovascular and cerebrovascular events are log linear correlation.The concept put forward of prehypertension or high normotensive blood pressure（120~139/80~89mm Hg）demonstrates that the risk of hypertension and coronary heart disease in prehypertensive population is significantly higher compared with the population <120/80mmHg, which suggests that there may be early damage of target organs such as heart, brain, kidney, eye and blood vessel in prehypertensive patients^[5].The epidemiological datas in China showed that 32.1% of the population aged 35-54 years has prehypertension, and the risk of stroke, coronary heart disease and cardiovascular events increases by 56.0%, 44.0% and 52.0% respectively^[6].There are more than 10 million people with hypotension in China^[7].With the increase of blood pressure to a certain extent, there will be hypertension related clinical symptoms and target organ damage.Therefore, the adjustment of diagnostic criteria for hypertension should be based on evidence-based medicine, and there are differences in race, diet structure and living habits between China and foreign countries,which needs consistent and need more in-depth study.

1.3 Target of antihypertension Chinese guidelines^[3] recommend that patients with low risk stratification of hypertension: <140/90mmHg, patients with high risk stratification of hypertension: < 130/80mmHg,consistenting with the new antihypertensive goal of the European guidelines^[1], but contrary to the 2017 USA guidelines^[2],The target of American blood pressure control is < 130/80mmHg for patients with stable coronary heart disease, chronic heart failure, chronic kidney disease, diabetes, even elderly patients in good condition aged over 65 years old .In Chinese guidelines, on the basis of the above, there are age stratification: (1) for patients over 80 years old with hypertension, the blood pressure is reduced to <150/90mmHg first, and then to <140/90mm Hg if they can tolerate it; (2) for elderly weakened patients with hypertension, the systolic blood pressure control target is < 150 mm Hg, but not less than 130 mm Hg as far as possible.According to the 2018 European hypertension guidelines^[1], the lower limit of blood pressure control should be ≥120/70mmHg for general hypertensive patients, and ≥130/70mmHg for chronic kidney disease patients and elderly patients over 65 years old. The new guidelines of China, the United States, and Europe define the goal of reducing blood pressure in hypertension, which aims to avoid the risk of excessive blood pressure and adverse cardiovascular events.

In conclusion, the guidelines and diagnostic criteria for hypertension at home and abroad are still imperfect.For example: (1) the diagnosis and treatment of hypertension (transverse hypertension) only emphasizes the value of blood pressure, age, risk factors and so on to start antihypertensive treatment and effect evaluation, but does not fully evaluate the objective indicators of clinical symptoms and target organ damage; "Longitudinal hypertension" ,the special subtype of essential hypertension (blood pressure≥140/90mmHg), is not covered or ignored / not recognized, or blood pressure<140/90mmHg is not covered, but patients do have objective evidence of clinical symptoms and target organ damage of hypertension.Therefore, our research team first innovatively put forward the concept of "longitudinal hypertension" (or atypical hypertension), with the purpose of improving the current deficiencies in the diagnosis and treatment of hypertension at home and abroad, so as to promote the health of the whole people and achieve the grand goal of a healthy world.

2.What is longitudinal hypertension (atypical hypertension)?

2.1 Origin of "longitudinal hypertension" Hypertension is divided into primary hypertension and secondary hypertension. Secondary hypertension is caused by other diseases, drug treatment effect is poor or invalid.With primary disease cured, blood pressure then becomes normal.While,the primary hypertension cann’t determine the causes through a variety of examination methods,nor be radically cured,but drug treatment is effective.Our research team believes that primary hypertension and secondary hypertension with blood presure≥140/90mmHg are transverse hypertension, which can also be called typical hypertension.The main results are as follows: (1) In the absence of antihypertensive drugs, the blood pressure measured in three clinics on different days is ≥140/90 mm Hg (Europe, China);(2) According to the 2017 American hypertension standard, blood pressure≥130/80mmHg, which is the scope of hypertension recommended by accepted guidelines.The "longitudinal hypertension" proposed by our research team should belong to primary hypertension, which is actually a subtype of primary hypertension (also known as atypical hypertension), or a special type of hypertension.

2.2 Concept of "longitudinal hypertension" The patient has abnormal clinical manifestations and instrument examination of hypertension,whose blood pressure is less than 140/90 mmHg but increased by 20-30 mmHg compared with his own 18-year-old blood pressure (adult basic blood pressure) .Above conditions meet the individual diagnostic criteria of hypertension,which can also be called atypical hypertension / progressive hypertension / historical hypertension / temporal hypertension / progressive hypertension / individual precise hypertension / private customized hypertension.According to Article 11 of the civil code of the people's Republic of China^[8], 18-year-old subjects are regarded as the baseline reference of "longitudinal hypertension". It is pointed out that citizens over 18 years old are adults. If minors (0-17 years old) are selected as the subjects, their age span is large, and it is not easy to operate or even error in the actual observation and comparison work.People who do not monitor their blood pressure at the age of 18 can obtain adult basic blood pressure by two methods: (1) clinical consultation:most people know that their basic blood pressure is low and often have a series of clinical manifestations caused by low blood pressure, which is easy for patients to know when they are young; (2) through 24-hour ambulatory blood pressure monitor:looking for the lowest values of systolic blood pressure and diastolic blood pressureb in 24-hour ambulatory blood pressure, combined with the patients' clinical symptoms and abnormal changes related to the increase of blood pressure in routine electrocardiogram, can be determined.

2.3 Diagnostic criteria of "longitudinal hypertension" (1) The patient's blood pressure is less than 140/90mmHg, but with 20-30mmHg higher than that of 18 years old; (2) The patient has clinical manifestations of hypertension; (3) special examination (functional / electrical / morphological / biochemical examination, etc.) showes abnormal indications of target organ damage inhypertension.

2.4 Diagnostic methods and key points of "longitudinal hypertension" (1) functional examination: occasional blood pressure / whole day mean blood pressure increased by 20-30 mmHg compared with that at the age of 18; (2) electrical examination: ECG / vectorcardiogram / Holter diagnosis: ①left atrium / left ventricle hypertrophy; ②myocardial ischemia (ST-T change); ③arrhythmia; (3) morphological examination: color Doppler ultrasound / X-ray / CT / MRI diagnosis: ① left atrium/ Left ventricular hypertrophy; ② arrhythmia; ③ abnormal cardiac function; (4) biochemical examination: hypertension related indicators are abnormal.

3.What are the advantages of longitudinal hypertension monitoring? What should general practitioners do?

3.1 Advantages of "longitudinal hypertension"monitoring Based on the origin, concept, diagnostic criteria, diagnostic methods and key points of "longitudinal hypertension", as general practitioner, we should change our thinking, change the traditional medical concept, change the point of view that clinical and medical technology can not communicate, and adopt specific diagnosis and treatment methods for specific patients.Through the introduction of primary hypertension, secondary hypertension and "longitudinal hypertension"(atypical hypertension / progressive hypertension / historical hypertension / temporal hypertension / progressive hypertension / individual precise hypertension / private customized hypertension) proposed by our research team,General practitioners have a preliminary understanding of "longitudinal hypertension", especially the practicability, rationality and scientificity of "longitudinal hypertension" in clinical diagnosis and treatment of hypertension, and it is significant to enrich the theory and practice system of hypertension, especially based on evidence-based medicine.It is concluded that the definition and nomenclature of "longitudinal hypertension" is more conducive to the development of clinical hypertension work.In order to keep "longitudinal hypertension" in mind, the advantages of monitoring "longitudinal hypertension" are described as follows: (1) "longitudinal hypertension" has the characteristics of atypical hypertension / progressive hypertension / historical hypertension / temporal hypertension / progressive hypertension / individual precise hypertension, and more has the characteristics of "private customized hypertension" diagnosis and treatment,which is relative to transverse hypertension.(2) Transverse hypertension focuses on group and individual blood pressure >140/ 90 mmHg,which emphasizes the change of "quantity" but ignores the change of "quality" (clinical manifestation and target organ damage of hypertension);"Longitudinal hypertension" emphasizes that blood pressure of the group and individual is 20-30mmHg larger than themselves, which not only emphasizes the change of "quantity" of each individual, but also emphasizes the change of "quality" of each individual.

3.2 general practitioners As a general practitioner, he should master the following skills: (1) he should be familiar with the symptoms and manifestations of hypertension; (2) he should be familiar with ECG / vectorcardiogram / ambulatory ECG / ambulatory blood pressure / ultrasound, X-ray, CT, MRI / laboratory examination and other hypertension diagnosis and treatment skills, and conduct ECG / vectorcardiogram / ambulatory ECG / ambulatory blood pressure examination for individuals / groups.In particular, the routine ECG can be used as a screening test for hypertension, which is not only a green test, but also can be widely used, because the ECG examination is cheap, and can be repeated for many times. It is not harmful to the human body, and the subjects are more willing to accept it, which has guiding significance for the diagnosis and treatment of "longitudinal high blood pressure";(3) he should understand and recognize that hypertension is a syndrome that causes damage to multiple organs (heart, brain, kidney, eyes, ears, etc.).

4.What are the similarities and differences between transverse hypertension and "longitudinal hypertension"?

4.1 Similarities and differences between transverse hypertension and longitudinal hypertension 4.1.1 Differences between transverse hypertension and longitudinal hypertension (1) Transverse hypertension,whose blood pressure≥140/90mmHg, increases by 20-30mmHg or even higher on the basis of 18 years old;"Longitudinal hypertension",whose blood pressure < 140/90mmHg, increases by 20-30mmHg or even higher on the basis of 18-year-old blood pressure, but the blood pressure is always <140/90mmHg.

4.1.2 Common points of transverse hypertension and "longitudinal hypertension" (1) Both types of hypertension have symptoms of hypertension, such as headache, dizziness, blurred vision, deafness, tinnitus, and fatigue; (2) both types of hypertension have ECG changes caused by target organ damage: left atrial / left ventricular hypertrophy, myocardial ischemia (ST-T change), arrhythmia.

4.2 Diagnosis and evaluation of transverse hypertension and "longitudinal hypertension" Both transverse hypertension and longitudinal hypertension can cause abnormal changes in the function, electricity, morphology, biochemistry and clinical symptoms of target organs such as heart, brain, kidney, eyes and ears.According to this, we can apply functional examination (clinic blood pressure, ambulatory blood pressure, cardiac function;cardiac electrical examination: routine electrocardiogram, vectorcardiogram, dynamic electrocardiogram) combined with clinical symptoms to comprehensively analyze and judge, accurately diagnose transverse hypertension and "longitudinal hypertension". At the same time, we can apply the above examination methods to accurately evaluate the treatment effect of transverse hypertension and "longitudinal hypertension" .According to the observation and research of ECG Department of the Second Affiliated Hospital of Zhengzhou University in the past 20 years, it is found that the application of ECG technology can early detect and accurately diagnose the ECG changes caused by transverse hypertension and "longitudinal hypertension" cardiac electrical damage, such as left atrial / left ventricular hypertrophy, myocardial ischemia (ST-T change), arrhythmia.The application of ECG technology can also accurately evaluate the treatment effect of transverse hypertension and "longitudinal hypertension", such as atrial / ventricular depolarization wave and repolarization wave: Ptfv₁ disappeared / QRS wave voltage decreased / ST segment depression returned to normal / T wave abnormal change improved / arrhythmia improved after treatment.

4.3 Relationship between "longitudinal hypertension" and physiological hypertension caused by agingsystem The blood pressure rise caused by longitudinal hypertension includes: (1) 20-30 mm Hg increase on the basis of the blood pressure at the age of 18; (2) symptoms of hypertension, such as headache, distension, dizziness, blurred vision, deafness, tinnitus and fatigue; (3) electrical changes of the heart (ECG changes) caused by target organ damage of hypertension: left atrium/ Left ventricular hypertrophy, myocardial ischemia (ST-T change), arrhythmia.Physiological blood pressure elevation is characterized by: (1) there may be a slow increase of blood pressure with age, but never a sudden increase of 20-30 mm Hg; (2) no symptoms of hypertension; (3) no changes of ECG caused by target organ damage of hypertension.

4.4 Treatment goals of transverse hypertension and "longitudinal hypertension" In terms of treatment, the goals of transverse hypertension and "longitudinal hypertension" are the same, and there is no difference.The specific manifestations are: (1) ambulatory blood pressure examination:

mean systolic / diastolic blood pressure reduces 20-30mmHg than before, even more;(2) The clinical symptoms are relieved or disappeared;(3) Cardiac electrical examination: atrial / ventricular depolarization wave and repolarization wave: Ptfv₁ disappeared / QRS wave voltage decreased / ST segment depression returned to normal / T wave abnormal change improved / arrhythmia improved after treatment.

5  What is the application prospect of longitudinal hypertension?

5.1         The origin, concept, diagnostic criteria, diagnostic methods and key points,diagnostic difference and common ground between longitudinal hypertension and transverse hypertension proposed by our research team,which expectes colleagues to discuss and improve the existence and application value of "longitudinal hypertension".

5.2         Our research team has carried out "longitudinal hypertension" for 20 years, and has accumulated a large number of cases and experience in diagnosis and treatment, but lack of multi center, big data and other evidence-based medicine verification and support.To carry out the research work of "longitudinal hypertension" can realize the normal blood pressure of the whole people, reduce the damage to human target organs caused by hypertension, promote the physical and mental health of the whole people, and build a "2030 healthy China".

The author's contribution: Li Zhongjian is responsible for the conception and design of the article, the overall supervision and management of the article; Zhang Fangfang, Yan qiongwen and Zhou Yuhan are responsible for the implementation and feasibility analysis of the research; Nie liantao and Ruan Bingxin are responsible for writing the paper; Jing Yan and Huang Juxiang are responsible for the revision of the paper; Li Shifeng is responsible for the quality control and review of the article.

There is no conflict of interest in this article

Feference

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Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.[J] .J Am Coll Cardiol，2018，71(19): e127-e248.DOI：10.1016/j.jacc.2017.11.006

[2]     WILLIAMS B，MANCIA G，SPIERING W，et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension.[J] .Eur Heart J，2018，39(33)：3021-3104.DOI：10.1093/eurheartj/ehy339

[3]     Hypertension Alliance (China), hypertension branch of China Association for the promotion of international exchange in health care, revision committee of Chinese guidelines for the prevention and treatment of hypertension, etc. Chinese guidelines for the prevention and treatment of hypertension (revised in 2018) [J]. Chinese Journal of Cardiology,2019，24(1):25-56.DOI：

10.3969/j.issn.1007-5410.2019.01.002 http://rs.yiigle.com/CN113805201901/1118901.htm

[4]     VASAN R，LARSON M，LEIP E， et al. Impact of high-normal blood pressure on the risk of cardiovascular disease.[J] .N Engl J Med， 2001， 345(18):1291-1297. DOI:10.1056/NEJMoa003417

[5]     GILES T，MATERSON B，COHN J，et al. Definition and classification of hypertension: an update.[J] .J Clin Hypertens

(Greenwich)， 2009， 11(11): 611-614.DOI：10.1111/j.1751-7176.2009.00179.x

[6]     SUN X，YUAN H.Review of sub-clinical Lesions in prehypertension［J］.Advancesin cardiovascular diseases，2010，31(2)： 197-200.DOI：10.3969/j.issn.1004-3934.2010.02.015

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Appendix: Interview with the author about the aticle:general practitioners should understand the subtype of essential hypertension "longitudinal hypertension"

Problem 1: The diagnostic criteria for hypertension is determined by a large amount of evidence-based medicine in the world. An important reason for not lowering the diagnostic criteria in China is that if the diagnostic criteria is lowered a little, the management population will increase significantly. At present, the main contradiction in China is the low awareness rate and treatment rate of hypertension. How to balance this problem?

1.The new guidelines in the United States have been similarly questioned, but there is an account in the guidelines. The cost of reducing the standard of hypertension and expanding the treatment population is far less than the cost of target organ damage caused by elevated blood pressure, and the direct beneficiaries are the patients themselves and the health of the national population. Therefore, the new guidelines in the United States recommend that the blood pressure should be controlled below 130/80mmHg (1 mmHg=0.133kPa) in a tolerable situation.

2.There is no change in the diagnostic criteria of hypertension in China, which is due to the consideration of race, diet structure, lifestyle and other reasons. It is also the goal of Chinese experts to find the criteria suitable for the Chinese population. However, in clinical work, blood pressure <140/90mmHg, patients with symptoms and abnormal changes of target organ damage by instrument examination are many.We can't ignore this kind of people just because we are worried about the expansion of the management population, which will lose the significance of individual diagnosis and treatment of doctors,nor can we achieve the grand goal of healthy China. 3. The low awareness rate can be made up by increasing the popularization of science and other measures,the low treatment rate is due to the single diagnosis of hypertension in the world, which is basically diagnosed only by measuring the blood pressure in the clinical room.The lack of ambulatory blood pressure monitoring and a variety of instruments to evaluate the diagnosis and treatment of target organ damage caused by hypertension makes it difficult for patients to understand the damage caused by hypertension.We propose that "longitudinal hypertension" is a subtype of essential hypertension, which is a supplement and improvement to essential hypertension. To summarize the characteristics and diagnosis process of this kind of population is not only the need of clinical practice, but also the need of patients, but also the need of healthy China.

Problem 2: Hidden hypertension and white coat hypertension exist in hypertension, which are related to target organ damage.What is the difference between longitudinal hypertension and the above two types of hypertension?

Hidden hypertension is high blood pressure (blood pressure>140/90mmHg) measured by family and normal blood pressure in clinical room. White coat hypertension is high blood pressure (blood pressure>140/90mmHg) measured in clinical room and normal blood pressure at home. Both of them are high blood pressure (blood pressure>140/90mmHg) and can lead to target organ damage. Our "longitudinal hypertension" is different from the above two kinds of hypertension. The blood pressure is less than 140/90mmHg, and it also has target organ damage.

Problem 3: The symptoms of hypertension are not specific. The ECG of tall and thin people shows high voltage in the left ventricle and the left atrium increased with age.How to judge whether it is physiological or caused by blood pressure fluctuation?

1. Although the symptoms of hypertension are not specific, that reflect the clinical symptoms of some patients with hypertension, which has certain guiding significance for the diagnosis of hypertension;

2.High and thin people can show high voltage of left ventricle, but it may be: (1) it is related to thin chest wall; (2) it is related to hypertension; (3) the two coexist;

3.The increase of age is not the enlargement of left atrium, but the prolongation and broadening of ECG P wave duration.The prolongation and broadening of P wave duration can be seen in two cases, one is the abnormal conduction caused by atrial block, the other is the enlargement of left atrium caused by hypertension, the stretching of atrial myocytes and the dilatting or thinning of atrial wall.The former is caused by atrial block, ECG manifestations the extension of P-wave duration and the decrease of P-wave amplitude.The latter is caused by the increase of blood pressure and atrial enlargement, ECG manifestationsP-wave amplitude is higher than that of atrial block, P-wave bimodal, Ptfv₁ abnormality, left ventricular high voltage, left ventricular hypertrophy, ST-T abnormality, arrhythmia, etc.

Question 4: what the article wants to emphasize is that everyone needs different blood pressure and different blood pressure threshold. The article should put forward a calculation method for individuals, which is similar to risk assessment. Is this more reasonable?

We emphasize that the blood pressure threshold of each person is different, and put forward the specific diagnosis basis and process of longitudinal hypertension: (1) the blood pressure in the clinical room is less than 140/90mmHg or the 24-hour ambulatory mean blood pressure is less than 130/80mmHg; (2) the patients have symptoms of hypertension; (3) the blood pressure of the patient increases 20-30 mmHg over his blood pressure when 18 years old; (4) The instrument examination has the basis of hypertension target organ damage, such as: ① ECG examination: A. left atrial / left ventricular hypertrophy, B. myocardial ischemia (ST-T change), C. arrhythmia; ② eye and ear examination showed changes of hypertension damage.

Of course, we can also evaluate the score of patients with longitudinal hypertension, such as: ECG abnormal change 1 item 1 point, 2 items 2 points, 3 items 3 points; clinical symptoms:1 item 1 point, 2 items 2 points, 3 items 3 points; blood pressure increment: younger basal blood pressure increased by 10mmHg 1 point, increased by 20mm Hg 2 points, increased by 30mmHg 3 points and other specific quantitative indicators.

Question 5: it is mentioned in this paper that the blood pressure level of "longitudinal hypertension" should be compared with the blood pressure level of 18-year-old people. How can people who do not monitor their blood pressure at 18-year-old diagnose "longitudinal hypertension"?

People who do not monitor their blood pressure at the age of 18 can obtain adult basic blood pressure by two methods: (1) clinical consultation:most people know that their basic blood pressure is low and often have a series of clinical manifestations caused by low blood pressure, which is easy for patients to know when they are young; (2) through 24-hour ambulatory blood pressure monitor:looking for the lowest values of systolic blood pressure and diastolic blood pressureb in 24-hour ambulatory blood pressure, combined with the patients' clinical symptoms and abnormal changes related to the increase of blood pressure in routine electrocardiogram, can be determined.According to this method, our research team has been in clinical application for nearly 20 years.

To sum up, there are still many unsatisfactory places for our team to creatively put forward the concept of "longitudinal hypertension" in the world.However, our research team firmly believes that in the process of continuous improvement, it will bring gospel to the accurate diagnosis, treatment and effect evaluation of patients with hypertension around the world, which may have more long-term significance for the early prevention of patients with hypertension, and has far-reaching and evidence-based medicine strategic guiding significance for the realization of healthy China.

 

 

[Expert profile] Li Zhongjian, chief technician, professor, master's supervisor, special reviewer of American circulation magazine, international well-known ECG expert, and doctoral/Master's thesis review expert of the academic degree center of the Ministry of education in 2020.Director of Zhengzhou University institute of electrocardiology, director of Henan electrocardiology diagnosis and treatment center,Visiting professor of Xiamen University.Director of Henan key medical discipline (ECG diagnosis specialty),former deputy director of China electrocardiographic information society/electrocardiographic consultation center, director of national and provincial electrocardiographic continuing education. Outstanding worker of electrocardiography in China, "my favorite health guard"and "outstanding person of scientific and technological innovation" in Henan Province.He obtained 17 scientific research achievements and projects, 13 national patents and 200 papers.At the invitation of the National Space Center and many international conferences, he gave lectures on "ECG identification research" and "fetal ECG";He was invited to attend many international conferences such as "world heart conference" and "international society of ambulatory electrocardiography and noninvasive electrocardiography";In China, he is the first person to put forward the scientific idea of "adhering to the road of electrocardiology with Chinese characteristics",leading the Department to win the national "youth civilization".

 

In China，the shortage of general practitioners（GPs） and difficulties in retaining general practice talents have produced great effects on the development of primary healthcare services，and also brought great challenges to the implementation and promotion of the tiered healthcare system. So it is necessary to formulate policies to maintain and improve the attractiveness of general practice as a career. To this end，we performed a SWOT analysis based on an overview of domestic general practice and general practice workforce，and proposed the following ideas：strengths consist of extensive policy support，continuous development of general practice education and developmental significance similar to a goal of building a healthy China；weaknesses include low social identity for GPs，and lack of efficient manage system for GPs；opportunities cover the reform of the pharmaceutical and healthcare system，construction of the medical consortium，and development of health information technologies；threats contain lack of limitations for some medical practice behaviors，training system for GPs and appropriate hardware infrastructure. Then we put forward recommendations as incentive solutions to enhance the attractiveness of general practice as a career and promote the sustainable development of general practice，including increasing the financial support for general practices，strengthening the development of a management system for general practices，broadening the promotion platform for GPs，and optimizing the configuration of the GP team.

Hospice care improves a patient's quality of life at the end of life via reducing his physical and mental sufferings，and also relieves the physical and mental burden endured by his family members. In recent years，rich experience in developing hospice care has been accumulated in other countries，with a prominent feature of GPs being primary providers of home-based hospice care. However，given that the development of hospice care in China started late，the development of relevant essential projects is weak，and the research on GPs involvement in hospice care is still in its initial stage，it is necessary for China to accelerate the construction of a hospice care system to meet the increasing demand for hospice care. In view of this，we analyzed and summarized the useful experience of GPs participating in hospice care in the US，the UK，Australia and other countries，then put forward insightful suggestions in accordance with current status and characteristics of China's hospice care system：establishing a multi-level hospice care system，supplemented by activity-based payment and health insurance coverage；formulating guidelines for home-based hospice care services with the clarified scope of practice and responsibilities of GPs；strengthening hospice care education and training for GPs and nurses to improve their competencies；raising the awareness of advance care planning among doctors and patients with effective publicity tools to promote the long-term development of hospice care in China.

Illness anxiety disorder（IAD）is a common mental disease encountered by community general practitioners （GPs），which often requires long-term treatment and follow-up. Although community health services are good applicable for treating IAD owing to its continuity and comprehensiveness，community-based management strategies for IAD are very limited，and the research on community GPs' perspectives regarding coping strategies for IAD is very rare. Based on a literature view of IAD，we performed an in-depth analysis of three essentials that community GPs should master for managing IAD：differentiating IAD from other illnesses，exploring potential factors associated with symptoms，evaluating available useful medical and information resources. Furthermore，we put forward IAD managing strategies for community GPs in accordance with features and ideas of community health services，including a thorough evaluation of symptoms and psychological states，implementing shared decision-making，and delivering continuous patient health education. Our study will help to enhance community GPs' management level of IAD.

In clinical practice，general practitioners frequently encounter patients with medically unexplained symptoms （MUS），which evoke a great challenge for both diagnosis and management.In this paper，we presented a case of generalized involuntary muscle beating over a duration of 2 months admitted to Department of Family Medicine，the University of Hong Kong-Shenzhen Hospital on July 13，2019.The diagnostic and therapeutic process of this case demonstrated routine application of biopsychosocial model in primary care，and a systematic approach incorporating the 4P model（namely，predisposing，precipitating，perpetuating and protective factors）to history taking，finding the clues and collecting the evidence that helps to explain the symptoms to the patient in an assuring way，facilitate active management，improve clinical outcome，and ultimately deliver whole-person care.

Doctor-patient communication competence is the essential quality of general practitioners（GPs）.Good communication between doctors and patients is not only the basis of patients' trust but also an important guarantee for the smooth implementation of GPs' community health service.At present，the influence of communication competence on doctor-patient relationship has attracted more and more attention and the training for doctor-patient communication competence has become one research focus.However，the increasingly tension of doctor-patient relationship indicates that the communication between doctors and patients is still not satisfactory.Therefore，this paper illustrates the current situation of training for doctor-patient communication competence at home and abroad，and emphasizes the necessity of improving the doctor-patient communication competence among GPs.Moreover，this paper draws on relevant foreign experience to explore concrete measures to improve the doctor-patient communication competence of GPs，such as setting up communication courses，applying various training forms，and strengthening the assessment of doctor-patient communication competence，in order to provide the theoretical reference for the education and training of doctor-patient communication competence of GPs in China.

Chronic obstructive pulmonary disease（COPD）is a common and frequently-occurring disease in clinical practice.In China，the number of COPD patients is nearly 100 million，and COPD constitutes another chronic disease with heavy disease burden besides hypertension and diabetes.However，unlike hypertension and diabetes，COPD has not received enough attention from patients，doctors and the government，and its early diagnosis and standardized diagnosis and treatment levels are still relatively low.General practitioners play important roles in the prevention，control and management of COPD，especially in early screening，management of patients in stable phase，as well as pulmonary rehabilitation.And it is imminent to establish a hospital-community-family COPD prevention and control model，conduct the general-specialty care，and develop standardized prevention and control of COPD in primary care.This paper discusses the role of general practitioners in the early diagnosis and management of COPD.

The number of patients with eating disorders is increasing nowadays China. It influences more and more adolescents and young women in psychosomatic health. This review focuses on the domestic and overseas new progress of concepts and classification， epidemiology， diagnosis， prognosis， influential factors and treatment from the professional point-of-view in eating disorders. Finally it gives some suggestions to general practitioners， providing guidance of diagnosis and treatment for eating disorders in China.

JI Yan，YAN Chunze，SUN Yange，DING Jing*
Continuing medical education（CME） is an important way for general practitioners（GPs） to update medical knowledge，improve job competency and teaching capabilities. Studies show that during the implementation of CMEs，there are some problems，such as insufficient organizational forms，simple implementation ways and GPs' low satisfaction. Moreover，the ideal ways for carrying out the CME remain controversial. Although the implementation ways for the CME are various，to increase GPs' satisfaction with it，the implementation ways still need to be enriched continually，and should be adequately selected to apply. We reviewed the implementation status and several common implementation ways of CMEs for GPs，aiming to provide a reference for the selection of appropriate implementation ways for CMEs.

Background　The resource allocation of general practitioners（GPs） is one of the basic indicators for the evaluation of health equity.At present，the research on the allocation equity of GPs in China is mostly limited to a single year or the regional data and lacks the research on the dynamic change trend of national data.Objective　To analyze the fairness of the allocation of GPs in China from 2013 to 2017 in order to provide a reference for optimizing the allocation of GPs and strengthening its scientific management.Methods　Based on the 2014—2017 China Health and Family Planning Statistical Yearbook and the 2018 China Health and Wellness Statistical Yearbook，we collected the number of GPs from each of its regions in China from 2013 to 2017.Lorenz curve and Gini coefficient were used to analyze the allocation equity of GPs in China from 2013 to 2017.Results　From 2013 to 2017，the number of GPs in China increased from 145 511 to 252 717 with an increase of 107 206，and the number of GPs per 10 000 people increased from 1.07 to 1.82 with an increase of 0.75.The Lorenz curve of the distribution of Chinese GPs according to the service population was close to the line of absolute fairness，while the Lorenz curve according to the service area had deviated from the line of absolute fairness.The Gini coefficient of the distribution of Chinese GPs according to the service population in 2013—2017 was 0.29，0.26，0.25，0.24 and 0.24，respectively，and the Gini coefficient according to the service area was 0.73，0.72，0.72，0.72 and 0.73，respectively.Conclusion　The allocation fairness of GPs by service population distribution is superior to that by service area distribution in China.The fairness by service population distribution is in a normal state，while that by service area distribution is in a highly dangerous state.The government should take measures to enhance the coordinated development of GP resources among different regions.

China is currently carrying out a new round of medical and health system reform，and general practitioners（GPs） play an important role in this medical reform.It is helpful to explore the value of GPs in the medical and health system to encourage various stakeholders to take measures jointly to promote the development of GP services.This article analyzed the current challenges faced by China's medical and health system from the aspects of basic medical coverage，medical resource utilization，medical treatment pattern，limitations of coping with chronic diseases，health cost flow，and doctor-patient relationship.It was proposed that GPs could play an important role in the following six aspects：to help to achieve the goal of "health care for all" in China；to balance the medical information asymmetry between doctors and patients and reduce excessive medical treatment in the medical system；to contribute to the formation of a reasonable medical treatment pattern and efficient use of health resources；to make medical services continuous，proactive，and interactive to meet the challenges of chronic diseases；to attract the attention to the prevention of diseases，so that the health input would get better output；and to improve the harmony of doctor-patient relationship.On this basis，this paper put forward some corresponding countermeasures and suggestions on how to better play the role of GPs in China.