Bound feet, pirate hospitals and frequent flyer patients: just some of the medical news stories out of China this week

Bound feet not all bad for bones

Women who had their feet bound according to feudal Chinese tradition are more prone to osteoprosis but their enhanced balance skills mean they do not have excessive fractures, a study has found. A review of more than 250 elderly women who had bound feet by researchers at Kunming Medical University found that they had higher rates of osteoprosis than women of similar age.
However they did not seem to be in worse health or be more prone to fractures, the study found.
"This might be explained by compensation in physical activity to improve body balance, implying the importance of improving or maintaining body balance in overall prevention strategies against fragility fractures," the researchers said.

Trademarks use to fight pirate hospitals 

The renowned Beijing Tianlun fertility hospital has trademarked its name after finding that other hospitals around China were setting up 'Tianlun' fertility clinics and claiming to be affiliated to the famous clinic.

Frequent flyer patient

A Jiangxi endocrinologist has been called to provide emergency inflight medical help to the same woman twice in a month, according to CAAC News. The doctor treated the women on a flight to Thailand after she fainted. On the return flight he again answered a call for help and found he was helping the same woman with the same problem.

More family doctors for Henan

The Henan government claims to have re-trained almost 10,000 doctors to work as family doctors in community clinics and township-level hospitals. The government said the re-training program meant that Henan could not make family doctors available to 60% of people in rural areas and 100% of people in urban areas.

 Guangdong gets locals to sign up for GP cover

The Guangdong city of Huizhou says it has  got 30% of target patient populations to enrol with a family doctor. The city health authorities want to arrange GP cover for children under five, pregnant women, the elderly and people with chronic diseases. The authorities say they aim to have 50% of people enrolled by the end of the year.

Tianjin hospital gets Dr Weixin

A hospital in Tianjin has set up a smartphone service to allow patients to get advice, information  and book appointments via their phones. However, users said the electronic hospital system was clunky, did not allow access to many departments and they still had to queue to pay for appointments

Serious disease insurance cover to be nationwide.

China's minister for social security has said that his department will fully introduce nationwide social medical insurance for serious diseases within the year. However, critics have saod that hospitals will use the cover to claim rebates for unneccessary treatments while local governments will not have the finances to support the scheme. Meanwhile a group from Renmin University in Beijing have suggested that micro-credit schemes be used to give poor rural people access to funds to pay for their medical bills. The scheme would operate in the same way as micro-credit programs running in developing countries to provides funds for business startups.

Family planning staff become child development aides

The staff of local family planning departments may move into child development work and away from enforcing the single child policy, if a pilot program in Shaanxi is successful. The program sees family planing agency staff assisgned to follow up children up to the age of three to ensure they are meeting basic development goals in care and education, according to Caixin.


And this week's violence against healthcare workers:

Zhejiang: An armed man opened fire in a Zhejiang hospital and had to be disarmed by police after he injured one man and threatened patients and staff in the Haiyang country hospital.

Shanghai: A drunk man took a hostage at knifepoint at the emergency department of Shanghai No. 9 People’s hospital yesterday morning and injured a policeman who intervened.

Hebei: a  gang armed with machetes smashed up the emergency department of Baoding Hospital and severed the hand of a man who was being treated for minor injuries from an earlier attack. The man had been involved in an earlier altercation with the gang and they had come for payback, police said.

Liuzhou: a man got 10 days administrative detention and was fined 200 yuan for attacking a female doctor at a Liuzhou hospital. The man hit the female doctor because he was unhappy with the treatment his father was receiving for a bladder problem.

Beijing: A patient with a grudge over hand surgery assaulted a surgeon at the Jishuitan Hospital. The patient had previously had eight stitches in his  finger and was unhappy because it did not bend the way it did before the injury.

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.

Clinical research from China in the medical journals ...

In the Journal of Thoracic Diseases, Dr Xiao Kun and colleagues at the Department of Respiratory Medicine, PLA General Hospital, Beijing, evaluate prognostic indicators for  Community-acquired pneumonia in elderly patients. In their study of 240 patients they found that Pneumonia Severity Index scores were the best indicator in predicting different clinical outcomes of aged patients with CAP, when compared to testing for N-terminal pro B-type natriuretic peptide (proBNP) levels and three other scoring systems. They also found that systolic BP might be as a protective factor for prognosis of CAP.

Celecoxib may be an effective way of preventing the formation of joint adhesions, according to Shanghai researchers. In the journal Experimental and Therapeutic Medicine, 

orthopaedic surgeons from the Sixth Affiliated People's Hospital of Shanghai Jiaotong University report on an animal experiment in which they tested the inhibitory effects of celecoxib and ibuprofen given for 30 days on joint adhesions. Few adhesions were seen in the celecoxib treated animals, suggesting that the drug “may provide a novel and potent approach for their prevention,” they conclude.

In the same journal, cardiologists from the People's Hospital of Zhengzhou University, Henan report that Chinese patients with chronic heart failure have poor outcomes by international standards. Survival rates of 685 patients with chronic heart failure (HF) and reduced ejection fraction (HFrEF) were assessed during follow up of around 30 months.

 The fatality rate was 28%, with most due to pump failure 6% due to sudden deaths. The predictors of mortality were advanced age, BMI, NYHA functional class and lack of oral β-blockers at discharge.

“Patients with heart failure and reduced ejection fraction have poor prognoses in China, particularly those patients with an LVEF of ≤35%. Therefore, cardiologists should strive to improve the prognosis of HF among Chinese patients and focus on the importance of the practical application of HF diagnosis and treatment guidelines,” the researchers said.

In the European Spine Journal, bone specialists from Jinan Military General Hospital, Shandong, show that the most important risk factors for recurrent fractures after vertebroplasty are osteoporosis and treated level at the thoracolumbar junction. In a one year follow up study of 175 patients who underwent vertebroplasty for first-time and single-level osteoporotic vertebral fractures. They found that recurrent fractures developed in 37 (21%) of patients. Higher fracture rates were seen in pateints higher BMD T-score, and treated vertebrae located in the thoracolumbar junction.

Bisphosphonate treatment worsens bone health in Chinese patients

Bisphosphonates may cause atypical stress fractures due to deterioration of mineral content of the femur

by Michael Woodhead
The anti-osteoporosis bisphosphonate drugs may prevent bone loss but long term use results in weaker bones that are more prone to fracture, Hong Kong researchers have shown.
In a study to assess the link between long-term bisphosphonate treatment for osteoporosis and atypical fractures, researchers from the  Department of Orthopaedics and Traumatology and Bone Quality and Health Centre at the Chinese University of Hong Kong, studied bone health in 28 elderly patients taking bisphosphonates.
They found that when compared to a control group of 37 elderly people, the total hip bone mineral density was no different in the patients who took bisphosphonates for osteoporosis prevention for four years. However, bisphosphonate-treated patients had lower bone mineral content in the femoral shaft, and they also had a weaker bone structure in the subtrochanteric and mid-diaphyseal regions and thus significantly lower bone strength. CT scans confirmed that there was significantly decreased trabecular density, bone volume ratio, trabecular number but increased trabecular spacing in tibia and distal radius. Other tests confirmed significantly lower stiffness and failure load in tibial bone. Biochemical studies also showed lower bone resorption and severely suppressed bone formation activity following bisphosphonate treatment.
The researchers say that the unchanged total hip bone mineral density between the two groups confirmed the beneficial effects of bisphosphonate on trabecular bone, thus preventing osteoporotic fractures in general. However, the inferior structural, densitometric and biomechanical properties at cortical bones, especially femur midshaft, need  special attention to look into the association between long-term bisphosphonate intake and the occurrence of stress fractures, they suggest. They  recommend that when patients taking bisphosphonates complain of proximal thigh pain or discomfort, X-rays should be used for screening. All patients prescribed bisphosphonates should be informed of the possibility of these potential bone weakness complications, they add.
"In conclusion, inferior biomechanical properties due to structural deterioration and poor bone mineral content at cortical bones of osteoporotic patients, together with the uncoupled bone remodelling process with long-term bisphosphonate intake were depicted in this study. These findings may explain high tension stress in the lateral sides of the subtrochanteric and midshaft regions is prone to stress fracture during normal daily activities. Until the risk factors of developing atypical fractures can be identified, patients under bisphosphonate treatment should be monitored closely to detect the potential problems, and early and prompt treatment should be given accordingly. "
And as the half life of the drug in the bone tissue is around ten years, plain film checking for stress fractures in case upper or mid-thigh pain is [advised], even after the drug is stopped, they suggest.
Source: Chinese Medical Journal

Clinical news in brief ....

Chinese herbalists at high risk of bladder cancer

Practitioners of traditional Chinese medicine who handle the toxic herb fangchi are at high risk of bladder cancers, a study has shown. Fangchi contains aristolochic acid which is known to cause urothelial carcinoma. Fangchi is commonly used in the Chinese herbal medicine industry and a study of 6,564 Chinese herbalists found that processing, selling or dispensing herbs containing fangchi significantly increased their risk of urothelial carcinoma  by more than a factor of two.
"Exposure to the Chinese herbal drug fangchi increases the risk of urothelial carcinoma in herbalists. Appropriate medical monitoring is warranted for workers who have similar exposure," say researchers.
Read more: Journal of Urology

Bone loss factors in Chinese postmenopausal women

With advancing age, lean mass begins to decrease in women aged over 65 years, but fat mass levels show no significant difference between the age groups. Both fat mass and lean mass positively correlate with bone mineral density decreasing rates. Fat mass is the most significant determinant of bone loss at the lumbar spine, whereas lean mass is the most significant determinant of bone loss at the femoral neck and total hip.
Read more: Endocrine Journal

50% of rural women have reproductive tract infections

A study of 1500 women aged 30 to 59 years old in Shanxi Province found that 54% had reproductive tract infections such as cervicitis, trichomonas vaginitis, and bacterial
vaginitis. The study also showed that 14% had suspicious benign breast disease , 1.4% had cervical precancerous lesions and 0.2% had suspicious breast cancers. All the women expressed interesting taking part in a low cost program of combined screening for  cervical cancer, breast cancer and
reproductive tract infections (RTIs).
Read more: Asia Pacific Journal of Cancer Prevention


Mercury causes birth defects in Chinese infants

High levels of mercury found in some pregnant Chinese women increase their risk of having a baby with neural tube defects, a study from has shown. Researchers from the Institute of Reproductive and Child Health/Ministry of Health Key Laboratory of Reproductive Health, Peking University found that the risk of neural tube defects was up to 18 times higher for babies who had in utero exposure to higher levels of mercury.
Read more: Reproductive Toxicology