Search

Background: Since 1968, China has trained about 1.5 million barefoot doctors in a few years' time to provide basic health services to 0.8 billion rural population. China's Ministry of Health stopped using the term of barefoot doctor in 1985, and changed policy to develop village doctors. Since then, village doctors have kept on playing an irreplaceable role in China's rural health, even though the number of village doctors has fluctuated over the years and they face serious challenges. United Nations declared Sustainable Development Goals in 2015 to achieve universal health coverage by 2030. Under this context, development of Community Health workers (CHWs) has become an emerging policy priority in many resource-poor developing countries. China's experiences and lessons learnt in developing and maintaining village doctors may be useful for these developing countries. Methods: This paper aims to synthesis lessons learnt from the Chinese CHW experiences. It summarizes China's experiences in exploring and using strategic partnership between the community and the formal health system to develop CHWs in the two stages, the barefoot doctor stage (1968-1985) and the village doctor stage (1985-now). Chinese and English literature were searched from PubMed, CNKI and Wanfang. The information extracted from the selected articles were synthesized according to the four partnership strategies for communities and health system to support CHW development, namely 1) joint ownership and design of CHW programmes; 2) collaborative supervision and constructive feedback; 3) a balanced package of incentives, both financial and non-financial; and 4) a practical monitoring system incorporating data from the health system and community. Results: The study found that the townships and villages provided an institutional basis for barefoot doctor policy, while the formal health system, including urban hospitals, county health schools, township health centers, and mobile medical teams provided training to the barefoot doctors. But After 1985, the formal health system played a more dominant role in the CHW system including both selection and training of village doctors. China applied various mechanisms to compensate village doctors in different stages. During 1960s and 1970s, the main income source of barefoot doctors was from their villages' collective economy. After 1985 when the rural collective economy collapsed and barefoot doctors were transformed to village doctors, they depended on user fees, especially from drug sale revenues. In the new century, especially after the new round of health system reform in 2009, government subsidy has become an increasing source of village doctors' income. Conclusion: The barefoot doctor policy has played a significant role in providing basic human resources for health and basic health services to rural populations when rural area had great shortages of health resources. The key experiences for this great achievement are the intersection between the community and the formal health system, and sustained and stable financial compensation to the community health workers. [ABSTRACT FROM AUTHOR]

Background: China has a high burden of diabetes mellitus (DM), and a large proportion of DM patients remain untreated for various reasons, including low availability of primary health care providers. DM patient management is one of the priorities in China's national essential public health programs. Shortage of health workforce has been a major barrier to improving access to health care for DM patients. This study examines the impact of the health workforce on outpatient utilization of DM patients. Methods: Data were collected from China National Health Service Surveys in 2008 and 2013, covering 94 rural counties and 156 urban districts, respectively, with a total of 15,984 DM patients. Household data and facility-based data at county/district level were merged. The health workforce was measured by number of physicians per 1,000 population in county hospitals and primary health centers (PHCs), respectively. Health care seeking behavior was measured by health care utilization and distribution of health providers of the DM patients. Multilevel zero-inflated negative binomial regression was used to analyze the impact of the health workforce on outpatient visits by DM patients, and a multilevel, multinomial logit model was used to examine the impact of the health workforce on choice of health providers by DM patients. Results: An increase in the number of physicians at both county hospitals and PHCs was associated with increased outpatient visits by DM patients, particularly more physicians at PHCs. With increased numbers of physicians at PHCs, outpatient visits among residents with DM in rural and western areas of China increased more than those in urban and eastern areas. More physicians at PHCs had a positive impact on improving the likelihood of outpatient visits at PHCs. The positive influence of increasing the number of physicians available to DM patients in rural and western areas was greater than that for urban and eastern DM patients. Conclusions: The health workforce is a key component of any healthcare system and is critical in improving health care accessibility. Strategies to increase coverage of health workforce at PHCs are crucial to achieving adequate levels of health services for DM patients. Allocation of health workforce should focus on PHCs in rural and low-income areas. [ABSTRACT FROM AUTHOR]

Background: The ratio of C-reactive protein to albumin, as a novel inflammation-based prognostic score, is associated with outcomes in cancer and septic patients. The diagnostic accuracy of the CRP/albumin ratio has not been assessed in colorectal surgery for postoperative complications. Methods: A total of 359 patients undergoing major colorectal surgery between 2012 and 2015 were eligible for this study. Uni- and multivariate analyses were performed to identify risk factors for postoperative complications. Receiver operating characteristic curves were developed to examine the cutoff values and diagnostic accuracy of the CRP/albumin ratio and postoperative CRP levels. Results: Among all the patients, 139 (38.7%) were reported to have postoperative complications. The CRP/albumin ratio was an independent risk factor for complications (OR 4.413; 95% CI 2.463-7.906; P < 0.001), and the cutoff value was 2.2, which had a higher area under the curve compared to CRP on postoperative day 3 (AUC 0.779 vs 0.756). The CRP/albumin ratio also had a higher positive predictive value than CRP levels on postoperative day 3. Patients with CRP/albumin ≥ 2.2 suffered more postoperative complications (60.8% vs 18.6%, P < 0.001), longer postoperative stays (10 (4-71) vs 7 (3-78) days, P < 0.001), and increased surgical site infections (SSIs) (21.1% vs 4.8%, P < 0.001) than those with CRP/albumin <2.2. Conclusions: The ratio of C-reactive protein to albumin could help to identify patients who have a high probability of postoperative complications, and the ratio has higher diagnostic accuracy than C-reactive protein alone for postoperative complications in colorectal surgery. [ABSTRACT FROM AUTHOR]

Background: Neonatal health (NH) remains a major problem in many countries. Children dying before 28 days often suffer from conditions that are preventable or treatable with proven, cost-effective interventions. The knowledge gaps are no longer about what should be done, but to understand why guidelines including these interventions are not followed. Using a behaviour change framework, this study explores neonatal health guidelines use and the role of management in supporting effective usage in two rural settings in China and Vietnam. Methods: Semi-structured interviews with policy makers, health care managers and providers (n = 49) and focus group discussions with women, husbands and grandmothers who had experienced maternal and NH care services within the last year (n = 7) were conducted. Data were analysed using the framework approach. Results: Guidelines are not readily available at county, township and village levels in the study sites in China, whereas, in Vietnam, guidelines are available, accepted and being used at facility level. Improvements in implementation could be made in both settings. Factors influencing guidelines use common to both settings included: lack of equipment and supplies; shortage of staff with NH care experience; and guidelines not in line with patient practices. Factors specific to China included: poor guidelines dissemination; and disagreement with guidelines. There was limited community engagement in NH services in China, whereas in Vietnam, community members were actively involved in decision making and provision of services. Managers have an important role in supporting NH guidelines use through: ensuring guidelines are available; allocating appropriate resources; supporting and monitoring staff in their use; and engaging with local communities to promote effective practices. Conclusions: Engaging managers to support implementation is crucial. Management systems that provide the necessary resources, competent staff, and monitoring, regulatory and incentive frameworks as well as community engagement are needed to promote adoption of guidelines. Further research on how best to strengthen local level management so that they tailor interventions to support guideline use to their specific context is needed. This will ensure that proven interventions to address NH problems are used, and that countries move closer to achieving the new Sustainable Development Goal 3 target. [ABSTRACT FROM AUTHOR]

Background: Fecal microbiota transplantation (FMT) induces remission in ulcerative colitis (UC). However, the treatment effect of FMT diminishes over time. Maintaining the diversity of the gut flora for long periods may improve the effects of FMT in UC. Pectin, which can be fermented by gut microbiota into short-chain fatty acids, is postulated to shape the composition and maintain the balance of gut microbiota following transplantation. This study investigated whether pectin could enhance the effects of FMT in UC patients. Results: Three FMT patients and four FMTP patients achieved the primary outcome. The Mayo scores of the FMTP group were lower than those of the FMT group at weeks 4 and 12 (P = 0.042 and P = 0.042, respectively). There were no differences in the diversity of the gut flora between the two groups at weeks 4 and 12; however, the composition of the gut flora of the FMTP group was more similar than the FMT group to that of the donor at all-time points post-treatment. Conclusions: Pectin decreased the Mayo score by preserving the diversity of the gut flora following FMT for UC. [ABSTRACT FROM AUTHOR]

Background: Increases in health care utilization and costs, resulting from the rising prevalence of chronic conditions related to the aging population, is exacerbated by a high level of fragmentation that characterizes health care systems in China. There have been several pilot studies in China, aimed at system-level care coordination and its impact on the full integration of health care system, but little is known about their practical effects. Huangzhong County is one of the pilot study sites that introduced organizational integration (a dimension of integrated care) among health care institutions as a means to improve system-level care coordination. The purposes of this study are to examine the effect of organizational integration on system-level care coordination and to identify factors influencing care coordination and hence full integration of county health care systems in rural China. Methods: We chose Huangzhong and Hualong counties in Qinghai province as study sites, with only Huangzhong having implemented organizational integration. A mixed methods approach was used based on (1) document analysis and expert consultation to develop Best Practice intervention packages; (2) doctor questionnaires, identifying care coordination from the perspective of service provision. We measured service provision with gap index, overlap index and over-provision index, by comparing observed performance with Best Practice; (3) semi-structured interviews with Chiefs of Medicine in each institution to identify barriers to system-level care coordination. Results: Twenty-nine institutions (11 at county-level, 6 at township-level and 12 at village-level) were selected producing surveys with a total of 19 schizophrenia doctors, 23 diabetes doctors and 29 Chiefs of Medicine. There were more care discontinuities for both diabetes and schizophrenia in Huangzhong than in Hualong. Overall, all three index scores (measuring service gaps, overlaps and over-provision) showed similar tendencies for the two conditions. The gap indices of schizophrenia (> 5.10) were bigger for diabetes (< 2.60) in both counties. The over-provision indices of schizophrenia (> 3.25) were bigger than diabetes (< 1.80) in both counties. Overlap indices for the two conditions exceeded justified overlaps, especially for diabetes. Gap index scores for schizophrenia interventions at the township-level and over-provision index scores for diabetes interventions at both village- and township-level showed big differences between the two counties. Insufficient medical staff with appropriate competencies, lack of motivation for care coordination and related supportive policies as well as unconnected information system were identified as barriers to system-level care coordination in both counties. Conclusion: Findings demonstrate that organizational integration in Huangzhong has not achieved a higher level of care coordination at this stage. System-level care coordination is most problematic at village-level institutions in Hualong, but at county-level institutions in Huangzhong. These findings suggest that attention be given to other aspects of integration (e.g., clinical and service integration) to promote system-level care coordination and contribute to the full integration of health care system in the pilot county. [ABSTRACT FROM AUTHOR]

Background: Clinical practice guidelines (CPGs) are formally developed statements that assist users to provide proper health care for a kind of disease and play a significant contribution in healthcare system. This study report the methodological quality of CPGs on constipation.Methods: The "Appraisal of Guidelines and Research and Evaluation" (AGREEII) instrument was developed to determine the quality of CPGs. A comprehensive search was developed using five databases and three guideline websites until/up to December, 2015. Four independent authors evaluated the methodological issues of the CPGs by the AGREEII instrument.Results: We identified 22 relevant guidelines on constipation from 1234 citations. The overall agreement among evaluators was 0.84 using the intra-class correlation coefficient. The mean AGREEII scores for the domains "scope and purpose" (51.77) and "rigor of development" (56.73) were moderate; afterward, three domains "stakeholder involvement" (32.23), "editorial independence" (29.59) and "applicability" (29.14) were low scores. The "clarity and presentation" (23.73) had the lowest scores.Conclusion: Although existing constipation guidelines may accurately reflect current clinical practices, many guidelines' methodological quality is low. Therefore, more emphasis and attentions should be taken to the development of high-quality guidelines. [ABSTRACT FROM AUTHOR]

Background: Nosocomial Methicillin-resistant Staphylococcus aureus (MRSA) enteritis is rare but can be fatal unless it is detected at an early stage and treated effectively. Dysbiosis of the gut is one of the leading reasons of MRSA enteritis. Fecal microbiota transplantation (FMT) is a burgeoning treatment to rectify this imbalance. But the impact of FMT on MRSA enterocoitis is still unknown yet. Methods: A total of 5 patients diagnosed as MRSA enteritis during the early postoperative period were given vancomycin 2 g/day for 3 days and FMT for three continuous days as a standard treatment. Result: There was a 100 % clinical response rate that all the symptoms resulting from MRSA enterocolitis disappeared and MRSA in the feces eliminated clearly. The microbiota profile in feces of the patients also regained balance. Conclusion: FMT can be a preferential measure to restore the dysbiosis caused by MSRA enterocolitis. [ABSTRACT FROM AUTHOR]

Background: Radical hysterectomy and radiotherapy have long been mainstays of cervical cancer treatment. Early stage cervical cancer (FIGO stage IB1-IIA) is traditionally treated using radical surgery combined with radiotherapy, while locally advanced cervical cancer is treated using radiotherapy alone or chemoradiotherapy. In this retrospective study, we describe and analyse the presenting clinical features and outcomes in our cohort and evaluate possible risk factors for postoperative morbidity in women who underwent surgery for chronic radiation enteropathy (CRE). Methods: One hundred sixty-six eligible cervical cancer patients who underwent surgery for CRE were retrospectively identified between September 2003 and July 2014 in a prospectively maintained database. Among them, 46 patients received radical radiotherapy (RRT) and 120 received radical surgery plus radiotherapy (RS + RT). Clinical features, postoperative morbidity and mortality, and risk factors for postoperative morbidity were analysed. Results: RS + RT group patients were more likely to present with RTOG/EORTC grade III late morbidity (76.1 % vs 92.5 %; p = 0.004), while RRT group patients tended to show RTOG/EORTC grade IV late morbidity (23.9 % vs 7.5 %; p = 0.004). One hundred forty patients (84.3 %) were treated with aggressive resection (anastomosis 57.8 % and stoma 26.5 %). Overall and major morbidity, mortality and incidence of reoperation in the RRT and RS + RT groups did not differ significantly (63 % vs 64.2 % [p = 1.000], 21.7 % vs 11.7 % [p = 0.137], 6.5 % vs 0.8 % [p = 0.065] and 6.5 % vs 3.3 % [p = 0.360], respectively). However, incidence of permanent stoma and mortality during follow-up was higher in the RRT group than in the RS + RT group (44.2 % vs 12.6 % [p = 0.000] and 16.3 % vs 3.4 % [p = 0.004], respectively). In multivariate analysis, preoperative anaemia was significantly associated with overall morbidity (p = 0.015), while severe intra-abdominal adhesion (p = 0.017), ASA grades III-V (P = 0.022), and RTOG grade IV morbidity (P = 0.018) were predicators of major morbidity. Conclusions: Radiation-induced late morbidity tended to be severe in the RRT group with more patients suffering RTOG/EORTC grade IV morbidity, while there were no significant differences in postoperative morbidity, mortality and reoperation. Aggressive resection was feasible with acceptable postoperative outcomes. Severe intra-abdominal adhesion, ASA grades III-V and RTOG/EORTC grade IV late morbidity contributed significantly to major postoperative morbidity [ABSTRACT FROM AUTHOR]

Background Sclerosing encapsulating peritonitis (SEP) is a rare cause of small-bowel obstruction. The optimal treatment for this condition remains controversial. Methods In this study, we performed a retrospective analysis of the data of 44 patients who underwent surgery for SEP between December 2001 and 2008 at our hospital. The long-term follow-up data of the patients were assessed for the recurrence of adhesive small-bowel obstruction (ASBO), and patient survival was assessed to evaluate the efficiency of tube splinting in the prevention of postoperative ASBO. Results Of the 44 patients who underwent surgery for SEP, 33 underwent simple enterolysis along with tube splinting, while the remaining underwent only simple enterolysis. The median follow-up period was 79.4 ± 24.8 months (range: 8-123 months). The rate of complications was 9.1% and 6.1% in the simple enterolysis group and tube-splinting group, respectively (P = 0.73). The recurrence rate of ASBO was lower in the tube-splinting group (6.7%) than in the simple enterolysis group (40%) (P = 0.02). Conclusion Our findings indicate that tube splinting may be more useful than simple enterolysis alone in preventing the recurrence of ASBO in patients with SEP. [ABSTRACT FROM AUTHOR]

Background: Contact tracing is especially useful for identifying an infection with few cases in the population, such as HIV in China. Little such research is available in China. Methods: Every newly diagnosed HIV case from 2008-2010 in Taizhou Prefecture, Zhejiang Province in China, was invited to participate as an "index case" in a contact tracing survey by providing contact information for up to eight sexual contacts who themselves were approached for voluntary HIV counseling and testing (VCT). Those who tested HIV-positive were then subjected to another contact tracing survey. This process was repeated until no more sexual contacts were reported or tested positive. Results: A total of 463 HIV-infected individuals were newly identified during the study period, including 338 cases who were identified from routine surveillance programs and 125 cases who were identified from the present contact tracing survey. Among these 463 cases, 398 (86.0%) served as 'index cases' in the survey, including 290 (85.8%) out of the 338 cases identified from routine surveillance programs and 108 (86.4%) out of the 125 cases identified from the present survey. These 398 'index cases' reported a total of 1,403 contactable sexual contacts, of whom 320 (22.8%) received HIV testing and 125 (39.1%) tested positive for HIV. Willingness to receive HIV testing was high among spouses and long term heterosexual or homosexual partners but extremely low among casual and commercial sex partners of 'index cases'. Consistent condom use was rare for all participants. A total of 290 independent sexual network components were constructed, with high complexity. Conclusion: Contact tracing is useful for identifying new HIV infections from spouses or long term sexual partners of HIV-infected individuals. The complicated sexual networks existing between and beyond HIV-infected persons provide opportunities for rapid spread of HIV in such areas. [ABSTRACT FROM AUTHOR]

Hypercatabolism is common under septic conditions. Skeletal muscle is the main target organ for hypercatabolism, and this phenomenon is a vital factor in the deterioration of recovery in septic patients. In skeletal muscle, activation of the ubiquitin-proteasome system plays an important role in hypercatabolism under septic status. Insulin is a vital anticatabolic hormone and previous evidence suggests that insulin administration inhibits various steps in the ubiquitin-proteasome system. However, whether insulin can alleviate the degradation of skeletal muscle protein by inhibiting the ubiquitin-proteasome system under septic condition is unclear. This paper confirmed that mRNA and protein levels of the ubiquitin-proteasome system were upregulated and molecular markers of skeletal muscle proteolysis (tyrosine and 3-methylhistidine) simultaneously increased in the skeletal muscle of septic rats. Septic rats were infused with insulin at a constant rate of 2.4 mU.kg-1.min-1 for 8 hours. Concentrations of mRNA and proteins of the ubiquitin-proteasome system and molecular markers of skeletal muscle proteolysis were mildly affected. When the insulin infusion dose increased to 4.8 mU.kg-1.min-1, mRNA for ubiquitin, E2-14 KDa, and the C2 subunit were all sharply downregulated. At the same time, the levels of ubiquitinated proteins, E2-14KDa, and the C2 subunit protein were significantly reduced. Tyrosine and 3-methylhistidine decreased significantly. We concluded that the ubiquitinproteasome system is important skeletal muscle hypercatabolism in septic rats. Infusion of insulin can reverse the detrimental metabolism of skeletal muscle by inhibiting the ubiquitin-proteasome system, and the effect is proportional to the insulin infusion dose. [ABSTRACT FROM AUTHOR]