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Keywords:

  • Emergency response;
  • medical treatment;
  • phase report;
  • Sichuan Province Wenchuan earthquake

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion and suggestions
  8. References

Objective To retrospectively analyze medical treatment during the Wenchuan earthquake and evaluate the emergency medical response.

Method On the basis of the data reported to the provincial disaster relief headquarters by cities and counties in Sichuan Province, we established a database for data processing by using SPSS v11.0. Descriptive statistical analysis was performed.

Results The emergency response of Sichuan health system was quick, effective, and powerful.

Conclusion In the face of extraordinary disaster, Sichuan Province effectively completed emergency medical treatment despite the enormous workload and associated difficulties achieving initial success in earthquake relief.

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Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion and suggestions
  8. References

Sichuan is a large inland province of China with a total area of 485,000 km2 and four terrain types: mountains, hills, plains, and plateaus. Sixty per cent of the region's land is above 1,000 m in altitude, and between any pair of towns there is usually only one road. Sichuan has 18 cities, three autonomous prefectures, 181 counties (cities and districts), and 4544 villages and towns. In 2007, Sichuan Province had a total population of 88,152,000, a birth rate of 9.2‰, a population mortality rate of 6.3‰, a natural population growth rate of 2.9‰, and the 25th ranking in nationwide per capita GDP of RMB 12,893 (1).

The total number of medical institutions at all levels in Sichuan Province is 21,273 containing 214,329 beds. There are 1,162 hospitals with 136,757 beds, of which 94,772 beds are in municipal hospitals (69.3%), and 41,985 beds are in county-level hospitals (30.7%). On average 2.43 beds are available per 1,000 people. There are 310,665 healthcare workers across the province, of which 254,811 (82.0%) are health technicians, 91,273 (29.4%) are registered physicians, and 73,327 (23.6%) are registered nurses. There are 2.89 health technicians, 1.03 registered physicians, and 0.83 registered nurses per 1,000 people.

At 14:28 hours on 12 May 2008 the Wenchuan earthquake occurred with a magnitude of 8.0 on the Richter scale. A total of 11 cities (prefectures) (52.4%), 67 counties (37.0%), and 950 townships (towns) (21.0%) in Sichuan were affected. There was a total disaster area of 280,000 km2, a hard-hit area of 125,000 km2 (25.8 %), an epicenter, or the worst hit area, of 11,000 km2 (2.3%), and a total affected population of 29.61 million (33.6%). In addition, most of the worst hit areas were inaccessible due to mountains and canyons. Traffic and communication disruptions caused by the earthquake further complicated matters. Blocked rivers and bad weather made it impossible for rescue workers, supplies, vehicles, and large-scale rescue equipment to reach some of the worst hit areas, making disaster relief extremely difficult (2).

By 12:00 hours on 30 May, 18 days after the earthquake, 68,858 people were confirmed dead, 18,681 missing, and 366,586 had been reported as injured. Hospitals across Sichuan Province had treated a total of 455,093 injured people from the disaster areas. Of those injured, 83,385 were hospitalized and 54,536 were subsequently discharged, 15,461 were seriously injured, and 2,483 people died. A total of 10,015 of those injured were transferred to 20 other provinces for further treatment and 12,492 remained in local hospitals. This article reports the Sichuan earthquake relief organization and medical treatment, with a goal of providing baseline data and decision-making references for earthquake disaster emergency medical relief in the future.

Materials and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion and suggestions
  8. References

Data resources

Data reported to the provincial disaster relief headquarters by cities and counties across Sichuan Province and the 2008 Statistical Yearbook of Sichuan Province (1) were primary sources. In the sources, statistics for the critically injured were reported. Diagnoses of the critically injured were made by different hospitals; therefore, standards may vary.

Statistical parameters

Statistical parameters included the number of disaster relief medical personnel from Sichuan Province, other provinces, Hong Kong, Macao, Taiwan, as well as overseas. Parameters also included the treated injured, hospitalized patients, discharged patients, the critically injured, people who had died, people who were transferred to other provinces, and those who remained in hospitals.

Statistical methods

We established a database for data processing using SPSS v11.0 software and performed descriptive statistical analysis.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion and suggestions
  8. References

Emergency response command

After the earthquake, the Sichuan Provincial Health Bureau immediately launched the top level emergency pre-plan. One hour after the disaster, the first emergency mobilization order was issued to the province's health system. Within two hours of the quake, the medical and health relief headquarters was set up and then was joined by the 12 May Sichuan earthquake relief headquarters, which was renamed the ‘Medical Care Assurance Group of the 12 May Sichuan Earthquake Relief Headquarters’. The group consisted of several teams with responsibilities including medical treatment, disease control, medical supply and demand, media coverage, comprehensive co-ordination, logistical support, transportation of the injured, as well as post-disaster reconstruction. Under the leadership of the provincial committee, the provincial government and the earthquake relief frontline co-ordination group of the Chinese Ministry of Health (MoH), the province's health system made disaster rescue and relief top priority, doing its utmost to support the relief work.

Under the direct leadership of the provincial earthquake relief headquarters, hundreds of people quickly gathered from the departments of Health, Drug Surveillance, Traditional Chinese Medicine, Economics, Traffic, Agriculture, and many others in an organized manner with clear responsibilities at all levels. It was a high-speed operation with strong implementation and coherent co-ordination in order to make the relief effort orderly and focused (Fig. 1).

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Figure 1. Organization chart of earthquake relief headquarters system.

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The focus of the first phase of the earthquake relief was medical treatment. The medical treatment group established a team that was responsible for on-site medical treatment management.

Medical teams

Two hours after the quake, the Sichuan Provincial Health Bureau quickly dispatched the first batch of 28 teams of 90 medical and disease control staff with 28 ambulances and first-aid medicines and equipment to Dujiangyan, Deyang, Shifang, Mianzhu, Beichuan, and other areas. At midnight on 12 May, the Bureau sent another 96 medical relief teams of 400 medical staff to Dujiangyan, Deyang, Shifang, Mianzhu, Beichuan, Pingwu, Guangyuan, and other disaster areas for rescue work. From the early morning of 13 May, the third batch of 51 teams of 314 medical staff organized by municipal health departments went to these areas, as well as Qingchuan and Ya’an, to rescue the wounded through the night.

Due to the severity of the disaster, the Sichuan Provincial Health Bureau immediately mobilized hospitals in 13 minimally affected cities for the rapid formation of three-tier medical rescue teams, while contacting the city of Chongqing and the state MoH for support. After 12 May thousands of medical teams rushed to the worst-hit areas by land, water, and air under risk of aftershocks, falling stones, and mud–rock flows. Search-and-rescue and medical treatments were carried out. Forty-eight hours after earthquake, 461 key medical staff members from different medical institutions across the province had set up three first-aid stations (tent hospitals) at Anxian, Mianzhu, and Dujiangyan for fast, accessible treatment.

On 22 May, 10 days after the quake, a Shanghai medical team of 20 staff with first-aid medicines and equipment, and satellite telephones air-dropped by helicopter to the villages of Gengda, Sanjiang, Ginkgo, and Caopo in Wenchuan County, where other medical staff could not enter as a result of traffic blocks. Eleven cities (prefectures), 67 counties (districts), and 950 villages across the province affected by the earthquake had complete medical coverage.

As of 15:00 hours on 30 May 2008 up to 50,456 medical staff had participated in frontline treatment, of which 41,240 (81.73%) were from Sichuan Province; 5,969 (11.83%) were from other provinces and municipalities; 3,048 (6.04%) were from the army, armed police, and public security; and nine medical teams of 199 staff came from Hong Kong, Macao, Taiwan, and eight foreign countries, accounting for 0.39% (Table 1). A total of 45,000 ambulances were dispatched. Between 12 and 30 May, the number of medical staff sent to disaster areas for frontline rescue efforts was developed in two stages: first a rapid growth in numbers and then steady growth (Fig. 2).

Table 1.  Origin of frontline medical relief staff
Medical relief staff sourceTotal numberProportion (%)
Inside province41,24081.73
Outside province596911.83
Army30486.05
Hong Kong, Macao, Taiwan, overseas1990.39
Total50,456100%
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Figure 2. Trend in number of medical teams arriving in the disaster area from inside and outside the province.

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The first stage from 12 to 15 May showed rapid growth. The disaster situation was uncertain immediately after earthquake as a result of road and communication disruption. With the gradual restoration of roads and communications, information continuously came from the disaster area; the severity of the disaster was greater than expected. Under the urgent action of governments and medical institutions at all levels, within three days medical staff sent by the nation and provinces for rescue showed rapid growth from 90 to 35,880 people, accounting for 71.11% of total medical relief staff. The number of medical staff on the frontline reached 540 on 12 May, 1,676 on 13 May, 4,265 on 14 May, and 35,880 on 15 May. Of these medical personnel 31,000 came from Sichuan Province, accounting for 86.40% of the total, while 4,880 came from other provinces, accounting for 13.60% (Fig. 3). Within 72 hours, the ‘golden time’ for saving life, most of the injured survived because of prompt medical treatment. Medical staff quickly reached the disaster areas from inside and outside of the province. This illustrates the rapid response of the health system, which played a vital role in saving lives (Fig. 2).

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Figure 3. Number of medical relief staff reaching the disaster area within 72 hrs.

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The second stage from 16 to 30 May was the period of steady growth. Eleven medical teams from Taiwan, Russia, Hong Kong, Japan, Italy, Macao, Germany, Cuba, Britain, France, and the USA participated in medical relief from 20 May to 7 June.

Medical treatment

Treatment at frontline hospitals

A frontline hospital refers to a hospital in the worst hit areas. Despite their own damage and interruptions in communication caused by the earthquake, frontline hospitals sent ambulances and medical staff as early as two minutes after the earthquake, while more than 70% of municipal and county-level medical institutions in the worst hit areas sent support within half an hour. Eighty-five per cent of the county-level medical institutions began to be involved in the rescue effort within half an hour. Forty minutes after the earthquake, the first patient from quake-hit Pengzhou arrived in Sichuan Provincial People's Hospital in Chengdu. Seventy minutes later, the hospital received the first batch of 12 injured people from Dujiangyan. Twelve hours after that, Sichuan Provincial People's Hospital, Deyang City People's Hospital, Mianyang City People's Hospital, Guangyuan City People's Hospital, and other four hospitals had admitted 3,000 injured people. With roads and communications totally disrupted, Aba Prefectural Health Department organized 12 medical teams with more than 70 members to bypass Lixian in order to get to Wenchuan, and 11 medical teams of more than 70 people to bypass Heishui, Songpan, and Maoxian for medical treatment, which became the first rescue teams to reach the epicenter. According to incomplete statistics, within 72 hours of the earthquake, Wenchuan, Lixian, Maoxian, Pingwu, and Chingchuan had treated 28,340 injured people relying on the local county, township, and village three-tier medical staff. (Table 2).

Table 2.  Number of injured treated at frontline worst hit hospitals within 72 hours of earthquake
Worst hit countiesTreatedHospitalized
Wenchuan  9800 820
Chingchuan  8530 420
Maoxian  4450 890
Lixian   720  80
Pingwu  4840 310
Total 28,3402520

Without orders from supervisors, hospitals in Chengdu, Mianyang, Deyang, Guangyuan, and other cities sent ambulances as early as 30 minutes after the earthquake to set up first-aid stations for emergency treatment and treat the injured in close co-operation with the rescue teams (3). According to frontline first-aid and classification procedures, the critically injured and non-critically injured were sent to the frontline and second-line hospitals for treatment immediately after emergency surgery and first-aid, respectively. The injured also used self-aid and buddy aid to win valuable time (Fig. 4).

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Figure 4. On-site medical treatment procedure for people injured in the earthquake.

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Treatment at second-line hospitals

In the face of a large number of wounded arriving at hospitals in a short period, hospitals across the province did all they could to stop elective surgery and close some specialty clinics, mobilize and discharge some less serious patients, and to build makeshift wards in available additional space. Additionally, they streamlined the rescue process by implementing a one-stop service at reception including triage, transfer, inspection, and admission to surgery. They also involved all doctors in the rescue regardless of medical specialties. Many medical staff worked for several days and nights without a break to treat the injured (4).

Hospitals across the province had admitted 21,404 injured people within 12 hours of the disaster, and 47,507 within 48 hours. They had treated 68,788 people including 41,825 inpatients within 72 hours (Fig. 5).

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Figure 5. Trend in number of injured people treated.

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Figure 5 shows an increasing trend in the numbers of injured people and inpatients in disaster areas. Most treatment for the injured was administered within the first two weeks after the earthquake, and then the patients of disaster areas in two weeks. Between 12 and 30 May, hospitals treated 455,093 injured people, and hospitalized 83,385, of whom 47,510 were hospitalized before 72 hours. More than 10,100 people received resuscitation, 27,700 had surgery, 54,536 were discharged, and 12,492 remained in hospital. All of the injured people received appropriate medical treatment. (These numbers do not include the injured rescued by the army, armed police, and public security.)

Third transfer for treatment

After the earthquake, General Secretary Hu Jintao and Premier Wen Jiabao repeatedly visited disaster areas to inspect and direct the disaster relief work, particularly concerning the treatment of those injured in the quake. From 12 to 31 May, 5 to 19 days after earthquake, in keeping with the important instructions of General Secretary Hu Jintao “to transfer the seriously injured but stable patients to other provinces and municipalities for better treatment in a timely manner”, 10,015 people who were hospitalized at Chengdu, Mianyang, Deyang, Guangyuan, and 11 other cities and prefectures were transferred to 367 hospitals in 58 cities of 20 other provinces and municipalities by 21 special trains and 99 special flights. Of those transferred, 5,053 traveled by train, 3,495 by air, and 1,467 by automobile. Of those transferred, 4,109 were from Chengdu, 2,916 from Mianyang, and 1,378 were from Deyang. Chongqing received 2,276 injured people, accounting for the largest number of transfers, while Jiangsu Province received 1,302 and Guangdong Province received 934 people.

Treatment for the critically injured

The earthquake caused a large number of traumatic injuries. According to the MoH Four Focus Principles on the treatment of critically injured, Sichuan Province concentrated on patients, experts, resources, and treatment to minimize mortality and disability of the injured. Three days after the earthquake, a large number of critically injured were sent to frontline and second-line hospitals. According to incomplete statistics (raw data records reported by hospitals), the critically injured accounted for 22% of the injured inpatients; of those, 2,483 died after being admitted, accounting for 2.98% of total inpatient numbers (Fig. 6). After hospital treatment, the number of critically injured decreased sharply from 15,461 (not including 2,904 critically injured people treated by army, armed police, and public security), to 1,440 on 30 May (Fig. 7), which shows effectiveness of treatment of the critically injured in Sichuan Province. Because of various diagnostic criteria on critically injured people in hospitals, as well as possible incorrect or missing data from the first days following the earthquake, statistics are based on discharge records from the hospitals.

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Figure 6. Proportions of people injured, critically injured people and the death toll in hospital.

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Figure 7. Trend in number of critically injured inpatients.

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Hospital infection control

On 16 May, four days after the earthquake, considering possible post-disaster epidemics of gangrene, tetanus, and intestinal and respiratory infections, the provincial headquarters immediately launched a pre-plan on infectious disease prevention. They asked for hospital infection control to be comprehensively applied throughout hospital reception, triage, laboratory, clinical diagnosis, isolation, wound handling, clinical treatment, sterilization, medical waste disposal, transferring, and terminal disinfection. They also strengthened supervision and inspection of implementation as well as simultaneously training relevant medical staff and volunteers. Every hospital set up a special infection ward and operating room. Patients with suspected infection were immediately sent into the infection ward, ambulances underwent strict sterilization, and post-operative waste was cremated after strict disinfection in strict accordance with medical waste management regulations. As of 30 May, hospitals across the province found 61 cases of highly suspected gas-gangrene infection, but no hospital infections were caused by gas gangrene, showing outstanding hospital infection control.

Early psychological intervention

People injured in the quake suffered from instability, fear, and anxiety. Suffering the pain of disability after injury, loss of family and friends, and destruction of homes and property, some experience severe emotional problems. People needed not only physical treatment but also psychological intervention and assistance. Only by effectively carrying out a comprehensive and integrated approach including rescue, treatment, psychological intervention, and resettlement after rehabilitation, can the pain caused by the disaster be alleviated.

With the national mobilization of 247 experts in psychological intervention under MoH coordination and more than 2,000 volunteers, psychological intervention groups were established to offer comfort and psychotherapy to affected individuals in order to encourage, help rebuild confidence, and prevent possible adverse post-disaster mental stress reactions and behaviors. Good outcomes were achieved in terms of preventing and reducing the impact of post-disaster stress on the physical and mental health of victims and rescue workers.

Combination of rescue and disease treatment

The Wenchuan earthquake caused tremendous damage to the healthcare system in Sichuan Province. In the worst areas the health network was completely disabled. In order to ensure basic medical care for disaster victims and inhabitants at resettlements, medical teams were promptly organized and well co-ordinated. Medical service was extended to the villages and families, carrying on ‘treatment on the injuries and disease, combination of prevention and treatment’, which formed the new post-disaster three-in-one medical pattern of treatment and disease prevention and control. To effectively solve the medical problems of the worst hit areas, after consultation with the Chengdu Military Area Command and other concerned departments, 21 field hospitals were set up in locations including Dujiangyan, Mianzhu, Beichuan, Qingchuan, Pengzhou, and Mianyang. Additionally, transitional hospitals were to be established to address health services for people where township health centers had been lost. By the combination of injury treatment and consultation for disease, medical treatment problems have been properly resolved.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion and suggestions
  8. References

Emergency response speed is the beginning

The promptness of the response to an emergency situation directly affects treatment outcomes. In the face of a major disaster, under the leadership of the MoH and with the help of the army and citizens, Sichuan Provincial Health Bureau rapidly mobilized the province's health force into the disaster area in organized groups. After only three days, more than 35,000 medical staff were deployed to the disaster area. It was the first time that Sichuan Province had to gather medical teams on a large scale within such a short time. The speed with which teams were organized and the care they gave played a key role in saving lives.

Co-ordinated effort is the foundation

In spite of the heavy workload of the earthquake relief mission, especially with the continual, large influx of domestic and foreign medical teams and relief materials into Sichuan, the emergency response mechanism improved rapidly with strong co-ordination and close collaboration on national and international levels. The achievement of multi-provincial, multi-national, multi-industry, and multi-department co-operation guaranteed the effectiveness of the operation.

Good organization is the structure

Powerful co-ordination and command made the Sichuan earthquake relief effort proceed in a controlled manner. The first stage was on-the-spot rescue. Within 72 hours medical staff sent to disaster areas reached up to 35,880 people, accounting for 71.11% of the total medical relief staff. Most people were rescued successfully at this stage. The second stage was treatment at hospitals. A large group of those injured was rushed to frontline or second-line hospitals. Every hospital tried to refine rescue procedures, focus on rescue quality, and ensure medical treatment as soon as possible for every injured person. The third stage was immediate treatment for those who had sustained critical injuries. The Four Focus Principle was put into effect in treatment of critically injured people to minimize mortality and disability resulting from injuries. The fourth stage was strict hospital infection control by thorough application of infection control procedures from hospital reception and triage to medical waste disposal, with strict supervision and clear responsibilities. The fifth stage was to transfer patients efficiently and to begin rehabilitation.

Materials are the guarantee

In order to make good use of relief medicines, medical devices and sterilization equipment, and to ensure disaster medical supplies were delivered to the frontline in time, the Medical Supply and Command Team was co-established by multiple industries and departments across the province, sharing joint management of distribution and supply with clear responsibilities and detailed workflow. The four-tier responsibility system from the province to city, city to county, county to town, and town to village was efficient. The supply and demand channels of medical relief supplies, material safety management, and transportation management had been normalized to an organizational structure, operation, and management mechanism. Close multi-department co-ordination ensured medical relief supplies reached disaster areas promptly and with precision. The amount of distribution for the month after the quake was more than the whole province's total amount in 2006. Such high demand and time constraints had rarely arisen in the history of Sichuan.

Consideration of local conditions

The first strategy used was the three-tier treatment and transfer used for medical treatment. It was essential to take different approaches for medical treatment according to the severity of each injury to ensure effective treatment for many wounded people in a short period. The second strategy was the Four Focus Principle for those with critical injuries. This treatment effectively reduced mortality and disability. The third strategy was the combination of rescue and disease treatment: a new three-in-one pattern of rescue, treatment, and prevention was established to deal with the disaster. The fourth strategy was early intervention to eliminate adverse psychological harm.

Conclusion and suggestions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion and suggestions
  8. References

The Sichuan medical emergency response to the major disaster was quick, effective, powerful, and well co-ordinated. The health system satisfactorily completed emergency medical treatment despite an enormous workload and immense contextual difficulty. They achieved a successful emergency medical response to the quake.

Suggestions for future disaster relief follow.

  • 1
    Create detailed emergency pre-plans. Although the governments and hospitals at all levels have developed a variety of emergency preplans, serious shortcomings were seen during a major disaster. In the future, pre-plans need to be developed to for effective emergency response when there are serious communication and transportation disruptions.
  • 2
    Increase numbers of qualified personnel and supply reserves in the field hospitals. Twenty-one field hospitals, which were set up in the worst hit area with army and civilian co-operation, played an active role in the earthquake medical treatment. This experience should be developed in order to carry out rational distribution of the donated field hospital supplies and equipment from other provinces and countries. In order to effectively use the field hospital experience, training programs should be offered across the province, and a rapid emergency response system should be established.
  • 3
    Improve training and equipment for intensive care facilities. Except for a few large hospitals, the intensive care unit (ICU) in most hospitals was too small, and lacked staff and equipment. ICU capability should be strengthened by training personnel in critical care medicine in ICU settings.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion and suggestions
  8. References
  • 1
    Sichuan Provincial Statistics Bureau, Sichuan Investigation Group. Sichuan Statistical Yearbook 2008. Beijing : China Statistics Press, 2008.
  • 2
    State Council earthquake relief headquarters. Regard to the current earthquake relief progress and mission in the next stage (May 27) 2008.
  • 3
    Lei BL, Zhou Y, Zhu Y, Huang XY, Han SR, Ma Q, et al . The emergency response of medical rescue in the worst-hit Mianyang areas after Wenchuan earthquake. Chinese Journal of Evidence-based Medicine 2008; 8(8): 5817.
  • 4
    Xie J, Du L, Xia T, Wang MY, Diao X, Li YP. Analysis of 1861 wounded inpatients and deaths in West China Hospital of Sichuan University after Wenchuan earthquake. Chinese Journal of Evidence-based Medicine 2008; 8(8): 5916.