Chinese General Practice

Discovering and Doing Family Medicine and Community Health Research　

Michael D Fetters，Timothy C Guetterman（writing），WANG Yang（translator），HAN Jianjun，XU Yanli，YANG Hui（reviser）

2019, 22(22): 2645-2648. DOI: 10.12114/j.issn.1007-9572.2019.00.405

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Original research plays a key role in improving the quality of clinical practice，and help clinicians in gaining academic reputation. However，as a discipline，family medicine is still lacking a research approach which is rigorous，easy to use，and conducted by family doctors. The primary care setting and patient have different characteristics from the secondary care，and the types of its research are systematically different from the types of research in specialized hospitals. This article is the editorial of a series of methodological articles for family medicine and community health. It summarizes the difficulties and challenges of family medicine research，demonstrates the background，purpose，applicable population，overall structure and purpose of writing these methodological articles，and introduces the core content of each article. Through this way，it provides a guidance for general practice researchers and clinicians to read follow-up articles.

Getting Started in Research，Redefined：Five Questions for Clinically Focused Physicians in Family Medicine　

William Ventres，Leanne Whiteside-Mansell（writing），ZHAO Xinyue（translator），HAN Jianjun，XU Yanli，YANG Hui（reviser）

2019, 22(22): 2649-2653. DOI: 10.12114/j.issn.1007-9572.2019.00.395

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Research is crucial to the development of family medicine around the world.However，family physicians in practice often hesitate to enter into investigative endeavours.Common reasons for such hesitation include limited exposure to the process of conducting research and the belief that research is best conducted by academic scholars.Our intent here is to encourage clinically focused family physicians' involvement in research activities by explaining how they can cultivate inquisitiveness so as to develop questions for exploration.We present an approach to research that focuses on five steps emergent from the day-to-day，habitual practice of family medicine，wherever in the world it is practised.We illustrate this approach by describing a successful practice-based research study.We conclude by inviting all family physicians to consider integrating research into their practice lives so as to expand their professional horizons and help educate the next generation of global family physicians.

Getting Started in Primary Care Research：Choosing among Six Practical Research Approaches　

Michael D Fetters（writing），ZHANG Yanan（translator），HAN Jianjun，XU Yanli，YANG Hui（reviser）

2019, 22(22): 2653-2659. DOI: 10.12114/j.issn.1007-9572.2019.00.396

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While many primary care practitioners want to conduct research，many also struggle with getting started.This article's purpose is to assist emerging researchers in identifying a topic of interest，to try the "fit" of feasible research approaches and commit to a research approach.The article addresses six objectives：identify how important primary care research comes from clinical stories；recognise how clinical stories become the source of research topics；discern how the research process resembles the care of patients；distinguish the essential features of six research approaches feasible for primary care researchers；evaluate the fit of the six research approaches featured in this special issue；and develop a list of steps that need to be taken to implement primary care research projects.Using "HPV（human papilloma） vaccination" as a hypothetical topic，the article illustrates how an emerging researcher can complete the worksheets.Using the HPV topic，a worksheet illustration shows how to complete the worksheets，and examples from the literature illustrate how actual studies have used six feasible research approaches for primary care：survey research，semistructured qualitative interviews，curriculum development，continuous quality improvement，clinical policy analysis and case study research.The worksheet exercises support choosing a feasible research approach for emerging researchers.Emerging researchers using these exercises can identify a topic，choose a research strategy aligned with the researcher's interest，create a study title，develop a list of the next steps，and be well positioned to implement an original research project.

Provincial Distribution and Influencing Factors of General Practitioners in China：a Spatial Econometric Analysis　

ZHAN Dashun，ZHANG Xiang

2019, 22(22): 2660-2665. DOI: 10.12114/j.issn.1007-9572.2019.00.440

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Background　The changes and development of China's economy and society urgently require the training and development of general practitioners（GPs）and the improvement of GP system.Also，the construction of GPs workforce has received attentions and support at the policy level.However，there are very few spatial econometric studies about GPs in China.Objective　To perform a spatial econometric analysis of provincial distribution and associated factors of GPs in China，offering a theoretical basis for geographical allocation of GPs.Methods　Data were collected from 5 volumes of China's Health and Family Planning Statistical Yearbook（2013—2017），and China Statistical Yearbook 2017.Spatial autocorrelation test and spatial econometric models were used to analyze provincial distribution and associated factors of GPs in China.Results　In 2016，the number of GPs per 10 000 people in China was 1.51.In eastern China，it was 2.03，which was higher than of central and western China.In 2016，the global Moran's I for provincial distribution of GPs was 0.219（P<0.05）．In spatial error model（SEM），λ=0.211（P<0.10），and model evaluation indices of SEM were superior to those of OLS.The results showed that the number of GPs was positively correlated with government health expenditure（P<0.05）．Conclusion　In general，the number of GPs in China is increasing rapidly，but is relatively insufficient to satisfy the health needs of the people.Moreover，there are inter-provincial spatial autocorrelation and regional imbalance in the number of GPs，which are mainly related to the differences in regional development level and government health expenditure.To increase the number of GPs，government health expenditure should be increased.

Factors Associated with Selection of Contracted Residents among Community General Practitioners：a Qualitative Study　

LI Donghua，ZHU Chun，SHEN Ao，MI Yikai，ZHANG Xingna，GU Huiying，TANG Zhihong

2019, 22(22): 2666-2669，2687. DOI: 10.12114/j.issn.1007-9572.2019.00.409

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Background　To enjoy contracted initial consultation services in primary care，residents need to sign a contract with the general practitioner（GP）．The contractual action is an important way to implement initial consultation in primary care，and also is a key measure to promote the transformation of residents' health-seeking behaviors.As a contract party，GPs are influenced by some factors during the selection of contracted residents.And identification of these factors is of great significance in improving the contract system.Objective　To investigate the factors associated with selection of contracted residents in GPs in Shanghai's Pudong New Area，providing recommendations for improving the development of contracted family doctor services.Methods　Voluntary participants were representative GPs delivering contracted family doctor services recruited from 13 community health centers in Shanghai's Pudong New Area〔 in which two-way choice system（residents can choose GPs and GPs can choose residents freely）was implemented〕by use of convenience sampling during March to April 2018.Personal interviews concerning factors associated with selection of contracted residents were conducted with them until data saturation was reached.Finally，the interview results of 20 GPs were included.Results　GPs' selection of contracted residents were influenced by their own conditions，residents' conditions and practicing environment.In addition，workload saturation，scope of practice，residents' perceptions of the contracted services and appraisal of number of contracted residents were also considered by GPs as the factors associated with selection of contracted residents.Conclusion　To further implement the contracted family doctor services，community hospitals can boost GPs' initiative in offering the services by improving the incentive assessment mechanism for assessing GPs' performance in delivering the contracted services，incentivize GPs to enhance their professional levels，and strengthen residents' understanding level of family doctor system.

Xuzhou Rural Residents' Intention and Its Influencing Factors of Having First Consultations in Primary Care during the Implementation of Hierarchical Medical System　

MIAO Chunxia，LI Hanhan，ZHUO Lang，WANG Wenhai，JIANG Jinxing，SUN Hong，ZHENG Juan，ZHAO Shihong

2019, 22(22): 2670-2674. DOI: 10.12114/j.issn.1007-9572.2019.00.244

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Background　The implementation of hierarchical medical system in a scientific and orderly way is a key approach to enhancing the efficiency of healthcare delivery，reasonably using healthcare resources，and reducing medical costs.In China，it is very obvious that rural residents prefer to seek healthcare in higher level hospitals instead of the primary healthcare institutions，which leads to the waste of health resources，and hinders the effective implementation of hierarchical medical system.Objective　To investigate Xuzhou rural residents' intention and associated factors of seeking healthcare in primary healthcare institutions for common diseases during the implementation of hierarchical medical system，providing a reference for the improvement of first consultations in primary care system.Methods　From July to August 2016，a survey was conducted among 800 rural residents selected from 4 counties of Xuzhou by stratified multistage random sampling.A structured questionnaire developed by our research team was used in the survey，which consists of demographic characteristics，views on the implementation of hierarchical medical system，and intention of having first consultations in primary care.Multivariate Logistic regression was used to analyze the influencing factors associated with the residents' intention of having first consultations in primary care.Results　The questionnaire survey achieved a response rate of 95.4%（763/800）．Of the respondents，82.1%（626/763）preferred to seek healthcare in primary healthcare institutions when having a common disease，mainly because of short distance and low medical cost.But 95.1%（726/763）preferred to seek healthcare in a general hospital when having severe conditions，mainly because of high-quality medical services，and good diagnostic and therapeutic equipments.Multivariate Logistic regression analysis showed that low medical costs in the past year，long distance between home and the nearest secondary or tertiary hospital，good treatment experience in the primary healthcare institution，supporting for the implementation of hierarchical medical system，and perception of the implementation of medical insurance programs being a facilitator for the development of hierarchical medical system were factors associated with higher probability of intending to have first consultations in primary care（P<0.05）．Conclusion　The rate of intention of having first consultations in primary care among Xuzhou rural residents is reasonable at large.Medical costs in the past year，distance between home and the nearest secondary or tertiary hospital，treatment experience in the primary healthcare institution，attitude toward the implementation of hierarchical medical system，and perception of whether the implementation of medical insurance programs could facilitate the development of hierarchical medical system are associated factors for intention of having first consultations in primary care.

Hotspots and Emerging Trends in Contracted Family Doctor Services Research：a Scientometric Analysis in CiteSpace　

LI Ze，WANG Songlin，ZHAO Jing，LIU Fangyu，HUANG Minting

2019, 22(22): 2675-2680. DOI: 10.12114/j.issn.1007-9572.2019.00.346

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Background　The implementation of contracted family doctor services is a major initiative to promote the development of hierarchical medical system and deepen the reform of medical and health care system.Understanding the research hotspots and emerging trends of contracted family doctor services is the foundation of further research.Objective　To systematically combine the research hotspots with emerging trends of contracted family doctor services.Methods　We used CiteSpace software to conduct a co-occurrence network analysis of authors，institutions and keywords of the articles indexed in CNKI database between 1 January 1986 and 29 September 2018.According to the time zone map of keywords and related policy documents，we summarized the emerging trends of the contracted family doctor services.Results　The emerging research trends showed that accelerated increase in the number of documents，the loose network of inter-regional research cooperation and the lack of breakthroughs in the area.Conclusion　At present，most of the research in the field of contracted family doctor services is empirical research.We should strengthen the application and innovation of relevant theories，and strengthen the close communication and cooperation between inter-regional organizations and authors in the future.

Desheng Contracted Family Doctor Services Model on the Basis of Doctor-nurse-assistant nurse Responsibility System　

HE Zhihong，WANG Lingyun，HAN Chengcheng，GAO Fengjuan，LIU Juhong，ZHANG Lei，MA Chunhong，WEN Xiuqin，XIE Yan，MA Pengtao

2019, 22(22): 2681-2687. DOI: 10.12114/j.issn.1007-9572.2019.00.370

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Contracted family doctor services is an embodiment of medical reform policy implementation and change of community service model.Based on the health needs of key groups such as the elderly and patients with chronic diseases，and the existing health human resources in the community，Desheng Community Health Service Center fully taps its internal potential，establishes a new doctor-nurse-assistant nurse team of contracted family doctor services，and builds a clear responsibility division and cooperation mechanism for different professionals within the team〔relying on Medical Treatment Partnership System and experts resources，professional team was built to continuously strengthen the comprehensive diagnosis and treatment ability of family doctors and improve the contract management level；enhance the ability of nurses to implement public health management，train specialty nurses in communities，establish nurses' health management room，guarantee the comprehensive and personalized health management rights and interests of contracted patients；incorporate non-professional staff （nurse assistants） into the contracted service team of family doctors to undertake more routine work，share team work pressure and expand service coverage〕. The computer assisted triage system was established to ensure that residents can enjoy differentiated services，so as to strengthen and consolidate the contractual service relationship between doctors and patients，implement the continuous management，and provide differentiated contract services.By keeping pace with the times，we would improve the supervision，management and incentive mechanism of performance appraisal，and promote the in-depth development of contracted family doctors services.After 8 years of practice and exploration，Desheng Community Health Service Center established a set of effective bottom-up practice operation model of contracted family doctors services.We have achieved much progress：the contracting rate，standardized management rate，control rate of chronic disease，community visiting rate，health behavior improvement rate，satisfaction rate of contracted residents and health literacy improvement rate of residents in the jurisdiction area have constantly increased.It effectively promotes the national medical improvement process，and contributes to primary treatment at the community level，two-way referral，different treatments in acute and chronic diseases，and hierarchical diagnosis and treatment.This model is worth learning and popularizing.

Relationship between the Age of Onset of Newly Diagnosed Type 2 Diabetes and Metabolic Syndrome　

LIU Linjie，LI Huiqiong，XU Yancheng

2019, 22(22): 2688-2691，2704. DOI: 10.12114/j.issn.1007-9572.2019.00.417

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Background　Diabetes is an important component of the metabolic syndrome（MS），which often combines with other metabolic components of MS.China's young and elderly diabetic patients are increasing year by year，but there is still a lack of studies on relationship of the age of onset of diabetes with MS and its components.Objective　To investigate the relationship of the age of onset of newly diagnosed type 2 diabetes（T2DM） with MS and other metabolic components of MS.Methods　431 patients with newly diagnosed T2DM were selected from Department of Endocrinology，Zhongnan Hospital of Wuhan University from January 2012 to May 2017.According to the age of onset，they were divided into early-onset diabetes group（EDM group，<40 years，n=72），middle-aged diabetes group（MDM group，40-59 years，n=232） and elderly diabetes group（ODM group，≥60 years，n=127）．The metabolic components of MS and MS in three groups were compared.Results　The prevalence rates of MS in all the newly diagnosed T2DM cases，EDM group，MDM group，and ODM group were 72.4%（312/431），79.2%（57/72），74.1%（172/232），and 65.4%（83/127），respectively.With the increase of onset age，the prevalence rate of MS in newly diagnosed patients with T2DM decreased（P<0.05）．Early onset age was associated with higher prevalence rates of overweight/obesity，elevated TG，decreased HDL-C and lower prevalence rate of hypertension（P<0.05）．There were statistical differences between the three groups（P<0.05）.The difference was between EDM and ODM（P<0.016 7）, but there was no difference between EDM and MDM，MDM and ODM（P>0.016 7）．Conclusion　The age of onset of newly diagnosed T2DM was closely related to MS，and the earlier the age of onset，the higher the risk of MS.

Association of Neutrophil-lymphocyte Ratio with Framingham Risk Score and Its Predictive Value for High-risk Cardiovascular Disease　

YANG Lihong，YANG Ruike，WANG Qingyi，LI Han，QIAO Peng，QIU Yanyan，WANG Yaqing，LI Qiunan，XU Jinyi

2019, 22(22): 2692-2697. DOI: 10.12114/j.issn.1007-9572.2019.00.379

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Background　Framingham risk score is a widely used method for predicting the 10-year risk of cardiovascular disease in high risk group.Neutrophil to lymphocyte ratio（NLR）is a newly suggested inflammatory marker associated with atherosclerosis.However，the correlation between NLR and Framingham risk score，and the predictive value of NLR for high-risk cardiovascular disease are still unclear.Objective　To explore the association of NLR with Framingham risk score，and its predictive value for high-risk cardiovascular disease.Methods　Participants were recruited from Henan Provincial People's Hospital from May 2017 to May 2018，including 168 outpatients and inpatients with essential hypertension from Cardiovascular Department〔observation group consisting of low-risk subgroup（n=66），intermediate-risk subgroup（n=53），and high-risk subgroup（n=49）stratified by Framingham risk score〕，and 55 physical examinees without hypertension from Physical Examination Department（control group）．Comparisons of clinical data were made between the control group and cardiovascular risk subgroups.Influencing factors for Framingham risk score were analyzed with the multivariate ordinal regression model.The value of NLR for predicting cardiovascular risk in high-risk population of cardiovascular disease was estimated by ROC curve analysis.Results　Sex ratio，mean age，systolic blood pressure，diastolic blood pressure，prevalence of diabetes，rates of use of drugs（statins，beta blockers，calcium antagonists，ACEIs/ARBs，diuretics），mean levels of systolic and diastolic blood pressure，total cholesterol（TC），high-density lipoprotein cholesterol（HDL-C），NLR，homocysteine，and left ventricular ejection fraction（LVEF）differed significantly across the control group and three cardiovascular risk subgroups（P<0.05），but mean body mass index（BMI），triglyceride，low-density lipoprotein cholesterol（LDL-C），ALT，creatinine，and fasting blood glucose levels did not（P>0.05）．Mean NLR increased successively in control group，low-，intermediate- and high-risk subgroups.Logistic regression analysis showed that age，systolic blood pressure，diastolic blood pressure，TC，LDL-C，HDL-C，NLR and LVEF were the influencing factors of Framingham Risk Score（P<0.05）．The results of ROC curve analysis showed that when NLR was 2.86，the Youden's index was the largest（0.560），the corresponding sensitivity was 0.796，the specificity was 0.764，and the area under ROC curve was 0.836〔95%CI （0.775，0.897）〕.Conclusion　NLR associated with Framingham Risk Score，and may has a certain predictive value for high-risk cardiovascular diseases.

Assistant Diagnosis for Coagulation Function and Platelet Parameters in the Diagnosis of Preeclampsia and Its Severity　

REN Danyu，WANG Yonghong

2019, 22(22): 2698-2704. DOI: 10.12114/j.issn.1007-9572.2019.00.436

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Background　Preeclampsia（PE）is a serious complication of pregnancy.The best cut-off values of coagulation function and platelet parameters can be used to screen for preeclampsia，but the interpretation of test results is often controversial.Objective　To explore the value of coagulation function and platelet parameters in the assistant diagnosis of preeclampsia and its severity.Methods　A total of 325 pregnant women delivered in the Second Hospital of Shanxi Medical University from May 2016 to September 2018 were selected as the study subjects，including 100 cases in the health group，46 cases in the gestational hypertension（GH）group，48 cases in the mild preeclampsia（mPE）group and 131 cases in the severe preeclampsia（sPE）group.The general clinical data，coagulation function indexes〔prothrombin time（PT），activated partial thromboplastin time（APTT），international normalized ratio（INR），fibrinogen（FIB）〕and platelet parameters〔platelet count（PLT），mean platelet volume（MPV），platelet distribution width（PDW），plateletcrit（PCT），platelet count/mean platelet volume（PLT/MPV）〕of four groups of pregnant women were compared.The ROC curve was used to analyze the assistant diagnostic value of coagulation function and platelet parameters for preeclampsia and its severity.Results　There were significant differences in the gestational weeks, the body mass index（BMI）, systolic blood pressure，diastolic blood pressure, neonatal body mass, blood coagulation function（PT，APTT，INR，FIR） and platelet parameters（PLT，MPV，PDW，PCT，PLT/MPV）between the four groups of pregnant women（P<0.05）.The results of ROC curve analysis showed that APTT，MPV，PDW have auxiliary diagnostic value for pre-eclampsia〔the area under ROC curve（AUC）were 0.61，0.63，0.66，respectively，P<0.05〕; APTT has auxiliary diagnostic value for pre-eclampsia severity （AUC=0.67，P<0.05），combined detection of APTT，PT，INR，FIB，PLT，MPV，PDW，PCT and PLT/MPV have a higher auxiliary diagnostic value for pre-eclampsia and its severity （AUC were 0.78, 0.75 respectively，P<0.05）. Conclusion　APTT，MPV and PDW are helpful in the diagnosis of pre-eclampsia，and APTT is helpful in the diagnosis of the severity of pre-eclampsia.APTT combined with other coagulation function indicators and platelet parameters is more helpful in the diagnosis of pre-eclampsia and its severity.

Characteristic of the Strength of Muscles Surrounding the Hip Joint in Chronic Low Back Pain Patients　

WANG Minjia，SHUI Xiaoping，WANG Guohan，LUO Yi，WANG Chun

2019, 22(22): 2705-2708. DOI: 10.12114/j.issn.1007-9572.2019.00.418

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Background　Muscle groups surrounding the hip joint are core muscles often being neglected，but they have an important impact on the stability and overall function of the lumbar spine.Objective　To explore the characteristics of the strength of muscles surrounding the hip joint in patients with chronic low back pain（CLBP），providing evidence for the rehabilitation treatment of CLBP.Methods　Participants were recruited from communities surrounding Jule Road，Wuhou District，Chengdu，and Sport Hospital Attached to CDSU during March to December 2014，including 64 with CLBP（CLBP group），and 29 without（control group）．Isokinetic muscle testing was performed by use of Contrex System-Top 1000 to measure the isokinetic strength of muscles surrounding the hip joint at various angles.Visual Analogue Scale（VAS） was used to evaluate the pain degree in CLBP group.Isokinetic strength of muscles surrounding the hip joint was compared between CLBP group and control group，as well as between the CLBP patients with different degrees of pain.Results　CLBP group showed less abduction peak torque/body weight（ABPT/BW） ratio and flexion to extension peak torque（FPT/EPT） ratios for isokinetic strength of muscles surrounding both the left and right hip joints than the control group（P<0.05）．44（68.8%）and 20（31.2%）cases in the CLBP group were evaluated with mild and moderate pain，respectively.Mild pain subgroup had greater flexion peak torque/body weight（FPT/BW） ratio and extension peak torque/body weight（EPT/BW） ratio for isokinetic strength of muscles surrounding the left hip joint and greater ABPT/BW ratio for that of the muscles surrounding the right hip joint compared with moderate pain subgroup（P<0.05）．Conclusion　Decreased abductor strength of hip joint muscles is a manifestation of CLBP patients.It can impair the hip flexion，extension and abduction strength，and the impairment increases with the severity.It is suggested that attention should be paid to the hip flexion，extension and abduction strength in those with severe pain.In addition，hip abduction strength can be used as a reference indicator for clinical diagnosis and rehabilitation efficacy of CLBP.

A Comparative Study of the Effects of Payment Methods by Medical Insurance on Self-management Behavioral Outcomes in Type 2 Diabetic Patients in Guangzhou and Macau　

CHEN Jing，LU Jiayan，WU Huier，WU Yanyi，TAN Yilin，ZHAO Ziyu，CHEN Peiyi

2019, 22(22): 2709-2713. DOI: 10.12114/j.issn.1007-9572.2019.00.343

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Background　The number of diabetes patients in China ranks first all over the world，and most of them are type 2 diabetes mellitus（T2DM）．Diabetes and its complications cause huge economic burdens on the patient，families，and the society.Recently，it has been found that most of T2DM complications could be prevented or delayed if there is adequate universal medical coverage.Objective　To investigate the effects of payment methods by medical insurance supported by different policies on self-management behavioral outcomes in T2DM patients.Methods　A total of 152 T2DM patients participated in the study，including 70 from a tertiary grade A hospital or a community hospital in Guangzhou，and 82 from the Diabetes Center or Inpatient Department，Kiang Wu Hospital in Macau during April 2017 to January 2018.All of them received 12-week self-monitoring of blood glucose with the same guidance and equipments（blood glucose meter，diabetes test strips，blood collection needle，and consumptions related to lab blood tests）provided by our research group.Comparisons of treatment payment methods，self-monitoring of blood glucose compliance，and glycated hemoglobin（HbA1c）were conducted between the two groups.Results　There was a significant difference in the treatment payment method between the two groups of patients during the study（P<0.05）．During the 12-week postdischarge intervention，the blood glucose records of patients from Guangzhou were significantly better than those of patients from Macau（P<0.001）．The treatment payment method was one of the influencing factors for the total frequencies of blood glucose measurements within the intervention period（P<0.05）．There were no significant differences in pre- and post-intervention HbA1c levels between the two groups（P>0.05）．Changes in HbA1c were positively correlated with the frequency of self-monitoring of blood glucose（rs=0.182，P<0.05）．Conclusion　Payment methods by medical insurance supported by different policies exert different effects on self-management behavioral outcomes in T2DM patients.Providing adequate self-monitoring of blood glucose consumables can improve the self-monitoring of blood glucose compliance.Self-monitoring blood glucose intervention can help T2DM patients control their blood glucose better.

Epidemiological Characteristics of 586 Children with Cerebral Palsy in Xinjiang　

YAN Baofeng，CAO Mingqin，LI Wenli，MUTALIFU?Nurehemaiti，AIKEBAIER?Halike，ALIMU?Sulaiman，TONG Lingxiao，XU Jian

2019, 22(22): 2713-2718. DOI: 10.12114/j.issn.1007-9572.2019.00.344

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Background　Geographical distribution of epidemiological studies about cerebral palsy in China is uneven.In particular，such studies conducted in northwestern China and other remote areas are insufficient.Objective　To explore the demographic characteristics and geographical distribution of children with cerebral palsy in Xinjiang，and to compare the clinical characterizations at birth and growth and development of such children by the type of cerebral palsy.Methods　This retrospective survey was conducted among 586 children with cerebral palsy treated at the Cerebral Palsy Center，the Second Affiliated Hospital of Xinjiang Medical University from January 2016 to April 2018.Clinical data were collected，and comparative analyses of demographic characteristics based on geographical divisions，clinical features at birth and growth and development based on cerebral palsy type were performed.Results　Among the 586 cases，most〔340（58.0%）〕were males；almost half〔250（42.7%）〕aged 7-10 years old；the number of cases〔318（54.3%）〕from southern Xinjiang was the most；Uygurs〔401（68.4%）〕were the most；spastic cerebral palsy〔271（46.2%）〕accounted for the largest percentage.Distributions of age and minzu differed significantly by region（P<0.05）．Maternal delivery mode distribution and prevalence of neonatal kernicterus varied significantly by the type of cerebral palsy（P<0.05）．There were significant differences in the distribution of turning over，sitting alone，crawling，standing up，walking alone，voicing，speaking complete sentences and controlling urine and stool among children with different types of cerebral palsy（P<0.01）；there were statistical differences in the average age of turning over，crawling，standing up，walking alone and speaking complete sentences among children with different types of cerebral palsy（P<0.05）．Conclusion　Spastic cerebral palsy is the major type of cerebral palsy；male children is more prone to cerebral palsy；most children with cerebral palsy are 7-10 years old；the cases mainly come from southern Xinjiang.Analysis and summary of clinical features at birth can provide guidance for the prevention of cerebral palsy.To avoid missing the most appropriate time for treatment，parents should put enough attention to their children's growth and development milestones.

Development of General Practitioners with Special Interests under Hierarchical Medical System in China and Its Enlightenment from Abroad　

LIU Ying，REN Jingjing

2019, 22(22): 2719-2721，2725. DOI: 10.12114/j.issn.1007-9572.2019.00.408

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The development of general practitioners with special interests（GPwSI）is conducive to reducing the cost of medical services in general hospitals，shortening the waiting time for patients，optimizing the allocation of medical resources，making the communication between GPwSI and specialists more smooth，and thus more conducive to the development of graded diagnosis and treatment system. In this paper，we discussed the prospects for the development of GPwSI in China under the hierarchical medical system.And then we reviewed the problems faced by the foreign GPwSI in the development and their enlightenment to China.In the end，we proposed some corresponding strategic advices to provide a reference for the development of GPwSI in China.

Exploration and Practice of the Cultivation of General Practitioners with Special Interests in the Standardized Training of Residents　

WU Weidong，YANG Kaichao

2019, 22(22): 2722-2725. DOI: 10.12114/j.issn.1007-9572.2019.00.416

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At present，a relatively complete education system for general practitioners（GPs） has been established in China，but there is no effective system for continuous professional development of GPs.The standardized training of residents（residential training） is an important part of continuing medical education.The cultivation of GPs with special interests（GPwSI） in the residential training can improve the competency of GPs and enhance their core competitiveness.This paper analyzes the necessity of carrying out GPwSI cultivation in the residential training and focuses on the training of GPwSI in dermatology in Lishui Central Hospital in Zhejiang Province with the discussion of its training effects and remaining problems.This paper aims to provide the reference for the exploration of the training modes and methods of GPwSI in other regions.

Status and Equity Analysis of Nonuse of Health Services in Middle-aged and Elderly Chronic Disease People　

LI Anqi，CHEN Mingsheng，WANG Zhonghua

2019, 22(22): 2728-2734. DOI: 10.12114/j.issn.1007-9572.2019.00.419

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Background　Fast population ageing leads to the increasing prevalence of chronic diseases in middle-aged and elderly people，which brings a heavy economic burden to both the patients and their families.Concurrently，poor chronic disease management and fair treatment compliance have been found in these populations.Moreover，nonuse of the needed services has also been identified in some individuals in these groups.Objective　Investigation the status of nonuse of health services in middle-aged and elderly chronic disease people，and to analyze whether the use of such health services is inequitable in middle-aged and elderly individuals with chronic disease.Methods　The research was conducted in February，2018.Demographic and economic characteristics，use of healthcare services，health status and functional indicators and other data about middle-aged and elderly people stemmed from the China Health and Retirement Longitudinal Study 2013.Health services（including outpatient，inpatient and physical examination services） that were not used were the dependent variables.Multivariate Logistic regression was applied to identity factors associated with nonuse of the abovementioned services in middle-aged and elderly people.Concentration indices were calculated and adopted to evaluate the equity in the use of such services in chronic disease groups by economic level.Results　 A total of eligible 4 509 individuals were included，of which 3 274（72.61%） suffered from chronic diseases.Among patients with chronic diseases，the prevalence rates of nonuse of outpatient，inpatient，and physical examination services were 20.62%（675/3 274），5.47%（179/3 274），and 60.11%（1 968/3 274），respectively.Individuals with chronic disease showed higher rates of nonuse of outpatient and inpatient services，and lower rate of nonuse of physical examination services compared with those without（P<0.05）．Among all the participants，age，employment/retirement status，annual household income per capita，residence，self-reported health status，chronic disease prevalence，depression prevalence，and ADL were factors influencing non-use of outpatient services（P<0.05）；employment/retirement status，self-reported health status，and BMI were influencing factors of non-use inpatient service（P<0.05）；age，education level，number of family members，social insurance enrollment status，annual household income per capita，residence，chronic disease prevalence and smoking status were associated with non-use physical examination services（P<0.05）．In individuals with chronic disease，nonuse of outpatient services was found mainly in those with high annual household income per capita（CI=0.022），while nonuse of inpatient and physical examination services were found mainly in those with low annual household income per capita（CI were -0.060，-0.048）．Conclusion　In middle-aged and elderly people with chronic disease，nonuse of physical examination services is affected by various factors，and nonuse of health services is mainly affected by social-economic factors.In view of this，recommended facilitation strategies for promoting equitable and rational distribution and effective use of healthcare resources，reducing nonuse of health services，and realizing equitable healthcare are as follows：the awareness of chronic disease prevention and treatment in middle-aged and elderly people should be increased，government agencies are suggested to develop new models and further improve the existing models for delivering hierarchical medical services，to incentivize residents to seek healthcare in primary care，and to train general practitioners，as well as to give differential reimbursement to middle-aged and elderly people with chronic disease.

Avoidable Hospitalizations for Diabetes in Rural Residents　

LI Feicheng，JIAN Weiyan，SUN Meiping

2019, 22(22): 2735-2738. DOI: 10.12114/j.issn.1007-9572.2019.00.437

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Background　In recent years，the total number of hospitalizations and healthcare expenditures in China's medical and health institutions have increased significantly.Diabetes hospitalizations belong to the category of avoidable hospitalizations.There is a lack of relevant research on avoidable hospitalization for diabetes in China.Objective　To analyze the situation of avoidable hospitalization for diabetes among rural residents in a region of eastern China，to provide evidence for reducing the occurrence of avoidable hospitalizations and health expenditures.Methods　A random sample of 136 887 hospitalized cases was obtained from the reimbursement data of residents who participated in the New Rural Cooperative Medical Scheme from 2008 to 2013 in an eastern region of China.According to the ICD-10 code，17 015 inpatients with diabetes mellitus were selected.According to the standard of avoidable hospitalization，13 052 cases of avoidable diabetes were obtained.The proportion of avoidable hospitalization cases to total hospitalization cases and the trend of avoidable hospitalization expenses of diabetes mellitus cases were analyzed.Results　The proportion of avoidable hospitalizations was 76.71%（13 052/136 887）．From 2008 to 2013，the proportion of avoidable hospitalizations for diabetes in total sample cases showed a downward trend.Specifically，the proportions were 11.15%（3 423/30 678） in 2008—2009，10.35%（5 423/52 364） in 2010—2011 and 7.80%（4 206/53 845） in 2012—2013，respectively.During the period，the avoidable hospitalizations for diabetes were mainly concentrated in secondary hospitals，accounting for 68.83%（11 776/15 994） of the total.In 2008，the average cost of per avoidable hospitalization for diabetes was 6 177.24 yuan，which increased to 6 842.87 yuan in 2010，and decreased to 6 560.78 yuan in 2012，but increased to 6 593.70 yuan in 2013.The proportion of avoidable hospitalization expenses for diabetes mellitus decreased from 9.10% （883.71/9 674.68）in 2008 to 4.73%（1 393.91/29 478.02） in 2013.Conclusion　In diabetic inpatients，the ratio of avoidable hospitalizations is high，resulting in the waste of medical resources and the increase of health expenditure.We should focus on improving the primary health care delivery system，guide patients to seek medical treatment rationally，and strengthen the collaboration among different levels of medical institutions.

Effects of Mindfulness-based Yoga Group Intervention on Maternal Postpartum Depression Following the Second Childbirth　

SHU Ling，TAN Chuang，WU Chuanfang，XI Mingxia，TAN Huimin，ZHAO Wei，QU Qunfang

2019, 22(22): 2739-2743. DOI: 10.12114/j.issn.1007-9572.2019.00.354

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Background　Having a second child increases the incidence of maternal perinatal anxiety or depression.The relationship between pre- and postnatal depression has always been a research focus.Mindfulness-based yoga can alleviate the maternal perinatal anxiety and depression.It is widely used in European countries and the America.However，there are few research on its effectiveness and feasibility in China.Objective　The aim of this study was to determine the effect of mindfulness-based yoga group intervention on maternal postpartum depression following the second childbirth.Methods　 By use of convenience sampling，86 women undergoing routine outpatient prenatal examination during the second pregnancy in a tertiary general hospital in Changsha，China，were enrolled between September 2017 and March 2018.They were equally divided into the control group，and intervention group by use of a random number table，receiving 6-week routine mental health nursing care，6-week routine mental health nursing care with mindfulness-based yoga group intervention，respectively.Pre- and post-intervention Zung Self-rating Anxiety Scale（SAS） scores，Edinburgh Postnatal Depression Scale（EDPS） scores，and serum cortisol levels in both groups were collected.Two groups were given a 6-week postpartum follow-up，during which the incidence of postpartum depression（EPDS>9.5 points） was obtained.Results　Altogether，38 cases in the control group and 40 in the intervention group completed the intervention and survey.No significant differences were found between two groups at baseline（P>0.05）．However，post-intervention mean scores of SAS，and EPDS and serum cortisol level in the intervention group were significantly lower than those of the control group（P<0.05）．Moreover，the incidence of postpartum depression in the intervention group was lower than that of the control group（P<0.05）．Conclusion　Mindfulness-based yoga group interventions have a good impact on the physiological and psychological state in women having a second childbirth，and also is effective in reducing the risk of having postpartum depression.

Differentiation of Social Isolation and Health Promotion Behaviors among Older Adults in the Community　

WU Fan，SHENG Yu

2019, 22(22): 2744-2748. DOI: 10.12114/j.issn.1007-9572.2019.00.372

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Background　With the increasing age，the decreasing social roles and the emergence of various negative life events，the elderly has become the high-risk group of social isolation.Social isolation affects the health outcomes of the elderly，and health promotion behaviors are protective factors to promote health.However，related researches are limited on the relationship between social isolation and health promotion behaviors of the elderly.Objective　To analyze the social isolation of older adults and the differences of health promotion behaviors with different types of social isolation.Methods　From July to December 2017，485 older adults from 15 community health service centers/stations in Dongcheng District，Xicheng District，Fengtai District and Shijingshan District of Beijing were selected by convenient sampling method.The survey was conducted using the General Information Questionnaire，Lubben Social Network Scale 6，and the Health-Promoting Lifestyle Profile Ⅱ.Results　Among 485 elderly people，111（22.9%）cases had social isolation；62（12.8%）cases had family isolation and 135（27.8%）cases had friend isolation.The total scores of health promotion behaviors ranged from 40 to 160，with an average of（101.61±16.58）．There was no significant difference in social isolation among the elderly with different age，sexes，monthly income，living style and physical conditions（P>0.05）．The social isolation status of the elderly with different education level was significantly different（P<0.05）．There was no significant difference in the scores of health promotion behaviors among the elderly with different age and physical conditions（P>0.05）．There were significant differences in the scores of health promotion behaviors among the elderly with different sexes，education level，monthly income and living style（P<0.05）．The total score of health promotion behaviors and the scores of interpersonal relationship，health responsibility，stress management，physical activity and spiritual growth of the elderly with social isolation were lower than those of the elderly without social isolation（P<0.05）．The total score of health promotion behaviors and scores of interpersonal relationship，stress management，physical activity and spiritual growth of the elderly with family isolation were lower than those of the elderly without family isolation（P<0.05）．The scores of health promotion behaviors，interpersonal relationship，health responsibility，stress management，nutrition，physical activity and spiritual growth of the elderly with friend isolation were lower than those of the elderly without friend isolation（P<0.05）．Conclusion　Social isolation will affect health promotion behaviors of older adults and friend isolation has a wider influence than social isolation and family isolation.Community healthcare providers should actively pay attention to the social isolation of older adults.Targeted nursing measures should be applied to prevent the social isolation of the elderly，so as to improve their health promotion behaviors and promote healthy aging.

The Relationship between Loss Characteristics and Mental Health of Shiduers（Parents Who Have Lost the Only Child）　

ZHANG Yudi，JIA Xiaoming

2019, 22(22): 2749-2754. DOI: 10.12114/j.issn.1007-9572.2019.00.340

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Background　Given the considerable quantity of shiduers（parents who have lost their only child），their mental health deserves close attention.This is related to loss characteristics，features directly concerning the object or event of loss.However，few studies have systematically investigated the relationship between various loss characteristics and shiduers' mental health.Furthermore，little research has explored shiduers' mental health according to both positive and negative indicators.Objective　To conduct a systematic investigation of the relationship between loss characteristics and shiduers' mental health.Methods　The subjects，466 shiduers from Beijing，Harbin，Zhengzhou，Chongqing，and Baotou，were selected by use of convenience and snow ball sampling from June to December 2017，and were investigated using a self-developed Loss Characteristics Questionnaire，the Center for Epidemiologic Studies Depression Scale（CES-D），the Zung Self-rating Anxiety Scale（SAS），the PTSD checklist（PCL），the Prolonged Grief Disorder-13（PG-13），the Posttraumatic Growth Inventory（PTGI），and the Adult Dispositional Hope Scale（ADHS）．Results　Duration since the child's death showed a significantly negative correlation with shiduers' anxiety（P<0.05），but demonstrated no significant correlation with shiduers' depression，post-traumatic stress disorder，prolonged grief disorder，post-traumatic growth，or hope（P>0.05）．The child's age at time of death was positively correlated with shiduers' depression and prolonged grief disorder（P<0.05），but not significantly correlated with shiduers' anxiety，post-traumatic stress disorder，post-traumatic growth，or hope（P>0.05）．Mothers who lost their only daughter had higher scores for depression，post-traumatic stress disorder，and prolonged grief disorder（P<0.05），whereas fathers had no such difference（P>0.05）．Shiduers with forewarning of the loss event had lower scores for post-traumatic stress disorder and higher scores for post-traumatic growth（P<0.05）than those with no forewarning.Scores for depression，anxiety，post-traumatic stress disorder，prolonged grief disorder，post-traumatic growth，and hope could not be predicted by the death of other important relatives after the child loss event（P>0.05）．The deceased child having offspring predicted lower scores for shiduers' anxiety and post-traumatic stress disorder（P<0.05）．Parents whose child died in an accident experienced higher prolonged grief and lower post-traumatic growth and hope（P<0.05）．Conclusion　Factors related to shiduers' mental health include duration since the child's death，the child's age at death，the child's gender，forewarning of the loss event，whether the deceased child had offspring，and cause of death.This study's results can be used as a reference for psychological counseling and guidance of shiduers.

New Advances in Research on Community-based Screening of Chronic Kidney Disease　

ZHOU Yangwei

2019, 22(22): 2755-2759. DOI: 10.12114/j.issn.1007-9572.2019.00.420

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With the aging of population and increase of diabetes and hypertension prevalence rates，the prevalence rate of chronic kidney disease（CKD） is also obviously increased.Due to poor prognosis and huge treatment costs in the end-stage，CKD has become a severe public health problem.In fact，early screening and early treatment can delay the progression and improve the prognosis of CKD.However，the screening rate is low due to insufficient attention.General practitioners play an important role in CKD screening.Community-based screening of CKD co-implemented by multiple parties helps to publicize CKD screening knowledge，implement the screening and transfer the patients.On the basis of literature review，we found that there is a dispute about the selection of screening modes and risk factors.We suggest that the Internet can be used as an assistant tool for the implementation of CKD screening，and screening programs can be based on the guideline recommendations.Besides，new cost-effective and non-invasive screening programs are being studied.Also，frequency of high-efficient screening needs more evidence.In addition，community-based CKD screening project needs further verification of its cost-effectiveness，which offers more evidence for the screening implementation.

Advances in the Etiology of Chronic Diarrhea in Adults　

ZHANG Lijuan，JIANG Yong，LIU Binghua，ZHANG Zhiguang

2019, 22(22): 2760-2765. DOI: 10.12114/j.issn.1007-9572.2019.00.378

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Chronic diarrhea is a group of clinical syndromes with multiple and numerous causes and the complex pathogenesis.According to the lesions，chronic diarrhea can be divided into gastric-derived type，intestinal-derived type，hepatobiliary and pancreatic-derived type，endocrine disease，neuroendocrine tumor and types with other causes of diarrhea in this article.The causes of chronic diarrhea which can be triggered by multiple organ system diseases are complex.To improve the clinical diagnosis and treatment of chronic diarrhea，the etiology of this disease is now reviewed in this article in order to effectively guide the clinical practice.

Advances in Research on Correlation between Blood Pressure Variability Indicators and Risk of Target Organ Damage in Hypertension　

YUAN Qingdan，SHEN Xiaomei

2019, 22(22): 2766-2770. DOI: 10.12114/j.issn.1007-9572.2019.00.334

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Hypertension is a recognized risk factor for target organ damage（TOD）and vascular events.However，office blood pressure（OBP）is difficult to accurately reflect changes of circadian blood pressure.Blood pressure variability（BPV）indicators as important predictors of cardiovascular events obtained by ambulatory blood pressure monitoring（ABPM）can provide more accurate prognostic information than OBP.TOD caused by hypertension is closely related to BPV.This article reviews the recent researches on BPV and the risk of TOD caused by hypertension，such as heart，brain，kidney，fundus and blood vessels，to illustrate the important roles of BPV indicators in evaluating the therapeutic effect and adjusting the treatment plan，and to provide a basis for individualized treatment strategies for hypertension.

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