OBJECTIVE To develop a standard of hierarchical management for patients with chronic obstructive pulmonary disease （COPD） from the perspective of pharmacists. METHODS The triangle hierarchical management model was used as the framework. Through literature research， the indicators of the hierarchical management standard for COPD patients were preliminarily compiled. A questionnaire was designed and administered to 18 experts， and Delphi method was conducted in two rounds to determine the contents of the standard. RESULTS The response rates for both rounds of expert consultation were 100%， with both authority coefficients of experts of 0.903 and Kendall coordination coefficiens of 0.279 and 0.189 for each indicator. The final established standard of hierarchical management for COPD patients included 25 stratified indicators and 17 pharmaceutical hierarchical management indicators. There were 9， 8 and 8 indicators in the high-risk， medium-risk， and stable layers， respectively， considering three aspects： disease， medication， and self-management level. The corresponding first-level， second- level， and third-level pharmaceutical management included 6， 6 and 5 indicators， respectively， including inhalation technical guidance， medication adherence guidance， treatment monitoring， and follow-up， etc. CONCLUSIONS The standard of hierarchical management for COPD patients established by Delphi method is scientific and reliable， which can provide a reference for pharmacists to carry out hierarchical management of COPD patients in China.

Objective:To establish the biology reference interval (RI) of peripheral blood procalcitonin (PCT) for children between 3 days and 6 years old in China.Methods:Totally 3 353 reference individuals with apparent health or no specific diseases were recruited in 18 hospitals throughout the country during October 2020 to May 2021. Reference individuals were divided into four groups: 3-28 days, 29 days - 1 year, 1-3 years and 4-6 years. Vein blood or capillary blood were collected by percutaneous puncture from every reference individual. The PCT level in serum and the capillary whole blood were assayed by Roche Cobas e601 and Norman NRM411-S7 immunoanalyzer. Outliers were deleted and 95th percentiles of every group were provided as RIs. Man-Whitney U test or Kruskal-Wallis test were used performed to assess the difference among different gender, age or method groups. Results:The difference of PCT distribution between male and female is not statistically significant, but the difference between serum and capillary whole blood is statistically significant. The differences between age groups are significant too. For Roche e601, serum PCT RI of 3-28 days group is <0.23 μg/L, 29 days - 6 years are <0.11 μg/L. For NRM411, Serum PCT RI of 3-28 days group is <0.21 μg/L, 29 days - 1 year: <0.09 μg/L, 1 - 6 years: <0.10 μg/L. For whole blood PCT, RI of 3-28 days group is <0.26 μg/L, 29 days - 6 years is <0.15 μg/L.Conclusions:Serum and capillary whole blood PCT have different RIs, however, capillary whole blood PCT testing is valuable in pediatric application. Children in 3-28 days show higher PCT levels than other age group. To establish the RIs and understand the differences among different groups are essential for the interpretation and clinical application of peripheral blood PCT testing results.

Objective:To investigate the pathogens and drug resistance of bacterial enteritis in children, analyze the clinical characteristics of bacterial enteritis in children, and provide basis for clinical diagnosis and treatment.Methods:The fecal culture strain and drug sensitivity of patients with bacterial enteritis admitted to our hospital from January 2016 to December 2020 were analyzed and summarized, and the clinical characteristics of patients who were infected by Salmonella and Escherichia coli were compared.Results:There were a total of 173 patients, aged from 21 days to 15 years, with a median age of 2.00(1.10, 3.54)years.Bacterial enteritis was most likely to occur in summer and autumn, and the incidence rate was 40.5% and 29.5%, respectively.One hundreds and seventy-three strains of bacteria were cultured in feces, including 148 strains of Salmonella(85.5%), 18 strains of Escherichia coli(10.4%), five strains of Staphylococcus aureus and two strains of Shigella.One hundreds and one of 141 patients who were infected with Salmonella were detected for leukocytes of in feces(71.6%), and four of 16 patients with Escherichia coli were detected for leukocytes(25.0%). The difference was significant( χ2=14.1, P<0.001). Eighty-eight of 113 patients(77.9%) who were infected by Salmonella with increased CRP(CRP>8 mg/L)and the proportion in Escherichia coli infection cases was 6/13(46.2%). There was significant difference( χ2=4.63, P=0.03). The drug sensitivity of Salmonella and Escherichia coli was summarized.There was no carbapenem resistant strain cultured; The sensitivity to piperacillin/tazobactam and cefoperazone/sulbactam was higher than 85%; The sensitivity to cefepime, ceftazidimeand ceftriaxone was higher than 75%; The sensitivity to ampicillin was lower than 30%, and the sensitivity to quinolones was between 20%-40%. Conclusion:Children aged 1-3 years are prone to bacterial enteritis in summer and autumn.The most common pathogens causing bacterial enteritis are Salmonella and Escherichia coli.White blood cells are more easily detected in feces of patients with Salmonella infection, and the increase rate of C-reactive protein in peripheral blood is higher.Patients with bacterial enteritis are recommended to use the third-generation cephalosporins and aforementioned antibiotics and piperacillin/tazobactam for empirical treatment.The sensitivity to quinolones is reduced, and may not be suitable for clinical application.

Objective:To explore the performance of the commonly used whole blood C-reactive protein (CRP) detection systems and give related recommendation on the performance requirements of detection systems.Methods:A total of 7 540 venous blood samples from 26 maternal, child and children′s hospitals were collected to conduct this multi-center study on the analytical performance of 5 commonly used whole blood CRP detection systems from March to April in 2019. The blank check, carryover, repeatability, intermediate precision, linearity, sample stability, influence of hematocrit/triglyceride/bilirubin, comparison with SIEMENS specific protein analyzer and trueness were evaluated. The 5 systems included BC-5390CRP autohematology analyzer, AstepPLUS specific protein analyzer, Ottoman-1000 Automated Specific Protein POCT Workstation, i-CHROMA Immunofluorometer equipment Reader and Orion QuikRead go detecting instrument. The 5 systems were labeled as a, b, c, d and e randomly.Results:Within the 5 systems, all values of blank check were less than 1.00 mg/L, the carryovers were lower than 1.00%. The repeatability of different ranges of CRP concentrations including 3.00-10.00, 10.00-30.00 and>30.00 mg/L were less than 10.00%, 6.00% and 5.00%, respectively, and the intermediate precision was less than 10.00%. The linearity correlation coefficients of the 5 systems were all above 0.975, while the slope was within 0.950-1.050. Whole blood samples were stable within 72 hours both at room temperature (18-25 ℃) and refrigerated temperature (2-8 ℃). The CRP results were rarely influenced by high triglyceride or bilirubin, except for the immmunoturbidimetric test based on microparticles coated with anti-human CRP F(ab) 2 fragments. When triglyceride was less than 15.46 mmol/L, the deviation of CRP was less than 10.00%. When bilirubin was less than 345.47 μmol/L, the deviation of CRP was less than 10.00%. CRP was more susceptible to Hct on the systems without Hct correction. The deviation of CRP between different Hct dilution concentration and 40% dilution concentration can reach as high as 67.48%. The correlation coefficients ( r) of 5 systems were all more than 0.975 in the range of 0-300.00 mg/L compared with Siemens specific protein analyzer. All systems passed the trueness verification using the samples with specified values of 12.89 and 30.60 mg/L. Conclusion:The performance of 5 systems can basically meet the clinical needs, but it is suggested that the whole blood CRP detection system without automatic Hct correction should be modified manually.

Teaching evaluation is an important part of the whole teaching process. In view of the shortcomings of the traditional final assessment, formative assessment has received wide attention from the education community with its characteristics of diverse assessing subjects, diverse assessment contents and diverse assessment tools. This paper introduces formative assessment into flipped classroom, and tries to construct formative assessment index system, which may provide the theoretical basis for the implementation of formative assessment in flipped classroom.

COVID-19 has swept globally and Pakistan is no exception.To investigate the initial introductions and transmissions of the SARS-CoV-2 in Pakistan,we performed the largest genomic epidemiology study of COVID-19 in Pakistan and generated 150 complete SARS-CoV-2 genome sequences from samples collected from March 16 to June 1,2020.We identified a total of 347 mutated positions,31 of which were over-represented in Pakistan.Meanwhile,we found over 1000 intra-host single-nucleotide variants(iSNVs).Several of them occurred concurrently,indicating possible interactions among them or coevolution.Some of the high-frequency iSNVs in Pakistan were not observed in the global population,suggesting strong purifying selections.The genomic epidemiology revealed five distinctive spreading clusters.The largest cluster consisted of 74 viruses which were derived from different geographic locations of Pakistan and formed a deep hierarchical structure,indicating an extensive and persistent nation-wide transmission of the virus that was probably attributed to a signature mutation(G8371T in ORF 1ab)of this cluster.Further-more,28 putative international introductions were identified,several of which are consistent with the epidemiological investigations.In all,this study has inferred the possible pathways of introduc-tions and transmissions of SARS-CoV-2 in Pakistan,which could aid ongoing and future viral surveillance and COVID-19 control.

Objective　To analyze clinical features of nerve injury caused bythe abuse of nitrous oxide.Methods　We retrospectively analyzed the clinical data of eight patients with nitrous oxide poisoning and summarized their clinical features.Results　Eight patients with nitrous oxide poisoning were all young and middle-aged with a history of exposure to nitrous oxide.Peripheral nervous system was impaired in eight patients,central nervous system was impaired in five patients,autonomic nerve was impaired in two patients,and two patient had neuropsychiatric symptoms.Vitamin B12 deficiency and homocysteine elevation were detected in eight patients.High doses of vitamin B12,methylcobalamin or adenosine cobalamin were effective.Conclusion　Long-term consumption of N2O can lead to megaloblastic anemia,nervous system injury and even fatal.

To unravel the genetic mechanisms of disease and physiological traits, it requires comprehensive sequencing analysis of large sample size in Chinese populations. Here, we report the primary results of the Chinese Academy of Sciences Precision Medicine Initiative (CASPMI) project launched by the Chinese Academy of Sciences, including the de novo assembly of a northern Han reference genome (NH1.0) and whole genome analyses of 597 healthy people coming from most areas in China. Given the two existing reference genomes for Han Chinese (YH and HX1) were both from the south, we constructed NH1.0, a new reference genome from a northern individual, by combining the sequencing strategies of PacBio, 10× Genomics, and Bionano mapping. Using this integrated approach, we obtained an N50 scaffold size of 46.63 Mb for the NH1.0 genome and performed a comparative genome analysis of NH1.0 with YH and HX1. In order to generate a genomic variation map of Chinese populations, we performed the whole-genome sequencing of 597 participants and identified 24.85 million (M) single nucleotide variants (SNVs), 3.85 M small indels, and 106,382 structural variations. In the association analysis with collected phenotypes, we found that the T allele of rs1549293 in KAT8 significantly correlated with the waist circumference in northern Han males. Moreover, significant genetic diversity in MTHFR, TCN2, FADS1, and FADS2, which associate with circulating folate, vitamin B12, or lipid metabolism, was observed between northerners and southerners. Especially, for the homocysteine-increasing allele of rs1801133 (MTHFR 677T), we hypothesize that there exists a "comfort" zone for a high frequency of 677T between latitudes of 35-45 degree North. Taken together, our results provide a high-quality northern Han reference genome and novel population-specific data sets of genetic variants for use in the personalized and precision medicine.

Objective? To explore the effects of clinical pathway in cancer pain management among cancer patients. Methods? We selected 114 cancer patients with pain and opioids pain management in Radiotherapy and Chemotherapy Center at Ningbo First Hospital of Zhejiang Province. A total of 56 cancer patients with pain from March to December 2018 were in observation group with nursing based on self-design clinical pathway; a total of 58 cancer patients with pain from May 2017 to February 2018 were in control group with routine nursing. The Numerical Rating Scale (NRS) was used to compare the effects of pain management of patients between two groups. We also investigated the medication compliance and pain management satisfaction of patients between two groups. Results? As time progressed, the NRS scores of cancer pain patients in the two groups decreased, and the interaction, time and intervention differences between the two groups were statistically significant (P＜ 0.01). One day before discharge, the score of NRS in breakout pain attack of patients of observation group was (4.78±0.59) lower than that (5.56±0.74) of control group; times of breakout pain of patients of observation group was (2.70±0.71) times per day less than (3.21±0.84) times per day of control group; the differences were statistical (P＜0.01). The medication compliance of patients of observation group was (6.69±0.97), higher than (6.02±1.10) of control group; patients' satisfaction with pain management of observation group was (87.84±7.21), higher than (75.93±6.95) of control group;the differences were also statistically significant (P＜ 0.01). Conclusions? Application of clinical pathway in pain management and nursing for cancer patients with pain can effectively management patients pain and improves patients' medication compliance and satisfaction with nursing.

Objective To explore correlation of sleep quality and fear of disease progression among cancer patients,so as to provide evidence to improve sleep quality among cancer patients undergoing in clinical practice. Methods A number of 144 cases of cancer patients in one Class Ⅲ grade A hospital in Ningbo were investigated by convenience sampling method from April to October 2016. Data of general information, Pittsburgh Sleep Quality Index(PSQI)and Fear of Progression Questionnaire-Short Form(FoP-Q-SF)were used. Spearman correlation analysis was applied to analyze the relation between sleep quality and fear disease progression of canner patients. A total of 144 questionnaires were sended,and 139 effective questionnaires were collected. Results Patients' score of PSQI was (8.93±4.49); patients' FoP-Q-SF score was (23.31±7.76). Sleep quality was positively correlated with fear of progression (r=0.385, P<0.01). Conclusions Higher level of patient's fear of progression is related to worse sleep quality. Nurses should instruct patients to understand the disease and the treatment correctly, to reduce the adverse impact on progression and emotion and to improve patients' sleep quality.