Table of Content

15 May 2018, Volume 21 Issue 14

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Monographic Research

Interpretation on 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke

WU Chuan-jie，SONG Hai-qing*

2018, 21(14):  1639-1644.  DOI: 10.3969/j.issn.1007-9572.2018.00.150

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2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke which published in the 2018 International Stroke Conference have changed greatly compared with the previous guidelines，and many changes have changed the current clinical practice. The most important of these include early vascular recanalization，acute hospital treatment and secondary prevention. Based on the actual situation of China，this article interprets the most important updates in order to offer help and advice for clinical practice in neurology.


Interpretation of Management of Acute and Recurrent Gout：a Clinical Practice Guideline from the American College of Physicians

XIONG Yi-fan，ZHAO Dong-bao*

2018, 21(14):  1645-1647.  DOI: 10.3969/j.issn.1007-9572.2018.00.132

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Gout is a common inflammatory arthritis resulted from excessive accumulation of monosodium urate.Its morbidity is increasing worldwide，so acute gout attack control and chronic gout management are very important.Of the guidelines for gout management published so far，Management of Acute and Recurrent Gout，a practice guideline developed by the American College of Physicians（ACP） in 2016，mainly including management of acute gout and urate-lowering therapy，is of authoritative significance.We intensively interpreted this guideline，and compared it with other 3 latest guidelines for gout management generated by the European League Against Rheumatism（EULAR） in 2016，British Society for Rheumatology（BSR） in 2017 and Chinese Rheumatology Association in 2016.And for the differences between these guidelines，we demonstrated the possible reasons.It is worth learning for Chinese primary care physicians.

Clinical Characteristics of Elderly Inpatients with Multimorbidity in Geriatric Department of a Tertiary Hospital in Beijing

YAN Wei1，LI Rui2，WANG Jie-ping1，ZHANG Hong-bo1，WU Wei1，WANG Fei1，ZHANG Jie3，ZHANG Xin-huan3，ZHU Zhong-hui4，5，DU Xue-ping6*

2018, 21(14):  1648-1656.  DOI: 10.3969/j.issn.1007-9572.2018.00.119

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Objective　To analyze the clinical characteristics of elderly inpatients with multimorbidity from Geriatric Department，Fuxing Hospital，Capital Medical University based on the collected medical records，providing theoretical evidence for the diagnosis and treatment of such patients.Methods　The enrolled elderly inpatients with multimorbidity were from Geriatric Department，Fuxing Hospital，Capital Medical University from April 1st，2016 to March 31st，2017.Based on the reviewing of their medical records，we analyzed the prevalence of chronic diseases and the involved systems，summarized the causes of hospitalization，incidence of infection and site of infection，and compared the prevalence of chronic diseases and incidence of infections by sex and age group（≥80 age group and <80 age group）．Moreover，the incidence of in-hospital acute complications，length of stay（LOS） and mean hospital costs per day between patients with infections during hospitalization and those without were compared.Results　761 inpatients（465 males and 296 females） aged 60 or over（125 patients <80 years old，and 636 patients≥80 years old） with multimorbidity and non-repetitive hospitalization history were analyzed.The number of chronic diseases in the inpatients ranged from 2 to 16.31.4%（239/761），19.3%（147/761）and 18.0%（137/761）had 9，11，8 chronic diseases，respectively.The number of systems involved by chronic diseases was 2-9 generally，in particular，the number of involved systems of 27.9%（212/761），25.9%（197/761） and 12.2%（93/761） of the patients was 5，6，4，respectively.With regard to the prevalence of chronic diseases，74.9%（562/761）were found with hypertension，73.9%（561/761）with hyperlipidemia，66.8%（505/761） with cerebral infarction，48.1%（366/761） with coronary heart disease and 38.1%（290/761） with diabetes.Sex was not significantly associated with the prevalence of cerebral infarction and other nervous system diseases except cerebral infarction，neuropathy，dementia，and sequelae of cerebral hemorrhage，prevalence of chronic obstructive pulmonary disease，prevalence of prostatic hyperplasia，and prevalence of musculoskeletal system diseases except osteoarthropathy，osteoporosis and cervical / lumbar disease（P<0.05）．Compared with those aged less than 80 years，patients aged 80 or over had much higher prevalence of coronary heart disease，chronic heart failure，arrhythmia，and peptic ulcer（P<0.05）．Systemic neoplasms（most were gastrointestinal neoplasms） were identified in 18.7%（142/761）of the inpatients.In terms of the causes for hospitalization，41.3%（314/761） were due to acute infection.Of the 46.5%（354/761） had infections，40 were found with hospital-acquired infections，and 82.8%（293/354） with pulmonary infection.Patients aged less than 80 years had much lower incidence of infections compared with those aged 80 or over（P=0.001）．Compared with those with infections，those without infections demonstrated much lower incidences of gastrointestinal hemorrhage，hypoproteinemia，anemia exacerbation，electrolyte disorder，impaired liver function，gastrointestinal dysfunction，pressure sore，respiratory failure，acute heart failure and lower mean hospital costs per day（P<0.05）．Conclusion　The majority of the elderly inpatients have 9 chronic diseases，and most of which are hypertension，hyperlipidemia，cerebral infarction，coronary heart disease and diabetes，involving 4-6 systems.Nearly half of these patients are prone to infections，which causes great economic burden.In view of this，individualized treatment is suggested for this population.

What can We Learn from Canadian Experience of General Practitioner Sign-up Model？

CHEN Dong-hui，GUAN Chun-li*，WANG Yan-li

2018, 21(14):  1657-1660.  DOI: 10.3969/j.issn.1007-9572.2018.00.144

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The general practitioner sign-up service in China is facing problems of the unsatisfactory signing rate，unsatisfactory service quality and so on.The root causes are the crisis of confidence between contractual parties，ambiguity of power and duties，and the absence or ineffective implementation of institutional guarantees.This article reviews the general practitioner sign-up model of Canada，which includes the signing and referral procedures，community clinic operating mode，family medicine wards and continuing medical education，and provides suggestions based on the current status of general practitioner sign-up model in China.


SBAR Communication Technique for Reducing Relocation Stress among Elderly People Newly Admitted to Nursing Homes

WANG Zhen-zhen1，TANG Lang-juan2*，TU Shu-hua3

2018, 21(14):  1661-1665.  DOI: 10.3969/j.issn.1007-9572.2018.00.134

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Objective　To explore the effect of SBAR communication technique on reducing the relocation stress among elderly people newly admitted to nursing homes.Methods　The enrolled participants were 118 elderly people newly admitted to a nursing home in Nanchang，57 of them treated with the conventional reception between April and September 2016 were assigned to the control group，and other 61 treated with the SBAR communication technique-based reception between March and August 2017 were assigned to the observation group.The Chinese version of 15-item Geriatric Depression Scale（C-GDS-15） was used to assess the depression status.The Chinese version of Stress Response Questionnaire（C-SRQ） was employed to evaluate the status of relocation stress.The symptoms of relocation stress occurred within a short period after admission were compared between the groups.Results　Compared with the controls，patients treated with SBAR communication technique-based reception were less likely to have symptoms of relocation stress within a short period after admission（P<0.05），and they demonstrated much lower C-GDS-15 total score at 1 week，1 month，2 months after admission（P<0.05），as well as much lower C-SRQ total score，emotional reaction score，somatic reaction score and behavioral reaction score at 2 months after admission（P<0.01）．Conclusion　SBAR communication technique reduces the incidence of relocation stress among elderly people and enhances the work efficiency of nursing homes via improving the reception mode，so it can be widely applied in such institutions.


Effect of Low T3 Syndrome on Death or Re-hospitalization in Patients with Pulmonary Hypertension due to Left Heart Disease

NIE Mei-ling，LIU Le，MA Han-ying*

2018, 21(14):  1666-1671.  DOI: 10.3969/j.issn.1007-9572.2018.00.131

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Objective　To investigate the relationship between low T3 syndrome and death or re-hospitalization in patients with pulmonary hypertension due to left heart disease（PH-LHD），and to estimate the value of low T3 syndrome in assessing the conditions and clinical outcomes of such patients.Methods　154 hospitalized PH-LHD patients from Beijing Anzhen Hospital，Capital Medical University were enrolled in 2015 and divided into a low T3 syndrome group（n=41） and a normal thyroid function group（n=113） according to their FT3 levels at admission.Baseline characteristics including laboratory findings were collected.All patients were given a telephone-based follow-up in January 2017，and events of death or re-hospitalization occurred between the discharge day and the follow-up day were evaluated.Results　In low T3 syndrome group， 2 cases were lost， and 6 cases were lost in normal thyroid function group.Compared with the normal thyroid function group，low T3 syndrome group demonstrated much higher re-hospitalization rate 〔61.5%（24/39） vs 41.1%（44/107） 〕（χ2=7.283，P=0.01），as well as significantly higher mortality〔46.2%（18/39） vs 15.9%（17/107） 〕（χ2=15.288，P<0.01）．Multivariate Cox regression analysis revealed that there was no significant correlation between low T3 syndrome and the re-hospitalization rate of PH-LHD patients 〔HR=0.849，95%CI（0.441，1.637），P=0.625〕，but BNP >400 ng/L 〔HR=2.496，95%CI（1.014，6.146），P=0.047〕 and low T3 syndrome 〔HR=2.353，95%CI（1.092，5.066），P=0.029〕 were the independent risk factors for death in PH-LHD patients.The area under the receiver operating characteristic curve（AUC） of FT3 was 0.759〔95%CI（0.664，0.854）〕 for predicting mortality，and the optimal cut-off point was found to be less than 4.195 pmol/L.The AUC of BNP was 0.800 〔95%CI（0.710，0.891）〕 for predicting mortality，and the best optimal cut-off point was identified to be greater than 600 ng/L.According to the DeLong test，there was no significant difference between the two AUCs（Z=0.693，P=0.488）．Conclusion　Low T3 syndrome is an independent risk factor for death in post-discharge PH-LHD patients.The routine detection of FT3 levels is of great significance to the risk stratification and prognosis assessment of PH-LHD patients.


Evaluation of Adherence to Secondary Preventive Drugs in Patients with Recurrent Acute Coronary Syndrome

ZHANG Xiao，HUANG Zhi-qi，CHEN Mu-lei*

2018, 21(14):  1672-1676.  DOI: 10.3969/j.issn.1007-9572.2017.00.206

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Objective　To evaluate the association of adherence to secondary preventive drugs with the interval between episodes of acute coronary syndrome（ACS） and previous episodes of ACS in patients with recurrent ACS.Methods　This cross-sectional study was conducted in 319 consecutive cases of recurrent ACS who received inpatient treatment in Beijing Chao-Yang Hospital，Capital Medical University between July and November，2016.We collected the patients' data about use of secondary preventive drugs for ACS〔antiplatelet drugs，statins，beta-blockers，angiotensin converting enzyme inhibitors（ACEI） or angiotensin Ⅱ receptor antagonist（ARB）〕，as well as the interval between episodes of ACS and previous episodes of ACS.Based on the interval between episodes of ACS，we assigned those with interval between episodes of ACS ≤1 year，>1-3 years，>3 years to group A（n=82），group B（n=93） and group C（n=144），respectively.And according to the previous episodes of ACS，we assigned those with once previous episode，≥2 times of episodes to group 1（n=207） and group 2（n=112），respectively.Chi-square test was used to analyze the association of adherence to secondary preventive drugs with the interval between episodes of ACS and previous episodes of ACS.Results　The rate of administration of beta-blockers，ACEI or ARB did not differ significantly between the patients by the interval between episodes of ACS（P>0.05）．In contrast，the rate of administration of antiplatelet agents and statins differed significantly between the patients by the interval between episodes of ACS（P<0.05）．Specifically，it was lower in group C than in groups A and B（P<0.01）．The rate of administration of statins，beta-blockers，and ACEI or ARB did not differ obviously between the patients by previous episodes of ACS（P>0.05）．The rate of administration of antiplatelet agents in group 2 was higher than that of group 1（P<0.05）．Conclusion　Among patients with recurrent ACS，the rate of administration of secondary preventive drugs was decreased；and the rate of administration of antiplatelet drugs and statins was reduced with the extension of the interval between episodes of ACS，indicating the awareness of taking secondary preventive drugs for ACS was decreased over time.Therefore，it is necessary to continuously strengthen the treatment consciousness of ACS patients to improve the adherence to secondary preventive drugs.


Effect of Kegel Exercise Combined with Hydrotherapy on Low Anterior Resection Syndrome and Quality of Life in Patients after Rectal Cancer Surgery ：a Clinical Study

DING Yu-zhen，SUN Lin*，SHEN Min-jing，YAO Han-hui，LIU Liu，CHEN Shan-shan，ZHANG Peng-nian，SONG Gui-qi

2018, 21(14):  1677-1681.  DOI: 10.3969/j.issn.1007-9572.2018.00.065

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Objective　To investigate the effect of Kegel exercise combined with hydrotherapy on low anterior resection syndrome（LARS） and quality of life in patients after rectal cancer surgery.Methods　The participants were 85 cases of low rectal cancer who underwent laparoscopic low anterior resection of rectal cancer in Gastroenterological Surgery，Anhui Provincial Hospital between March 2014 and December 2016.Using an Excel formula and excluding the cases failing to complete the study，they were randomly divided into control group（41 cases） and observation group（40 cases） after admission.Both groups received the conventional nursing after surgery，the observation group additionally received Kegel exercise intervention.At 1，3，6 months after surgery，two groups' LARSS score and LARS severity were assessed by the Chinese version of Low Anterior Resection Syndrome Scale，and the quality of life status was assessed by the Chinese version of EORTC QLQ-C30，respectively.Results　Compared with the control group，the observation group demonstrated lower average LARSS score at 1，3，6 months after surgery（P<0.05），and better severity distribution of LARS at 3，6 months after surgery（χ2=6.544，χ2=6.687，P<0.05）．At 1，3，6 months after surgery，higher scores of cognitive functioning，role functioning and emotional functioning were found in the observation group（P<0.05）．Moreover，at 3，6 months after surgery，higher scores of physical functioning，social functioning and general health status were identified in the observation group（P<0.05）．Conclusion　Kegel exercise combined with hydrotherapy can improve the LARS，quality of life，as well as the recovery of patients undergoing anus-preserving surgery for low rectal cancer.


Investigation of Prognostic Influencing Factors and Treatment Options in Treatment-naive Patients with Metastatic Nasopharyngeal Carcinoma

CHEN Xue1，YE Dong2，LIU Kai-tai1*，BEI Yan-ping1，ZHENG Lu1

2018, 21(14):  1682-1688.  DOI: 10.3969/j.issn.1007-9572.2017.00.215

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Objective　To investigate factors affecting the prognosis of treatment-naive patients with metastatic nasopharyngeal carcinoma，to provide evidence for the development of treatment strategies and inform on the prognosis of treatment-naive metastatic nasopharyngeal carcinoma.Methods　A total of 52 treatment-naive patients with metastatic nasopharyngeal carcinoma admitted to the Department of Radiotherapy，Lihuili Hospital of Ningbo Medical Center between January 2011 and September 2016 were enrolled and given chemotherapy.The patients' clinical data were recorded，and the patients were followed up until March 2017.The factors affecting the prognosis of the patients were analyzed.Results　Patients were followed up for a median of 32.3 months（range 4.4-79.8 months） and had a median survival period of 29.4 months.The 2-，3- and 5-year overall survival rates were 55.9%，45.8% and 18.5%，respectively.The 3-year overall survival rate did not significantly differ in terms of gender，age，pathologic T stage，lung metastasis，distal lymph node metastasis，number of metastatic foci，number of chemotherapy cycles，management of metastatic foci，hemoglobin level，albuminlevel，alkaline phosphatase level，fibrinogen concentration and albumin-to-alkaline phosphatase ratio（AAPR） level（P>0.05），and significantly differed in terms of pathologic N stage，bone metastasis，liver metastasis，multi-organ metastasis，short-term efficacy，radiotherapy of primary foci，lactate dehydrogenase level and D-dimer level（P<0.05）．Multivariate Cox regression analysis identified N3 stage 〔HR=6.315，95%CI（2.004，19.904）〕，liver metastasis 〔HR= 5.810，95%CI（2.200，15.341）〕，multi-organ metastasis 〔HR=3.770，95%CI（1.317，10.793）〕，non-radiotherapy of primary foci〔HR=5.537，95%CI（1.740，17.620）〕 and serum alkaline phosphatase level of 100 U/L and higher 〔HR=7.657，95%CI（2.313，25.344）〕 as the risk factors for poor prognosis（P<0.05）．Conclusion　Pathologic N stage，liver metastasis，multi-organ metastasis，radiotherapy of primary foci and alkaline phosphatase level are factors affecting the prognosis of treatment-naive patients with metastatic nasopharyngeal carcinoma.These findings may facilitate treatment options，thereby improving overall survival rates.


Influencing Factors of Difficulties in Elective Endotracheal Intubation during Endoscopic Retrograde Cholangiopancreatography　

ZHANG Hao1，GAO Li-li2，XUE Bing1，CAI Lei1*

2018, 21(14):  1689-1693.  DOI: 10.3969/j.issn.1007-9572.2018.00.028

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Objective　To explore the influencing factors for the difficulties in elective endotracheal intubation during endoscopic retrograde cholangiopancreatography（ERCP），providing a reference for assessing the patient's surgical risk，and formulating targeted strategy for such difficulties.Methods　We recruited 1 120 patients who initially underwent ERCP in Department of General Surgery，Shanghai Pudong Hospital from 2012 to 2016.Of them，202 with difficulties in endotracheal intubation during ERCP and 918 without were assigned to difficult intubation group，and successful intubation group，respectively.We reviewed their data such as gender，age，preoperative incidence rates of comorbidity，stone incarceration，ampullary neoplasms，emergency ERCP，and indications of ERCP，as well as the anatomical variants〔duodenal diverticulum，pancreaticobiliary maljunction，papilla abnormalities，fistula，suspected biliary stricture and sphincter of Oddi dysfunction（SOD）〕.Results　Multivariate Logistic regression analysis showed that the preoperative stone incarceration〔OR=11.420，95%CI（5.569，23.414）〕，preoperative ampullary neoplasms〔OR=3.370，95%CI（2.023，5.609）〕，central asymmetrical diverticulum of the papilla〔OR=4.970，95%CI（2.862，8.623）〕，intradiverticular papilla〔OR=26.210，95%CI（8.126，84.533）〕，confluence of pancreaticobiliary duct wall〔OR=6.990，95%CI（1.121，43.557）〕，common channel of pancreaticobiliary ducts〔OR=16.670，95%CI（2.621，106.073）〕，axial deflection of papilla〔OR=20.180，95%CI（11.748，34.655）〕，papillae enlargement〔OR=16.710，95%CI（8.753，31.896）〕，papillary stenosis〔OR=13.640，95%CI（5.199，35.764）〕，suspected biliary stricture〔OR=2.100，95%CI（1.067，4.129）〕 and SOD〔OR=2.900，95%CI（1.516，5.564）〕 were influencing factors for difficulties in elective endotracheal intubation during ERCP（P<0.05）．Of the 202 patients with difficulties in endotracheal intubation，131（64.8%） underwent papillotomy，100（49.5%） used deep enterscopy technique，92（45.5%） used double wire-guided technique，and 90（44.6%） changed the guidewire for another.Fifty（24.8%） used one assistant technique，95（47.0%） used two，and 57（28.2%） used three.And 151（74.8%） achieved successful endotracheal intubation by using assistant techniques.Additionally，the incidence rates of hyperamylasaemia，digestive tract bleeding and perforation，pancreatitis，as well as cholangitis did not differ significantly between those achieved successful endotracheal intubation after overcoming difficulties and those achieved it without difficulties（P>0.05）．Conclusion　Related anatomical factors and disease characteristics may be used as the predictors for difficulties in elective endotracheal intubation during ERCP.What's more，these assistant techniques can be adopted to reduce the intubation failure and operative time based on the patient's conditions.These results provide a rationale for improving the diagnosis and treatment of pancreatobiliary disease.


Effects of GATA-4 Overexpressed Mouse Bone Marrow Mesenchymal Stem Cells on the Promotion of Cardiomyocyte Differentiation through Exosomes　

HE Ji-gang1，HAN Jin-xiu1，LI Bei-bei1，LI Hong-yuan1，YAN Dan2，REN Jing-yu2*

2018, 21(14):  1694-1698.  DOI: 10.3969/j.issn.1007-9572.2017.05.y16

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Objective　To explore the effect of GATA-4 overexpressed mouse bone marrow mesenchymal stem cells（BMSCs） on the promotion of the differentiation of BMSCs into myocardial cells through exosomes.Methods　GATA-4 overexpressed BMSCs of 10 healthy 4-week-old SPF grade mice selected from January to June in 2016，were constructed by transfecting these cells with the lentiviral vector GV308 carrying GATA-4.Doxycycline（DOX） was added to induce this gene.SBI ExoQuick-TC was then applied to extract the secreting exosomes.Co-culturing was performed between GATA-4-BMSCs-exosome and BMSCs for group A，between GATA-4-free-vector-BMSCs-exosome and BMSCs for group B，and between BMSCs-exosome and BMSCs for group C for 72 h.BMSCs were cultured for group D and myocardial cells were cultured for group E，for 72 h，respectively.Fluorescence staining was conducted to qualitatively determine the expression of cTnT，α-actin，Connexin 43，and Desmin.qPCR was performed to quantitatively identify the expression of these specific antigens in the myocardial cells.Results　The results of immunofluorescence assay showed that the nucleus was stained blue with DAPI in group A，and the expression of green cTnT，α-actin，Connexin 43，Desmin；the nuclei were stained blue with DAPI in group B，C，D，no expression of green cTnT，α-actin，Connexin 43，Desmin；the nucleus was stained blue with DAPI in group E，and the expression of green cTnT，α-actin，Connexin 43，Desmin.The results of qPCR assay showed that the expression levels of cTnT，α-actin，Connexin 43 and Desmin in the 5 groups differed significantly（P<0.05），specifically，the expression levels of cTnT，α-actin，Connexin 43 and Desmin in group E were higher than those in group A（P<0.05）；the expression levels of cTnT，α-actin，Connexin 43 and Desmin in groups A and E were higher than those in groups B，C and D（P<0.05）．Conclusion　The exosomes secreted by GATA-4-overexpressed-BMSCs can effectively promote the differentiation of BMSCs into myocardial cells.


Effect and Mechanism of Acupoint Catgut Embedding Therapy in Protecting against Myocardial Ischemia Reperfusion Injury in ZDF Rats　#br#

WANG Yi-ming1，YANG Xiao-yue1，ZHANG Xin-xin2*

2018, 21(14):  1699-1703.  DOI: 10.3969/j.issn.1007-9572.2018.00.074

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Objective　To investigate the effect of acupoint catgut embedding therapy on the expression levels of Bcl-2，Bax and Caspase-3 in ZDF rats with myocardial ischemia reperfusion injury.Methods　This study was carried out from January 2015 to May 2016.Twenty-four male ZDF rats of grade SPF were selected and divided into 4 groups（ blank group，ischemia-reperfusion group，ischemic preconditioning group，catgut embedding pretreatment group） randomly，with 6 rats in each.The blank group received no intervention except conventional feeding.On the day after 7-day adaptive feeding，ischemia-reperfusion group first received myocardial ischemia for 30 min，then received reperfusion for 60 min；the ischemic preconditioning group first received 3 rounds of 5-min myocardial ischemia and 5-min reperfusion，then received 30-min myocardial ischemia and 60-min reperfusion.On the first day of adaptive feeding，the catgut embedding pretreatment group received catgut embedding at Neiguan，Danzhong，and Xinshu acupoints.On the day after 7-day adaptive feeding，the catgut embedding pretreatment group received 30-min myocardial ischemia and 60-min reperfusion.Serum catalase（CAT） and nitric oxide（NO） were detected by enzyme-linked immunosorbent assay.And the expression levels of Bcl-2，Bax and Caspase-3 in myocardium of ZDF rats were detected by Western blotting.The ultrastructure of myocardium was observed by electron microscope.Results　Compared with blank group，the serum CAT and NO levels decreased significantly in ischemia-reperfusion group（P<0.05）．And ischemic preconditioning group，catgut embedding pretreatment group had the higher levels of CAT and NO than those in the blank group and ischemia-reperfusion group（P<0.05）．The blank group had the lowest relative expression levels of Bcl-2，Bax and Caspase-3（P<0.05）．Compared with ischemia-reperfusion group，ischemic preconditioning group and catgut embedding pretreatment group had higher relative expression levels of Bcl-2 and Caspase-3，but lower relative expression levels of Bax（P<0.05）．Electron microscopy showed that，in the myocardial tissue of the ischemia-reperfusion group，there was a large amount of swollen mitochondria with vesicular structure and decreased matrix density，while only a small amount of swollen mitochondria could be seen in the myocardial tissue of the ischemic preconditioning group and catgut embedding pretreatment group.Conclusion　Acupoint catgut embedding therapy may protect against myocardial ischemia reperfusion injury of ZDF rats by inhibiting cell apoptosis and promoting autophagy via up regulating the expression of Bcl-2 and Caspase-3，and down regulating Bax expression.


Effect and Safety of Total Hip Arthroplasty versus Hemiarthroplasty for Fresh Femoral Neck Fractures in the Elderly：a Systematic Review　

ZHANG Xiao-yun1，XIA Tian2*，CHEN Yue-ping1，ZHU Ji-chong2，FENG Yang2，TANG Xian-neng2，ZHUO Ying-hong2，LAN Jiao2，ZHAO Bin2

2018, 21(14):  1704-1712.  DOI: 10.3969/j.issn.1007-9572.2018.14.013

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Background　Both total hip arthroplasty（THA） and hemiarthroplasty（HA） are common treatment methods for fresh femoral neck fractures in the elderly.However，although there are many retrospective studies or non-randomized controlled trials comparing the efficacy and safety of the two，relevant systematic reviews are rare.Objective　To systematically evaluate the efficacy and safety of THA versus HA for fresh femoral neck fractures in the elderly.Methods　From January to March 2017，we searched Cochrane Library，Medline，EMBase，CNKI，VIP and Wanfang Data Knowledge Service Platform and printed journals for randomized controlled trials（RCTs） evaluating the efficacy and safety of THA and HA for fresh femoral neck fractures in the elderly，and reviewed the references of the relevant RCTs published in the printed journals.Data were extracted from eligible RCTs and quality assessment was conducted.Results　Twelve RCTs 〔quality grade：A（3），B（6），C（3）〕 were included involving 1 310 patients.Meta-analysis showed that compared with those receiving HA，patients receiving THA had much higher Harris score at 1-year follow-up〔MD=3.93，95%CI（2.09，5.77），P<0.000 1〕.However，there were no significant differences between the two groups in Harris score when the follow-up interval was 2 years，3-4 years and more than 4 years（P>0.05）．The revision rate was similar in both groups at 1-year，2-year and 3-4-year follow-up（P>0.05），but patients with THA showed much lower revision rate when the follow-up interval was longer than 4 years〔RR=0.27，95%CI（0.14，0.54），P=0.000 2〕.The wear rate of the acetabular component showed no significant differences between two groups at 1-year，and 2-year follow-up（P>0.05），but it was much lower in patients with THA when the follow-up interval was 3-4 years〔RR=0.05，95%CI（0.01，0.22）〕 and longer than 4 years〔RR=0.05，95%CI（0.01，0.31）〕（P<0.05）．The fatality rate was similar in both groups at 3 different follow-up periods（1 year，2-4 years，> 4 years）（P<0.05）．The dislocation rate was similar in both groups at 1-year，2-4-year follow-up（P>0.05），but it was significantly increased in THA patients when the follow-up interval was longer than 4 years 〔RR=2.33，95%CI（1.27，4.29），P=0.006〕.Two groups showed no significant differences in the deep infection rate at 3 different follow-up periods（1 year，2-4 years，> 4 years），incidence of postoperative pain，and incidence of postoperative complications（P>0.05）．Conclusion　The differences in Harris score，revision rate，wear rate of acetabular component，and dislocation rate between patients with THA and those with HA changed according to the time of follow-up，while the fatality rate and deep infection rate did not.


Prophylactic Use of Theophylline on the Prevention of Renal Dysfunction in after Perinatal Asphyxia Neonates：a Meta-analysis

ZHANG Ruo-lin，ZHANG Jun-han，WANG Ying，SHUAI Lan-jun，LI Xiao-yan，HE Qing-nan*

2018, 21(14):  1713-1718.  DOI: 10.3969/j.issn.1007-9572.2017.00.276

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Objective　To systematically assess the effect of prophylactic use of theophylline（ThP） for the prevention of renal dysfunction（RD） in after perinatal asphyxia（PA）neonates.Methods　We searched PubMed，Medline，Web of Science，Cochrane Library，CBM，CNKI and Wanfang Data Knowledge Service Platform databases for randomized controlled trials assessing the effect of prophylactic use of ThP for the prevention of RD in neonates after PA collected as of July 31，2017.We assessed the quality of the included articles and extracted needed information from them.Incidence of RD，serum creatinine（Scr） level，glomerular filtration rate（GFR），urinary β2-microglobulin（β2M） level and fatality rate were analyzed by RevMan 5.2.6 software.Results　Six randomized controlled trials with moderate biases were included.Three hundred and seventy-eight neonates receiving either ThP（intervention group，n=190） or placebo（control group，n=188） were analyzed.Compared with placebo，ThP treatment was associated with lower incidence of RD〔RR=0.35，95%CI（0.25，0.49），P<0.000 01〕.Scr level was similar on the 1st day after PA〔WMD=0，95%CI（-0.08，-0.07），P=0.910 00〕between groups but declined on the 3rd and 5th days after PA in the intervention group 〔WMD=-0.57，95%CI（-0.68，-0.46），P<0.000 01；WMD=-0.35，95%CI（-0.53，-0.16），P=0.000 20，respectively〕.GFR showed no difference between groups on the 1st day after PA〔WMD=1.68，95%CI（-1.05，4.41），P=0.230 00〕，but it was significantly higher on the 3rd and 5th days after PA in intervention group than those in the control group〔WMD=14.30，95%CI（11.73，16.87），P<0.000 01；WMD=10.59，95%CI（7.72，13.47），P<0.000 01，respectively〕.ThP treatment was associated with lower level of urinary β2M on the 1st day after PA〔WMD=-7.23，95%CI（-8.65，-5.81），P<0.000 01〕.There was no significant difference in fatality rate between two groups 〔RR=0.92，95%CI（0.54，1.55），P=0.750 00〕.Both 8 mg/kg and 5 mg/kg ThP significantly decreased the incidence of RD 〔RR=0.37，95%CI（0.22，0.62），P=0.000 20；RR=0.34，95%CI（0.22，0.52），P<0.000 01〕.The funnel plot graph of incidence of RD showed good symmetry，indicating no obvious publishing bias.Conclusion　Prophylactic use of ThP has a protective effect on preventing after PA neonatal RD.However，due to the limitation of sample size and without evaluation of long-term neurodevelopmental outcome，it is not yet to recommend the routine prophylactic use of ThP in after PA neonates.


Bronchial Provocation Test Improved by Inhaling Hypertonic Saline Delivered by a Quantitative Nebulizer for the Diagnosis of Asthma in Patients of All Ages　#br#

YANG Jian-ya1，CHEN Yuan-bin2，ZHOU Ming-juan2，ZENG Jin-mei2，WU Lei2，LI Han3，LIN Lin2*

2018, 21(14):  1719-1722.  DOI: 10.3969/j.issn.1007-9572.2018.00.133

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Objective　To investigate the value of bronchial provocation test improved by inhaling hypertonic saline delivered by a quantitative nebulizer for the diagnosis of asthma in patients of all ages.Methods　1 094 outpatients suspected with asthma were enrolled from Guangdong Provincial Hospital of Chinese Medicine from February 2016 to February 2017.Based on the corresponding definitions of the WHO，they were divided into adolescent group（148 aged 5-17 years），young and middle-aged group（835 aged 18-59 years） and elderly group （111 aged 60 or over）．All of them underwent the conventional pulmonary function test and modified bronchial provocation test with inhaled hypertonic saline delivered by a quantitative nebulizer.The rate of patients with provoked positive bronchial reactions as well as incidence of adverse reactions were compared between the groups.Results　Totaled 164（16.2%） were found with provoked positive bronchial reactions，including 53 adolescent cases，93 young and middle-aged cases，18 elderly cases，accounting for 35.8%，11.1%，12.6% of the corresponding age group，respectively.The rate of patients with provoked positive bronchial reactions differed significantly between the 3 groups（χ2=60.201，P<0.01），to be specific，it was much higher in the adolescent group than that of other two groups（P<0.01）．The common adverse reactions secondary to the modified bronchial provocation test in all the patients were cough，chest tightness，dyspnea，wheezing，shortness of breath，pharyngeal itching，but no severe asthma attacks and other severe adverse reactions were found.The incidence of cough varied significantly between the groups（P<0.05），while that of chest tightness，dyspnea，wheezing，shortness of breath，pharyngeal itching and so on did not（P>0.05）．Conclusion　The modified bronchial provocation test is suitable for the diagnosis of asthma in patients of different ages，especially children.


Application of CTCA based on Force CT and High-pitch Turbo Flash Scan Mode in Patients with Different Heart Rate

YANG Jia-hu，FENG Yue，ZHANG Jian-jun*

2018, 21(14):  1723-1726.  DOI: 10.3969/j.issn.1007-9572.2017.00.231

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Objective　To investigate the image quality and radiation dose of computed tomography coronary angiography（CTCA） based on a 3rd generation dual-source SOMATOM Force CT（Force CT） and high-pitch Turbo Flash scan mode when being used in patients with different heart rate（HR）.Methods　A total of 98 patients who underwent CTCA at Zhejiang Hospital between August and November 2016 were selected for this study.The patients were divided into three groups according to the HR during the CTCA scan：A group（HR≤65 beats/min，47 cases），B group（65 beats/min<HR≤75 beats/min，24 cases），and C group（HR>75 beats/min，27 cases）．The patients in all three groups were scanned using Force CT and the high-pitch Turbo Flash scan mode.The image quality of various segments of the coronary artery in the three groups was scored subjectively.The dose-length product（DLP） and effective radiation dose（ED） of each group were recorded and compared.Results　The images of 1 443 coronary segments were obtained and evaluated.There were 1 291 segments（89.47%） that scored 1 point for image quality，149 segments（10.33%） had 2 point image quality，and 3 segments（0.20%） scored 3 points for image quality.Gender had no significant effect on HR，image quality，DLP and ED（P>0.05）．The average DLP of the patients was（51.3±12.8） mGy?cm and the average ED was（0.72±0.18） mSv.There were significant differences in the image quality，DLP，and ED among the three groups（P<0.05）．The image quality scores of the B and C groups were higher than the A group（P<0.05），while the DLP and ED of the C group were higher than the A and B groups（P<0.05）．Conclusion　The CTCA based on Force CT and the high-pitch Turbo Flash scan mode has clinical application value for patients with different HR，particularly for patients with HR≤65 beats/min.The appropriate acquisition phase is chosen according to the patient's HR and the images meeting diagnostic requirements can be obtained.Moreover，the effective radiation dose can be < 1 mSv.


Ultrasound Disease Activity Score in 28 Joints and DAS28 Score for the Assessment of Rheumatoid Arthritis Disease Activity：a Comparative Study

CHEN Guang-yao1，LUO Jing2，ZHENG Si-si1，HE Chun-xiao1，MA Xiao2，XU Yuan2*，TAO Qing-wen2*

2018, 21(14):  1727-1729.  DOI: 10.3969/j.issn.1007-9572.2018.14.017

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Objective　To evaluate the sensitivity and consistency between ultrasound disease activity score in 28 joints（US-DAS28） and DAS28 score in the assessment of disease activity in patients with rheumatoid arthritis（RA）．Methods　127 RA patients receiving outpatient or inpatient care from Department of TCM Rheumatology，China-Japan Friendship Hospital from January 2013 to July 2017 were recruited.Their 28 joints，including proximal interphalangeal joints，metacarpophalangeal joints，wrist joints，elbow joints，shoulder joints and knee joints，were checked.DAS28 score was calculated based on the number of tender and swollen joints identified by clinical examination，patient self-assessment of general joint status and C-reactive protein（CRP） level.And US-DAS28 score was calculated in accordance with the number of swollen joints identified by gray-scale ultrasound.Results　The average number of swollen joints identified by clinical examination was less than that found by ultrasound〔2.0（0，4.0）vs.5.0（2.0，8.0）〕（Z=-7.783，P<0.001）．Moreover，DAS28 score was lower than US-DAS28 score〔（3.43±1.18） vs.（3.69±1.03）〕（tpaired= -9.668，P<0.001）．Pearson correlation analysis showed that there was a positive correlation between DAS28 score and US-DAS28 score（r=0.968，P<0.001）．The degree of disease activity assessed by US-DAS28 score was more serious than that by DAS28 score（Z=-4.680，P<0.001）．Conclusion　There is a good consistency between US-DAS28 and DAS28 score for assessing RA disease activity，but US-DAS28 score has a higher sensitivity，so it can provide an aid for clinical treatment.


Clinical Characteristics and Literature Review of the Insulin Autoimmune Syndrome　

WEI Jun-fang1，ZHAO Yan-yan2*，ZHAO Lin-lin2，MA Xiao-kun2，HAO Xiao2，WU Wen-xun2，QIN Gui-jun2

2018, 21(14):  1730-1734.  DOI: 10.3969/j.issn.1007-9572.2017.00.252

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Objective　To improve the awareness of insulin autoimmune syndrome（IAS） by analyzing the clinical characteristics of IAS and combing with relative literatures reviewing.Methods　A total of ten patients with IAS diagnosed by Department of Endocrinology and Metabolism in the First Affiliated Hospital of Zhengzhou University from January 2007 to May 2017，we retrospectively reviewed these patients' clinical features，including general information，clinical symptoms，past history，laboratory tests and imaging studies，treatment and follow-up situation.Results　There were 5 males and 5 females in 10 IAS patients.The age ranged from 21 to 74 years old and 6 patients were over 60 years old.The onset time of hypoglycemia of ten was at night and early morning.Five cases with the history of exposure to mercapto drugs，3 cases with the history of insulin application，the other 2 patients without obvious reasons.The results of OGTT showed that 4 patients with diabetes mellitus，3 with impaired glucose tolerance，1 with normal glucose tolerance.Ten cases of serum insulin cell antibody（ICA） and glutamic acid decarboxylase antibody（GADA） were all negative，while insulin autoimmune antibody（IAA） were all positive.The serum insulin levels were extremly high in all these cases，while the serum C peptide levels were disproportional.Ten patients were given less food，more meals，high cellulose and low carbohydrate diet，3 patients with acarbose，6 patients with glucocorticoid，5 patients who had the history of exposure to mercapto drugs discontinued the corresponding drugs，and all of them no episodes of hypoglycemia occurred.Nine cases were followed up and 1 case were lost.The follow-up time was 1-12 months，and 8 patients had no hypoglycemia symptoms again.Conclusion　IAS is a rare endocrine disease，especially high incidence in the elderly.IAS should be considered in patients with hyperinsulinemic hypoglycemia.Routinely test IAA might be helpful to avoid misdiagnosis and unnecessary surgery.


Clinical Features and Diagnosis with Treatment Analysis of 13 Patients Suffering from Acute Intermittent Porphyria　

ZHANG Jian，HU Yi-ting，HOU Hong-tao，ZHENG Ji-min，LIU Na，ZHAO Hong-wei，BAI Yun，SU Shao-hui，WANG Yu-zhen*

2018, 21(14):  1735-1737.  DOI: 10.3969/j.issn.1007-9572.2017.00.232

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Objective To investigate the clinical features，diagnosis methods，and current treatment of acute intermittent porphyria（AIP） in order to facilitate early detection and treatment.Methods　A retrospective analysis of 13 AIP patients，who were hospitalized in the Hebei General Hospital from March 2010 to June 2017，was performed to collect the data pertaining to AIP clinical data，laboratory tests，treatment methods and their therapeutic efficacy.Results　Among the 13 AIP patients，3 presented with a fever，7 with nausea and vomiting of stomach contents without hematemesis，8 with abdominal tenderness，and 10 with abdominal pain，reduced exhaust and defecation，general malaise and tachycardia，as well as orange urine，which turned kermesinus/wine red after a 2 h sun exposure.There were 12 patients with increased intracellular zinc porphyrin and 13 patients with positive urinary porphobilinogen.In addition，8 patients had positive uroporphyrin，10 patients suffered from anemia，and 6 patients had decreased serum sodium.Hemobilirubin was normal for all patients.Finally，7 patients had abnormal alanine aminotransferase and 4 patients exhibited abnormal aspartate aminotransferase.The AIP patients improved soon after treatment with arginine hemoglobin or high concentration of glucose.Conclusion　Abdominal pain，neuropsychiatric symptoms，and darkening of urine color are the main clinical manifestations of AIP.Arginine hemoglobin and high concentrations of glucose are effective treatments for patients with AIP.


Intention of Practicing at Multiple Institutions among Healthcare Providers in China：a Survey Conducted during the Construction of the Medical Association　#br#

ZHAO Ru-cheng1，HU Bin2*

2018, 21(14):  1738-1743.  DOI: 10.3969/j.issn.1007-9572.2018.14.020

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Objective　To investigate the intention and awareness level of the strengths of practicing at multiple institutions among healthcare providers in China during the construction of the medical association，identifying methods for guiding doctors' multi-site practice reasonably.Methods　From March to April 2017，we recruited some clinicians，medical technicians，nurses，medical researchers and hospital managers from 4 tertiary hospitals in Shanghai and surveyed them for collecting the sociodemographic characteristics，awareness level of the strengths of practicing at multiple institutions，and effects of practicing at multiple institutions on personal and hospital's development.Results　Of the 500 healthcare providers，422（including 256 clinicians） returned responsive questionnaires，with a response rate of 84.4%.According to the survey results，only 11（4.3%） clinicians practiced at two or more medical institutions，and 30（7.1%） clinicians did not approve of practicing at multiple institutions.With regard to the strengths of practicing at multiple institutions，the majority of respondents believed that it could promote the reasonable flow of health talents〔72.0%（304/422）〕，reduce the excessive workload of healthcare providers from tertiary hospitals 〔64.7%（273/422）〕，improve the accessibility of medical services 〔69.7%（294/422）〕，improve the level of patient satisfaction with medical services〔52.6%（222/422）〕，was promising in China 〔59.5%（251/422）〕，could improve the income of doctors 〔76.3%（322/422）〕，raise the working enthusiasm of doctors 〔74.2%（313/422）〕，and promote the professional level of doctors〔54.0%（228/422）〕.However，46.2%（195/422） thought that practicing at multiple institutions could increase the doctors' workload，20.4%（86/422） considered that it could hinder the promotion or professional development of doctors，and 23.5%（99/422） believed that it would lead to increased probabilities and risks of making malpractice.In addition，76.8%（324/422）of them believed that practicing at multiple institutions would be more favorable to primary- or second-level hospitals，56.2%（237/422） thought it would narrow the gap of professional level between private and public hospitals，but 45.0%（190/422），50.9%（215/422） of them considered that it would not bring adverse effects on the development of tertiary hospitals，weakening the brand characteristics.Conclusion　Most respondents believed that practicing at multiple institutions could promote the reasonable flow of health talents，reduce the excessive workload of healthcare providers from tertiary hospitals，improve the accessibility of medical services，improve the level of patient satisfaction with medical services，and some intended to practice at multiple institutions.During the construction of the medical association，using incentive mechanism and protecting doctors' legal rights and interests are of great significance in reasonably guiding doctors' practicing at multiple institutions and promoting the reasonable allocation of health resources between the members of the medical association.


Status and Associated Factors for Second-birth Intentions among Women of Childbearing Age in Chongqing during the Implementation of the Universal Two-child Policy in China　

YANG Xiao-chang1，PU Chuan2*

2018, 21(14):  1744-1749.  DOI: 10.3969/j.issn.1007-9572.2018.00.113

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Objective　To explore the status and associated factors for second-birth intentions among women of childbearing age in Chongqing during the implementation of the universal two-child policy in China.Methods　We implemented this study by using questionnaire，in-depth expert interviews.The questionnaire survey was conducted in a random sample of 2 000 women of childbearing age from 5 districts/counties（300-500 from each district/county） extracted from the 5 major functional areas of Chongqing（one from each major functional area） by stratified random sampling，and the in-depth expert interviews were carried out among 14 relevant health workers randomly selected from Chongqing Health and Family Planning Commission and the First Affiliated Hospital of Chongqing Medical University.Results　1 954 questionnaires were returned，and 1 837 of them were responsive，achieving a response rate of 94.0%.The women thought that the average ideal number of children was 1.74，and 936（50.9%） of them wanted to have a second child.The second-birth intentions differed significantly by age，educational attainment，household monthly income per person，number of years of marriage，type of family that the couple born in，and number of children ever born（P<0.05）．498（27.1%） wanted to have a second child out of their own will.Interviews showed that second-birth intentions were influenced the most by economic constraints.495（46.3%） of 1 068（58.1%） with a child wanted to have a second child.Wanting to have a second child was owing to one's own will and the thought of having a second child can promote the growth of both children，while no intention to have a second child was due to great economic burden and lack of time and energy to care a second child.The number of ideal children of women of childbearing age at different age and family per capita monthly income was statistically significant（P<0.000 1）．Conclusion　With the implementation of the two-child policy，the proportion of women of childbearing age with the intention of having a second child in Chongqing has increased to a certain extent，but is lower than the national level.Moreover，second-birth intentions are found to be boosted insignificantly by the implementation of this policy，while they were affected significantly by economic constraints.


Research Situation and Application Prospect of Combined Multiple Tumor Markers Detection in Digestive System Neoplasms　

HE Wei-ming1，LU Guang-xing1，LIANG Bi-yu1，HE Yu-qing2，3*

2018, 21(14):  1750-1756.  DOI: 10.3969/j.issn.1007-9572.2017.00.175

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Digestive system neoplasms are tumors with high morbidity and mortality.Tumor markers are implicated in tumor initiation and development，so tumor marker detection is one important method for cancer screening and diagnosis in present day.However，single tumor marker detection is not conducive to the screening and early diagnosis of tumor due to their low sensitivity and specificity.Therefore，it is important to develop notably efficient methods of combined multiple tumor markers detection for the screening and early diagnosis of digestive system neoplasms.This review summarized current studies of combined multiple tumor markers detection in digestive system neoplasms in order to provide the theoretical basis for the evaluation of its clinical application value and development prospect.


Progress of Resting State Functional MRI in the Study of Parkinson's Disease　

SHI Yuan-yuan，WANG Tian-jun*

2018, 21(14):  1757-1760.  DOI: 10.3969/j.issn.1007-9572.2018.00.098

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Parkinson's disease（PD） is a common neurodegenerative disease.The development of neuroimaging promotes intensive study of the pathophysiological mechanisms of PD.To study PD，quantitative magnetic resonance techniques have been widely used，among which resting state functional MRI（rs-fMRI） has attracted substantial research attention.This article reviews the progress of PD neuroimaging and rs-fMRI，and the application of rs-fMRI in studying PD.


Recent Advances in Internet-based Intervention for Postpartum Depression　

MU Ting-yu，LI Yu-hong*

2018, 21(14):  1761-1764.  DOI: 10.3969/j.issn.1007-9572.2018.00.018

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With the development of perinatal medicine and transformation of medical model，postpartum depression has received extensive attention，studies about postpartum depression interventions are also increasing.With the development of the Internet and information technology，internet-based health interventions for target populations are rising gradually.We reviewed the recent developments in internet-based interventions including internet-based intervention for postpartum depression at home and abroad，analyzed the difference between domestic and foreign studies，providing a basis for further study of internet-based intervention for postpartum depression in China.