Drug sale reforms; Autistic children abused; Tibetan monks don't get hypertension; Guangzhou's first private clinic; Doctors stabbed in Fuzhou; Tax breaks for private health insurance

by MICHAEL WOODHEAD
The move to stop county-level hospitals from deriving their income from 15% markups on pharmaceuticals will severely dent their revenue stream and threaten services, health economists have warned. China has already trialled  drug commission bans in 300 county hospitals and now plans to extend the system to 1000 hospitals nationally, Caixin reports. However, the plan could leave hospitals short of funds and thus reduce the level of services and hurt the morale of medical workers,  academics and doctors say. The State Council has said local governments should help hospitals to make up for the lost income from drug sales. However,Wang Zhen, a research fellow at the Chinese Academy of Social Sciences, said local governments were already strained financially and they don't have extra money for hospitals.Wang said that without government subsidies and other measures in place, scrapping the markup practice might wind up creating other problems because hospitals will find alternative ways to make money.

Children with autism in China face experience high rates of physical abuse from their parents and family members, a study from Henan shows. In a survey of 180 children with autism, Zhengzhou researchers found that 36% had recently experienced severe physical maltreatment such as slapping on the face, being beaten with objects or kicked. Less severe physical maltreatment such as being slapped, or shaken was experienced by 86% of autistic children.

Tibetan monks have low rates of hypertension, according to a study carried out in Gansu. The survey of 984 monks found that 19% had hypertension, compared to 34% of the local population. However, despite having low rates of high blood pressure, there were also low rates of awareness, treatment and control of hypertension among monks, the researchers found.

Encouraged by new government policy a surgical oncologist has opened Guangzhou's first major private clinic. The clinic set up by Dr Lin Feng will offer speedy diagnosis and high quality treatment by a well known surgeon previously practicing at the renowned 3rd Hospital of Guangzhou. The clinic charges about 2-3000 yuan fees, and offers high quality diagnosis and surgery without the long waits and rushed consultations of public hospitals, its operators say.

Two doctors at a Fuzhou hospital were stabbed in an attack by a 66-year old male patient, local media report. One male and one female doctor were seriously injured by the man armed with a 40cm knife who had been attending the Fuzhou hospital to have his haemorrhoids treated. A hospital spokesman said the man was unhappy with the treatment he received for his haemorrhoids and stabbed a female doctor in the hip. The male doctor who tried to restrain him was also stabbed in the arm.

Tax breaks are to be introduced for Chinese consumers who take out private health insurance, the government has announced. People who spend more than 2,400 yuan on commercial health insurance policies per year will now only pay individual taxes on income above 3,700 yuan per month, instead of 3,500 yuan, CCTV has reported. The move is part of a government campaign to encourage Chinese people to  purchase private health policies in addition to their standard government benefits.

Hypertension treatment outdated; Infants hit by Group B Streptococcal infections; Liver disease brings ruinously medical bills; Caesarean sections the norm; Li Keqiang unhappy with pace of health reforms

by MICHAEL WOODHEAD
Treatment of high blood pressure in China is quite backward because it is exactly that - treatment of just the raised blood pressure, with no attention to other cardiovascular risk factors. Cardiologists now emphasise that it is essential to treat a person's overall cardiovascular risk, not just focus on single risk factors such as blood pressure. But a study carried out in 274 hypertensive patients in Zhejiang found that  found that 28% were still smoking, 39% drank regularly and only 21% exercised frequently. The average salt intake per day was above the national recommended level of 6g. The study also found that most patients were taking only one drug for high blood pressure, which was inadequate to control their blood pressure. Many were taking 'herbal' medicines that actually contained out of date and dangerous western antihypertensives such as reserpine. As the authors conclude: "The study revealed outdated and inadequate treatment and health education for hypertensive patients, especially for those who have high risk scores for CVD. There is a need to review the community-based guidelines for hypertension management."

In Shenzhen, researchers at the Children's Hospital have shown that invasive group B streptococcal infection is an important pathogen in infants under 90 days old, resulting in in high mortality and neurological sequelae. The streptococcal infection strains showed strong resistance to clindamycin and erythromycin.

Liver disease is an expensive condition that often sees families facing ruinous medical bills in China. A study carried out at a Kunming hospital found that the average yearly cost of medical treatment for hepatitis B was 19,496 RMB, while patients with cirrhosis faced bills of up to 46,061 RMB. While public medical insurance helped pay for some of the costs, catastrophic health expenditure occurred for families affected by all these illnesses.

China's high rate of caesarean sections will be difficult to bring down to more healthy levels, according to researchers. In a  survey of a112,138 women they found the cesarean delivery rate was 55% and as high as 66% in some regions. Two thirds of the cesarean deliveries were scheduled and performed before labour  and about 40%%  were performed without any recognised medical indications. About 57% of the caesareans were done on request of the mother.

Meanwhile, the progress of health reform is obviously too slow for the Premier Li Keqiang. This month he has called for more medical reform measures to overcome 'difficulties' in the healthcare system. In written instructions he identified problems areas that needed attention, such as hospitals should be prevented from being "financed by drug sales" He also said that more effort should be given to reform of county-level hospitals and more serious diseases needed to be covered by medical insurance. His orders came after reform measures were introduced across all county-level hospitals and are now being piloted in 100 city-level hospitals.

Rural doctors in China; Free cancer screening; New TB vaccine; Do doctors have good cardiac skills?

by MICHAEL WOODHEAD

In a sign of the increasing concern about the demise of rural healthcare, China's 1.4 million rural doctors have now been given their own professional organisation.
Although it's not quite a trade union, the Chinese Medical Association has established a rural doctors section that will represent the interests of the many village doctors. The move is in response to the ageing of the semi-skilled workforce, most of whom lack medical degrees and have only high school education and a short training course on healthcare provision. According to the CMA, the new Rural Doctors Association "will assist the government to strengthen and promote rural doctor team building for the survival and development of rural medicine and safeguard the legitimate rights and interests of rural doctors."
Earlier this year Premier Li Keqiang acknowledged that it was important to retain doctors in rural areas, because their primary care role was "more effective than building a large hospital." The State Council acknowledged that rural doctors were the cornerstone of primary healthcare for hundreds of millions of rural residents.
However, most rural doctors are approaching retirement and younger people do not want to work in remote 'backward' areas in a role that is poorly paid and has few career prospects. Rural doctors by decree are paid the same salary as rural teachers - which is a pittance.Their miniscule pensions are an even greater cause for complaint.

Free screening programs for breast cancer and cervical cancer are to be developed nationally in China, according to the National Health and Family Planning Commission. The ministry said 48 million women in rural China had already received cancer screening interventions since 2009,  and there were now plans to increase promotion of screening services, co-ordinated by the All-China Women's Federation.

Despite studying medicine for seven years, China's junior doctors are unable to manage the basics of dealing with a heart attack, a study shows. A survey of 362 new medical graduates found they had little knowledge about basic cardiac diagnosis and resuscitation. Only about 50% of the doctors were able to identify common normal and abnormal ECG changes such as ventricular fibrillation. Likewise only half knew the basics of which drugs should be given for such conditions. The findings showed that many medical graduates were unprepared to manage the most common cardiac emergencies said researcher Dr Xi Huijun and colleagues from the Changhai Hospital, Shanghai.

China is leading the world in developing a new TB vaccine to replace the largely ineffective BCG vaccine against tuberculosis. At a TB vaccine conference held in Shanghai, researchers heard that a vaccine called Vaccae developed by an Anhui pharmaceutical company is in Phase 3 trials, whereas other candidate vaccines from other countries are only in the preliminary stages. Researchers said the vaccine would probably of most use in the elderly, who are expected to account for more than half of tuberculosis cases in the future.

When it comes to health, for China the numbers are staggering

by Michael Woodhead
In western countries hardly a week goes by without some disease condition being put in the spotlight in a press release saying "Condition X affects Y million people a year and costs Z million dollars". 
If industry has a stake in the matter then this is usually followed by a statement saying that the Condition X is underdiagnosed and undertreated and if only we used Drug A or Test B then we would avoid prevent much suffering and save the health budget in the the long run.
This sort of thing is now happening with health conditions in China, except the numbers are bigger by a factor of ten or even a hundred. Take osteoporosis, for example. An analysis published this week shows that there are about 2.3 million osteoporotic fractures a year in China, costing $10 billion in health costs. And if you think that's bad, wait until you see their projection for 2050 - the researchers estimate that with the ageing population there will be 6 million fractures a year costing $25 billion. And as predicted, the report's authors say that "screening and intervention policies must urgently be identified in an attempt to minimize the impact of fractures on the health of the burgeoning population as well as the healthcare budget."

A similar dire warning was made this week for hypertension and diabetes in China. An article in the Journal of the American College of Cardiology said that China was facing a cardiovascular disease epidemic as three out of four Chinese people are in poor cardiovascular shape due unhealthy eating, smoking and obesity. On a similar note, a study from Shenyang showed that 50% of older adults had hypertension and poor cholesterol levels. And a report in The Lancet this week shows that China has 300 million smokers and that tobacco causes 1 million premature deaths a year. The numbers are so big they are incomprehensible. And yet at least the Lancet offers a workable solution: cigarette taxes. It says that if cigarette taxes were raised by 50% this would result in 231 million years of life gained over 50 years and also produce an additional US$703 billion in extra tax revenues from the excise tax. The overall effect would be to relieve financial burden on the poor by avoiding diseases such as lung cancer and the consequent medical bills and time off work. But does Xi Jinping have the gumption to increase cigarette taxes?

For yet another set of mind boggling numbers turn to the example of cervical cancer. With no Pap test screening program, tens of thousands of Chinese women develop this disease and die of it each year, even though it is preventable. Western countries have long had screening programs and are now tackling cervical cancer with the HPV vaccine for young women. Some health economists have crunched the numbers for China and estimated that a national vaccination program of HPV vaccine for 9-15 year old girls, between 2006 and 2012 would have prevented 381,000 cervical cancer cases and 212,000 related deaths. They say that a HPV vaccination program could be implemented in China at a cost of about $50 per girl for the whole set of vaccinations and program costs. In total this would cost China about $160 million, but would ultimately prevent hundreds of thousands of deaths from cervical cancer - and also be cost effective.

A final example: stomach cancer. This causes  hundreds of thousands of deaths in China every year. And yet researchers have found that regular use of low dose aspirin could reduce the risk of stomach cancer (and other common cancers such as colorectal cancer) by as much as 40%. In other words, if Chinese people took a regular dose of aspirin they could avoid many fatal cancers, not to mention the protective cardiovascular benefits against stroke and heart attack. Whether these would be outweihed by increased bleeding risk remains to be seen.

I think what I am trying to say here is that when it comes to ill health in China, the numbers are often too large to be imagined. But that also means that measures that produce only modest reductions in rates of disease can also have major impacts on the absolute numbers of illness.

And while talking of high rates, let's return to my favourite bugbear about healthcare in China - the infusion. I have been guilty in the past of blaming backward thinking among the Chinese masses for insisting on having an infusion for every ailment. I hope I haven't hurt the feelings of the Chinese people and perhaps I owe them an apology. A study from a bog standard Hubei hospital shows that a staggering 96% of antibiotics used in the hospital wee given parenterally (ie by injection or infusion rather than orally). The authors of the report contrast this with the rates of about 30% of IV antibiotic use seen in European hospitals.

However, they blame the profit motive among hospital managers for the widespread use of antibiotic infusions - noting that hospitals depend on drug sales for a major part of their income. Therefore it will be interesting to see what happens when the Chinese government tries to eliminate this source of income for hospital by introducing cost price pharmaceutical billing this year (ie not charging a markup).  How will hospitals  fund their services? The government only covers about 20% of their running costs. There are already predictions that costs will be shifted to medical procedures - and trigger even more overservicing.

At least there is some discussion taking place of these kinds of problems and some in the government are acknowledging that there is still a long way to go in health reform. This week a very frank and bleak account of the ills of rural Chinese health system was published. Doctors and hospital managers said quite bluntly that the rural healthcare system in China is being hollowed out - older doctors are retiring, and nobody is taking their place. Young doctors do not want to work in rural hospitals, partly because the ban on commissions from pharmaceuticals means they can make only a tiny income. And patients do not want to be treated in them. And so the county and township hospitals are becoming ghost hospitals - deserted compared to the overcrowded city hospitals, where rural Chinese flock when they have a serious health problem.

Fact of the week: Chinese primary care (community health centre) doctors earn only 3000-4000 yuan a month. Primary care doctors account for only 4% of doctors in China.

Statin therapy has disappointing results in Chinese patients

by Michael Woodhead
Only about one in four Chinese patients taking a statin have their cholesterol levels under control, according to a new study.

A review of the effects of statin therapy in 8965 outpatients with cardiovascular disease from 200 clinical departments of 122 hospitals across China found that about 75% of patients still had poorly controlled lipid levels.

The findings, published in the International Journal of Cardiology showed that despite taking long term statin therapy in medium to high doses, about 75% of patients had an above-target LDL-cholesterol level. In a similar manner elevated levels of total cholesterol and triglycerides as well as low HDL-cholesterol persisted in 34–43% of patients despite statin therapy, according to Professor Wei Yidong and colleagues at the Department of Cardiology, Shanghai Tenth People’s Hospital and Tongji University School of Medicine.

Only about 10% of patients overall had optimal levels of all lipid measures (LDL, HDL and triglycerides) despite taking statins. Patients with diabetes had slightly better control of lipid levels (43%) compared to those without diabetes (39%).

The study authors said it was not clear why patients taking statins did not have good control of their lipid levels. Oddly, there appeared to be no relationship between the potency of the statin doses and the degree of lipid level control.

About 77% of patients taking low doses of statins had LDL-C not at goal, compared to 72% of patients taking medium potency regimens and 74% of patients taking high potency courses of statins.
Chinese patients may need more intensive lipid-lowering therapy with additional agents other than statins, to improve their lipid levels. Patients may also need more attention on lifestyle factors such as diet and exercise before starting statin therapy, they added.

However, they could not rule out poor adherence to treatment a a possible cause of the poor lipid control.

Medical comic strips | Anti-smoking laws weakened | No support for Orphan Diseases

A female doctor in Shanghai draws weekly comic strips and posts them on WeChat to try demystify medical jargon and improve doctor-patient relations
Dr Chen Haiyan, a cardiac ultrasonographer at the Shanghai Zhongshan Hospital has used the comic strips to explain conditions such as heart defects and high blood pressure in easy-to-understand ways. She also tries to explain the daily life of medical staff and show they are human in an effort to defuse the major tensions that have triggered many recent violent attacks against hospital staff.

Health experts have expressed disappointment that Beijing's proposed anti-smoking regulations have been watered down. The latest draft legislation only bans smoking in "shared indoor public places," compared to a previous draft that banned smoking in all indoor public areas, said Professor
Wang Qingbin, a legal expert at the China University of Political Science and Law,
"By banning smoking only in 'shared' indoor public areas, the legislators are giving officials with their own offices a chance to smoke, which is against the spirit of equality," Wang said, adding that it will only make law enforcement all the more difficult.

China lacks adequate health systems to deal with rare 'orphan' diseases such as Duchenne Muscular Dystrophy, medical experts say. At a recent conference on rare diseases at the Children's Hospital of Fudan University experts called for legislation and policies on the prevention and treatment of rare diseases that affect more than 10 million people in China."Related regulations should be created to help provide better support to patients with rare diseases and their families," said Li Dingguo, chairman of the rare disease branch of the Shanghai Medical Association.

What the Chinese can learn from Tibetans about hypertension

by Michael Woodhead
I've always wondered why Tibetans could be so healthy when they seem to subsist on a diet composed of dairy and meat, perhaps with the odd potato thrown on the fire. 

One of the staples of the Tibetan diet is tsampa - the butter 'tea' which is more like a salty yak butter tea-milkshake. This is not your EasyWay shake - tsampa is made with barley and is often accompanied by a glob of fermented yak milk sometimes known as kurut - similar to the products seen in Xinjiang.

Now it seems there is a hidden healthy component of Tibetan dairy products that has powerful antihypertensive properties, as strong as the drugs prescribed by western cardiologists. The blood pressure lowering effects come from the fermented milks produced by 259 Lactobacillus helveticus - a kind of probiotic ACE inhibitor if you like. Something in the Lactobacillus has potent effects on Angiotensin Converting Enzyme (ACE), the same system that is the target of modern antihypertensives such as enalapril.

In a recent study conducted by dairy technologists at the Inner Mongolia Agricultural University, Huhho, the fermented milk product was found to contain antihypertensive peptides that lower blood pressure by about 12 mmHg for six to 12 hours. That is fairly impressive BP lowering - and would be useful in a typical hypertensive patient with a systolic BP of 140/95mmHg who wanted to get to a target of 120mmHg.

As well as keeping Tibetans healthy, Dr Chen Yongfu and colleagues say the newly-identified probiotic/peptide may have potential as "a valuable resource for future development of functional foods for hypertension management."

The Chinese midday nap causes high blood pressure

by Michael Woodhead
The common Chinese habit of having a midday nap - or wujiao (午觉)- is bad for blood pressure, researchers from Wuhan have shown.
In a study of blood pressure levels in more than 27,000 people, Dr Wang Youjie and colleagues from the School of Public Health, Tongji Medical College, Wuhan found that those taking daytime naps had significantly higher blood pressure than non-nappers. The risk of hypertension was directly related to the length of the midday nap, with those napping for more than 30 minutes being at significantly higher risk.
Writing in the Journal of Hypertension, Dr Wang said taking daytime naps could result in the elevation of evening cortisol levels, which may lead to high levels of blood pressure. The increased risk of hypertension in people who nap might also be related to sleep apnoea, the researchers suggested. They noted that midday napping is a also a risk factor for diabetes mellitus
"We postulate that midday napping might increase the risk of diabetes and hypertension
through the mediation of pathophysiological pathway(s) underlying metabolic syndrome, such as insulin resistance or increased inflammation," they said.
Dr Wang noted that napping is a common habit in China, ingrained from childhood, and practised by 80% of Chinese college students, even though it is "more a habit than a
physiological need", according to a recent survey.
"Considering that midday napping is a common practice, these findings have important implications for further investigation of the potential health consequences of napping and of the optimum nap regimen for elderly people," they concluded

Cardiologists accused of overusing coronary stents for profit

by Michael Woodhead
One of the top stories in China's national Xinhua news site today concerns the case of a man who had nine coronary stents implanted at a cost of 150,000 yuan (US$24,000) for one operation. 
His family say they were shocked to hear of the number of stents - especially as the 58-year old man with blocked coronary arteries did not feel any better after the operation.  The accused the hospital authorities of Chifeng in Inner Mongolian of blatant 'overtreatment' and profiteering. A Xinhua reporter quoted the family as saying their father went in for an operation and was found to have extensive coronary artery blockage - the surgeons then recommended coronary stents, which they said would be better than a bypass grafting operation. However after the implanted six stents they told the family the man would need three more to complete the procedure, otherwise the first six would be wasted. 
The family agreed. but were amazed when they received the final bill for 150,000 yuan. They said they had not expected such a high bill and would have to borrow a lot of money to pay the medical fees.
The Xinhua reporter quoted other health authorities as saying that some cardiologists were abusing the system and overusing stents  because they got a high commission for each one implanted. Each stent cost up to 20,000 yuan and a doctor might get 2000 commission. An internet search of the term 'stent abuse' revealed that many families were making complaints online about having to pay large sums of money for multiple stent insertions. A spokesman for the hospital said it was sometimes necessary to insert multiple stents for one patient, and this was the clinical decision of the surgeon - there was no set rule or guidelines.  However, other medical experts said it was usual only to have one or two stents in a cardiac operation, and some hospitals had a rule that operations that required more than three stents had to be discussed with other surgeons and informed consent obtained form the patient and the family. The academic said that 12% of stent operations involved overtreatment and 38% of procedures are of questionable necessity.

Three reasons why you shouldn't have a heart attack in China

by Michael Woodhead
This week's major new research findings on heart attack in China have been reported as showing a four-old increase - as if China is simply catching up with the west in terms of heart disease. The media reports missed the more important message from this study, which is that treatment of heart attack in China still has a long way to go.
To understand the findings of the Chinese research you need to know a bit of context. In western countries such as the UK and the US there has been a real revolution in the way that heart attacks are treated - and some very real progress in surviving a heart attack. Just a few decades ago, a heart attack was a death sentence - few people survived them, and those who did often were crippled by the ongoing coronary disease or killed off by recurrent attacks. These days, all that has changed because coronary arteries can be unblocked. With early recognition of the signs, and swift transport to hospital (with early rescue treatment started in a cardiac-equipped ambulance), a heart attack can be a survivable event with a reasonably good prognosis for the person who has their blocked coronary arteries cleared and kept open with a stent and or a 'clotbuster' (thrombolytic). Long term prospects are also improved for those who take the right medical therapies such as anti-platelet drugs, beta-blockers and statins - and of course for those who make the necessary lifestyle changes of stopping smoking, doing more activity and eating healthily.
What the report in the Lancet shows is that China is still decades behind the west when it comes to these basic steps - and the survival rates for heart attacks reflect this. The report from the so-called 'China PEACE—Retrospective Acute Myocardial Infarction Study' is one of the first national snapshots of heart attack treatment to come out of China. It sampled about 4% of all coronary treatment units, and found that  - as reported, rates of ST-segment Elevation Myocardial Infarction (STEMI) heart attack rose about four-fold (from 4 per 100 000 in 2001 to 16 in 2011). It also showed that in many aspects there had been little progress in treatment of heart attack over the last decade. Firstly, most people who have a heart attack in China take far too long to get to hospital - averaging about 12 hours. Compare that to western countries, where the average time from the onset of coronary symptoms to actually going under the knife is now as little as three to four hours (remember there can be delays of hours between being admitted to hospital and getting into the catheter lab, the so-called 'door to balloon time').
These long delays in getting to hospital mean that Chinese people with heart attacks are missing out on the 'treatment window' for re-opening those blocked coronary arteries - this is best done within the first few hours of a heart attack before cardiac tissue starved of oxygen dies. The study results showed that less than half of Chinese patients qualified for treatment, and only about a quarter got reperfusion procedures, whereas in western countries about 80% of heart attack patients have treatment such as angioplasty and stenting to re-open occluded coronary vessels.
And in terms of additional medical treatments, Chinese patients also miss out. While most now are prescribed blood-thinning aspirin and a statin (lipid lowering) drug, only about 60% get the recommended cardiovascular drug treatments such as beta-blockers and ACE inhibitors. With these continuing 'treatment deficits' it's not surprising that survival rates for heart attack have improved little in China over the last decade.
The Lancet commentary thus concludes by saying:
"Major emphasis must be placed on early patient presentation (requiring public education of acute myocardial infarction symptoms and prompt response), followed by rapid diagnosis and reperfusion therapy in all appropriate patients (ultimately with primary percutaneous coronary intervention or a pharmacoinvasive strategy). Equally important is establishment of high-quality continuity of care and efforts at secondary prevention after hospital discharge."
In other words, Chinese patients need three things:
1 To recognise signs of a heart attack and get to a hospital immediately.
2. To get early coronary reperfusion treatment from a cardiac unit.
3. To be prescribed the basic drugs to preserve and maintain coronary function.
(I haven't even touched on things like the lack of cardiac rehab and the sky-high smoking rates in China).
The question is: does China have the paramedics, cardiologists and hospital facilities to achieve a Great Leap Forward in coronary care?

Daily Mail fake miscarriage | 120 seconds per patient | Dogs a hepatitis risk | Atrial fibrillation untreated

The Daily Mail has been running a fake story claiming that a pregnant Changsha nurse had 'lost her baby' after being attacked by relatives of a cancer patient who died. Chinese media reported the attack but said she was fortunate to have avoided a miscarriage.

A doctor at a Guangzhou hospital could only spend an average of one and a half minutes per patient when he was the only clinician on duty and had a waiting room of 100 patients to see in one morning.

About 20% of dogs and 6% of cats in Guangzhou are infected with hepatitis E, a new study has shown. The high rates of hepatitis infection should raise concern about the eating of dogs, warn researchers from the South China Agricultural University.

China should not copy the US private model of healthcare according to Nobel prize winning economist Daniel McFadden, of the University of Southern California. Professor McFadden said that when looking at healthcare systems around the world, the most efficient are those where the community medical providers are either employed by the government or employed by companies that are largely contracting to the government and not operating as private businesses.

Hospital staff in the Muslim Xinjiang province have been told not to fast during Ramadan. The request was made at a meeting on upholding ethnic minority unity, “in order not to affect normal work and life." Muslim hospital staff members were requested to sign their pledge of compliance in a “responsibility book.”

One in ten emergency department patients leave without being seen by a doctor, according to a study carried out in Chengdu hospitals. Those who left tended to be families who arrived on foot with children who had less serious problems.

Most Chinese people with atrial fibrillation go untreated, with only 40% receiving anticoagulants, according to a study from Fuwai Hospital and Peking Union Medical College, Beijing.The study also showed that only 26% of people treated for  atrial fibrillation received adequate treatment.

Reform of the medical school curriculum is needed in China as many medical schools are still using outdated and ineffective teaching methods that fail to keep pace with developments in medicine, according to a study from Tongji University, Shanghai.

Iron deficiency anaemia is common in rural parts of central China, where only about 40% of infants have an adequate diet, a study by the UNICEF Office for China, Beijing, shows. Malnutrition and anaemia was more of a risk for ethnic minorities and for those living in poor mountainous areas.

Six of the top medical news stories from China

1. China has a huge shortage of midwives, and would need a further 800,000 to meet the WHO standard of one for every thousand women of child-bearing age, according to a new report. Health officials say the problem will worsen as China adopts a two child policy.

2. Efforts to control pneumococcal disease and Haemophilus influenzae type b (Hib) in children by vaccination are failing due to low immunisation rates and delayed immunisation, a study from Shanghai shows. A review of vaccination records for 28,000 children up to the age of seven found that 51% had one dose of Hib vaccine and 11.4% had one dose of pneumococcal vaccine. Only 8.2% of children had Hib vaccine at the right time and only 0.5% had timely pneumococcal vaccine. Rates were particularly poor for migrant children, the study found.

3. Rates of hypertension have increased in China and yet treatment and control of the condition remain poor, according to researchers from Shandong. In a study of more than 4000 people they found that the incidence of hypertension increased from 2.9 per 100,000 people in 1991–1997 to 5.3 in 2004–2009 Antihypertensive treatment and control rates for hypertension were 5.7% and 1.7% in 1991–1997 and 19.9% and 7.6% in 2004–2009, respectively.

4. The rate of disabilities from road crashes in China has skyrocketed as the number of cars on the road has increased over the last two decades. The incidence rate for road traffic disabilities increased over time from 1.50 per 100,000 people in 1980 to 11.2 per 100 000 persons in 2005, according to Professor Zheng Xiaoying of the Institute of Population Research, Peking University.

5. Malaria is still a major problem in central China especially during floods and rainy periods of the summer. A study from Mengcheng County, Anhui found that there were 3683 malaria were notified during the study period of May to October 2007 Most of the cases occurred a week to a month after flooding and waterlogging. Public health action should be taken to control the potential risk of malaria epidemics after wet weather, the researchers from Shandong University said.

6. The recent outbreaks of H7N9 avian influenza also resulted in many mild and asymptomatic infections as well as severe life threatening cases, researchers from Guangdong have reported. Their surveillance program noted 21 cases of infection in Guangzhou, China in 2013 and 2014, of which several were mild or asymptomatic infection. Family clusters occurred, suggesting limited person-to-person transmission of the H7N9 virus, they said.

6 clinical stories from China

1. Abuse of prescription and over-the-counter drugs is  common among Chinese high school students, a study from Guangzhou has shown. The survey of more than 20,000 students found that more than one in twenty had abused medical drugs at some time. The most common drugs of abuse were analgesics (4%), followed by cough syrups with codeine (2%) and valium or tramadol (1%). Peer pressure was one of the major influences in illicit use of prescription and OTC drugs, and it was also more common in children who already smoked, according to researcher Dr Wang Hui of the Guangzhou Centre for Disease Control and Prevention, writing in the journal Drug and Alcohol Dependance.


2. The agricultural practice of burning straw is a major overlooked contributor to smog and air pollution in Chinese cities, say respiratory physicians from the Shanghai Jiao Tong University Affiliated Sixth People’s Hospital. Burning straw caused PM2.5 levels to reach 194 μg/m3 in Nanjing, which far exceeded the daily average maximum allowable concentration of 75 μg/m3, they note in the American Journal of Infection Control. The pollution is linked to respiratory illness and infections such as pneumonia, they say, and thus needs to be regulated.

3. China has a north-south divide when it comes to hypertension in children, a new review has found. shows. Children and adolescents in the north China have hypertension rates of  18% (Beijing) or 23% (Shandong) whereas those in South of China including Shanghai and Changsha have hypertension rates ranging from 3% to 11%, according to researchers from School of Public Health, Shandong University, Jinan. The higher prevalence of hypertension in the north might be due to higher dietary salt intake they say in the International Journal of Cardiology. 

4. The inherited condition of highly-elevated cholesterol levels, familial hypercholesterolaemia, occurs in about one in 200 Chinese people but is rarely detected, a study from Jiangsu suggests. In a study of more than 9000 people they found that about 0.5% had the condition, which confers a very high risk of cardiovascular disease and early death. They suggest that screening to aid detection and family tracing is carried out by hospital cardiology departments.

5. Gastric cancers account for a fifth of all cancer deaths in China and are especially common in younger women, a study from Guangzhou has found. The review of more than 2000 cases of gastric cancer found that the malignancy was common in older men but was also frequently seen in women under the age of 40.  Most patients had advanced stage disease at diagnosis, suggesting that better detection and treatment of early gastric cancer  is needed.

6. Chinese children are at risk from inappropriate prescribing of medicines, say paediatricians in a letter to The Lancet this week. Dr Tang Wenchu and colleagues from the First People's Hospital of Huzhou University Medical College, Zhejiang, say about a third of medicines taken by children are indiscriminately prescribed, and children are also at risk because there are few paediatric formulations of medication in China. The lack of a national adverse drug reaction surveillance system also means that children may have side effects that are not acted on, they say.

Clinical Friday - news briefs from the medical journals

An outbreak of Hand, Foot, and Mouth Disease in Changchun in 2013 affected more than 1125 children and was caused by Coxsackievirus A6 researchers report. They say the finding of a different causative strain means that vaccination against enterovirus EV71 will not solve the millions of cases of the disease in China every year.

More than 80% of elderly people in Beijing are infected with the stomach bug Helicobacter pylori that predisposes to ulcers and gastric cancer, a study has found. The infection rate with the more pathogenic type 1 H. pylori strain was 56%, researchers found.

Patients with H7N9 influenza living in rural areas were more likely to be female and caught the infection from backyard poultry breeding, a study from Zhejiang has shown.

Heart failure has a poor prognosis in China with 40% patients dying within four years if they have chronic heart failure with reduced ejection fraction, a study from the National Center for Cardiovascular Diseases and Peking Union Medical College shows.

More than one in ten patients attending China's overcrowded hospitals leave without being seen, a study has found. Patients who left without waiting for treatment tended to have less serious illness and have arrived on foot, according to researchers from the Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu.

Uric acid may have a role in hypertension, according to researchers from Xinjiang. In a study of 3778 children and adolescents they found that increasing levels of serum uric acid were associated with high blood pressure.

The most common forms of cancer in China are lung cancer (20.5%), stomach (11%), colorectal (10%) and liver cancer (10%) according to new figures from the National Central Cancer Registry.

Daqing strikes gold with diabetes prevention study

by Michael Woodhead
The oil town of Daqing in north China is now becoming famous for something quite different - preventing diabetes. 
Results from a 23-year study conducted in the city have show that people at risk of diabetes can avoid progressing to the disease and almost halve their risk of death by adopting a healthier diet and doing more exercise.
The findings from the study, published in the Lancet Diabetes & Endocrinology this week have been hailed as a breakthough by international experts because they answer many of the difficult questions about how diabetes may be prevented and its harms minimised.
The study started in 1986, when 577 people with impaired glucose tolerance were assigned to either an intervention group that received advice on diet and/or exercise, or a control group. The lifestyle coaching sessions lasted for six years during which participants received regular encouragement to eat more vegetables and consume less sugar and alcohol, and encouraged them to do more physical activity in their spare time.
Now after more than 20 years of follow up, researchers have found that the people who received the lifestyle advice had a cardiovascular death rate of 1% compared to 20% in the control group. The overall death rate was 28% in the lifestyle group compared to 38% in the control group. Rates of progression to diabetes were 73% in the lifestyle group and 90% in the control group.
"These findings emphasise the long-term clinical benefits of lifestyle intervention for patients with impaired glucose tolerance and provide further justification for adoption of lifestyle interventions as public health measures to control the consequences of diabetes," said lead study author Professor Li Guangwei of the Department of Endocrinology at the China-Japan Friendship Hospital, Beijing.
Commenting on the findings, Professor Nicholas Wareham of Cambridge University said the study was a "real breakthrough, showing that lifestyle intervention can reduce the risk of long-term cardiovascular consequences of diabetes." He said the study showed that lifestyle change could be achieved in the real world and it was notable that the effects were particularly strong in women.

Schistosomiasis test | Cancer snapshot | Stroke survival: six medical news stories from China

A simple and accurate test for schistosomiasis developed by Shanghai researchers could help in the eradication of the disease in China. The rSP13-ELISA method is an affordable serology test for markers proteins of Schistosoma japonicum. The test is highly specific, sensitive and affordable, according to researchers from Tongji University, Shanghai, in an article in Lancet Infectious Diseases this week.

 One in five Chinese people will develop cancer and 13% will die of cancer before the age of 74, data from the nation's cancer registries show.  The most common cancers in China are lung cancer, gastric cancer, liver cancer, oesophageal cancer, colorectal cancer, pancreatic cancer, breast cancer, leukemia and lymphoma, which account for 80% of all cancer deaths.

Chinese people with stroke are more likely to survive now than they would have five years ago, say researchers from the Second Military Medical University, Shanghai. A decrease in mortality from stroke probably reflects advancements in stroke care and prevention. With better survival rates, we should pay more attention to rehabilitation and quality of life for stroke patients. 

Two children in Shanghai have died from hand foot and mouth disease, the infection caused by EV71 enterovirus. The children were from migrant worker families and attended a Jinshan District care center blacklisted over hygiene issues.

Hospital are making large profits from mortuary services, the Global Times reports. Morgues are changing huge markups for services such as preparing corpses for burial and families typically pay 10,000 yuan for cremation and burying services. 

Cardiologists have dismissed internet claims that rubbing inside the elbow is  an effective way to treat people who have had a heart attack. The advice being circulated on social media sites claims that thromboses can be dislodge by  massaging blood vessel near the elbow.

Breast cancer is different in China:  women get it  at a younger age, are  less likely to have breast- conserving surgery and less likely to have positive oestrogen receptor cancers.

No benefit from high dose atorvastatin: Hunan study

For people who have had a heart attack, taking a high dose of atorvastatin (up to 40mg/day) has no added benefit over a moderate dose (10mg/day) a study has shown.
In a two year clinical trial involving more than 1300 patients with acute coronary syndromes (ACS), cardiologists from the Second Xiangya Hospital of Central South University, Changsha, found that the dose of statin had no impact on the primary end points of cardiac death, non-fatal acute myocardial infarction, revascularization, ischaemic stroke and unstable angina or severe heart failure requiring emergency hospitalization. The patients' lipid levels were low initially (mean LDL cholesterol level of 2.7mmol/L) and declined by 20% in the moderate dose statin group and 27% in the intensive statin group, respectively.
"For ACS patients with a relatively low baseline LDL cholesterol level who received optimized current medication and interventional therapy, the incremental LDL cholesterol reduction of 6.4% achieved by double-dose statin did not bring significant clinical effectiveness," the researchers concluded.
The findings are published in Atherosclerosis.

Breaking news - China medical news in brief

by Michael Woodhead
Genetic sequencing to reveal inherited traits such as high risk breast cancer gene BRCA1 has been banned in China until adequate standards can be set, the Beijing News reports. The order was made by the China Food and Drug Administration (SFDA) and the National Health and Family Planning Commission. An official said DNA sequencing was being promoted by some clinics and companies at the costs of thousands of yuan to detect conditions such as cancer, but the testing technology had not been authorised or verified and the charges not standardised.

Rural patients with dementia or depression have death rates three to four times higher than those of their urban counterparts, a study from Anhui has found.

A shortage of blood group O supplies in Beijing has caused the cancellation of elective surgery for many patients. The Beijing Daily reports that a 47-year old man who required cardiac surgery had his operation postponed because there was no blood group O available, only the more common B group. The man's family tried to donate blood but they found they were all group B. A return to the man's home town to try find donors from friends and family also proved unsuccessful. The man and his family resorted to placing adverts in the Beijing newspapers to try solicit blood donations. Doctors said the New year period was always a time of blood donor shortages as the traditional sources of blood donation - students - went home for extended periods.

Chinese people are subject to far too many useless, dangerous and wasteful medical tests in routine check-ups, an article Global Times claims. Citing the experiences of a visiting US physician, the Times asks why so many tests such as X-rays are offered as art of compulsory regular medical check for employment and other purposes when there is little scientific evidence to support them. Chinese clinicians agreed, putting much of the blame on private clinics which they said offered 'warmer service' but which exaggerated the risk of illness and the need for investigations. Clinic staff often act more like sale people than doctors and they offer unnecessary tests to an unwary public who do not have the medical knowledge to make an informed decision, the experts said. One group  has estimated that the health checks market will be worth 300 billion yuan ($49.44 billion) by 2020.

News in brief: clinical studies from China

Measles is now rare in Guangzhou thanks to vaccination, but complete eradication will require vaccination of transient populations who now account for more than half of cases.

People who have a heart attack in China delay going to hospital for more than two hours, often because they don’t recognise the symptoms or their importance.

Chinese people consume dangerously high amounts of salt, with a Yantai study showing that 97% of men and 87% of women had intakes of over 6 g salt per day (mostly from added salt and soy sauce). Salt intake was related to high systolic blood pressure.

More than one in four new mothers in Guangzhou experience post-partum depression.

Compulsory routine infant vaccination with pneumococcal conjugate heptavalent vaccine would reduce pneumococcal disease in China by at least 32%, would prevent 2,682 deaths in the first five years of life and would save $1,190 million.

In rural China epilepsy goes untreated or undertreated in two out of three people with the condition, a Sichuan study has found. One third of people with epilepsy did not know about the disease and had not sought medical help.

The cultural pressure for gay men in China to marry means that their wives face a high risk of HIV and syphilis, researchers from Ningbo say. They found that only one in four gay men always used condoms with their wives, which explained HIV rates of more than 8% in women married to gay men.

Low vitamin A levels are linked to eye cysts (chalazia) in south west China

Weather has an important influence on measles transmission in China, with infection more likely after cold spells and during dry weather.

Doctor attacked for refusing drip | National roaming needed for medical insurance | Community HIV testing | Hand, foot and mouth disease surveyed

Doctor assaulted for refusing to put feverish child on IV drip
China's unscientific obsession with IV infusions for every malady has been brought into focus by an assault on a doctor at a Shenzhen hospital. In a widely reported story, it was said that a family attacked a doctor at a Shenzhen children's hospital when the doctor refused to arrange an IV infusion for a one year old child with a cold. The child had been brought into the hospital by his parents and was given oral medication after it was found to be feverish and diagnosed with a viral respiratory tract infection. However, the family were not satisfied with the oral medication and went back to see the doctor to demand their child be given an 'infusion'. When the doctor refused, the child's father smacked him in the face several times until the doctor was bleeding from the mouth. The attack was only stopped after the intervention of security guards and nurses. The attacker was taken into police custody where he will remain for at least three days while his case is investigated.

Health insurance won't work for floating population
China's goal of providing universal national health insurance is being hampered by the huge 'floating population' of migrant workers, a report has found. While more than 90% of the population are now covered by some kind of medical insurance scheme, the reality is that China's 240 million  'floating population' cannot take advantage of their insurance because it is only valid in their home town or province. This means that many migrant workers and their families from rural and regional areas face large medical bills that they cannot get any compensation for. IN some cases, floating workers will return home to take advantage of medical facilities where they can get some reimbursement, the report said. Integration of China medical insurance schemes is fraught with difficulty because different provinces and cities have different insurance schemes with different premiums and entitlements, the report notes. This means that local hospitals and health insurance schemes are unwilling to deal with 'outside people'. The solution may be some kind of 'national roaming' scheme for health insurance, the report concludes

Community HIV testing a hit
Rapid HIV testing is well accepted and detects many HIV positive people when offered by community clinics in China to high risk patient , a study has shown. In a trial of rapid HIV testing involving 42 sites community health centres in China, 23,609 patients underwent HIV testing. The positive screening prevalence was 0.41%, which is higher than in general hospitals (0.17%). Published in PLOS One, the study findings provide concrete evidence to support the involvement of community health clinics in the expansion of HIV/AIDS testing and case finding, said the researchers from the National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing.

Hand foot and mouth disease surveyed
China's largest ever study of hand, foot, and mouth disease has shown that it is most common in June in north China, whereas southern China has semiannual outbreaks in May and September. The review of seven million cases cases of hand, foot, and mouth disease showed the annual incidence was 1·2 per 1000 person-years, of which 2457 (0·03%) were fatal. The incidence and mortality were highest in children aged 12-23 months, according to the study published in the Lancet Infectious Diseases.

Hypertension more common among Mongolians
A study carried out in northern China has found that hypertension is more common among ethnic Mongolians. Mongolian and Han populations in northeast China. In a study of 4753 Mongolian people and 20,247 Han people, rates of newly diagnosed hypertension over a four year period
were 12.64 per 100 person-years for Mongolians and 9.77 for Han. The rates of awareness of hypertension were low for both Mongolians (36.5%) and Han (42.3%) Likewise, rates of treatment (13.1% vs. 18.2%) and control of hypertension (0.7% vs. 1.3%),were low among both Mongolian and Han population, the study in PLOS One found.