Chinese General Practice

Interpretation of the Probiotics in the Management of Lower Gastrointestinal Symptoms in Clinical Practice：an Evidence-based International Guide Updated in 2018

LI Zhong-xin，ZHAO Zhao-long，CHENG Shi-chao

2018, 21(24): 2899-2903. DOI: 10.12114/j.issn.1007-9572.2018.00.170

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Specified probiotics benefitting irritable bowel syndrome（IBS） and antibiotic-associated diarrhea was put forward by the Probiotics in the Management of Lower Gastrointestinal Symptoms in Clinical Practice：an Evidence-Based International Guide by the ESPCG in 2013，and the effects of probiotics on gastrointestinal diseases were studied and verified further by more than 70 randomized controlled trials in the recent 5 years.Based on a systematic review of the results of these studies combined with a consensus reached by using Delphi technique，8 experts updated the Probiotics in the Management of Lower Gastrointestinal Symptoms：an updated Evidence-Based International Consensus，proposed that specified probiotics can reduce the symptoms of IBS，and can prevent antibiotic-associated diarrhea and diarrhea associated with Helicobacter pylori eradication therapy with good safety.We intensively analyzed the updated main essentials with relevant studies and data，with a view to providing a reference for general practitioners using probiotics to treat or prevent lower gastrointestinal symptoms.

Colorectal Cancer Screening and Influencing Factors of Compliance and Abnormal Lesions of Colonoscopy in Zhongshan Community，Songjiang District，Shanghai from 2015 to 2017　

LI Jing，ZHUANG Li-yan，HUANG Cheng，ZHU Hui-ying，HUANG Dan

2018, 21(24): 2904-2909. DOI: 10.12114/j.issn.1007-9572.2018.00.116

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Objective　To analyze the results of colorectal cancer screening in Zhongshan Community，Songjiang District，Shanghai from 2015 to 2017，and to investigate the factors affecting the colonoscopy compliance and abnormal lesions of colonoscopy.Methods　According to the guidelines for colorectal cancer screening in community population in Shanghai，the residents at ages of 50 to 74 years living in the Zhongshan Community，Songjiang District，Shanghai were enrolled from 2015 to 2017.In 2015，all qualified residents were enrolled，and in 2016 and 2017，those with positives screening one year before and those at an age of 50 years at that year were enrolled.All community populations were given primary screening of colorectal cancer by means of risk assessment and fecal occult blood test （FOBT），and the positives were defined as positive results in primary screening，who were advised to receive colonoscopy in designated hospitals.Results　A total of 6 994 residents were screened for colorectal cancer in Zhongshan Community，Songjiang District from 2015 to 2017，including 4 132 residents in 2015，1 604 cases in 2016 and 1 258 cases in 2017．The overall positive rate of the primary screening was 25.25%（1 766
/6 944），the positive rate of FOBT and questionnaire were 5.96% （417/6 994） and 21.12% （1 477/6 994），respectively，and the positive rate of both FOBT and questionnaire was 1.83% （128/6 994）．There were 239 residents （13.53%） receiving colonoscopy，among whom 124 cases （51.88%） were abnormal for colonoscopy.Among the colonoscopic examinations，the highest frequency of detection was seen in adenoma，followed by enteritis.Multivariate Logistic regression analysis revealed that single FOBT positivity 〔OR=42.967，95%CI（22.019，83.844）〕 and FOBT-questionnaire double positivity 〔OR=30.059，95%CI（11.723，77.074）〕 were factors affecting the compliance with positive of first colonoscopy screening （P<0.001），and age 〔OR=3.104，95%CI（1.177，8.189）〕 was a factor affecting the abnormal primary screening results by colonoscopy （P=0.022）．Conclusion　The positive rate of initial colorectal cancer screening in Zhongshan Community，Songjiang District is similar with that in other communities in Shanghai from 2015 to 2017；however，the compliance with colonoscopy is significantly lower in high-risk populations in Zhongshan Community，Songjiang District than in other regions of Shanghai.Positive results in primary screening and age are risk factors affecting the compliance with colonoscopy and abnormal lesions of colonoscopy in community residents.

Investigation of Prevalence and Factors Influencing Mild Cognitive Impairment in Elderly Community Residents in Shanghai　

ZHANG Yuan，WANG Zhi-liang，XU Hua，WANG Hui，YANG Zhu-jie，PENG Lei，SONG Yuan-yuan，XU Guang-zheng，WANG Chun-yan，ZHANG Fu-liang，PENG Shu-ying，CHI Gui-fen，LU Ai-ping，MEI Xin-chun，SHEN Yuan

2018, 21(24): 2909-2915. DOI: 10.12114/j.issn.1007-9572.2018.00.009

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Objective　To investigate the prevalence of mild cognitive impairment （MCI） in elderly people living in Shanghai City and to analyze the influencing factors，in order to provide a scientific basis for establishing an early community intervention model for dementia.Methods　This study was a survey investigating cognitive function in elderly people in the Xuejiahui district，as part of the "Shanghai Elderly Brain Health Cohort Study".Between July 2016 and June 2017，a total of 1 033 elderly people living in the Tangzijing，Xuhui New Village，Taidong，Lingling and Nandan communities in the Xujiahui district were selected to complete a survey questionnaire.The questionnaire included demographic information （sex，age，living status，education duration，and career features），lifestyle and habits （smoking history，drinking history，tea drinking history，exercise，dietary habits，hobbies，handedness，sleep abnormalities，diet abnormalities），BMI，health complaints （including complaints of memory decline，depressed mood，decreased work and study ability，and decreased daily life），history of hypertension，heart disease，diabetes，hyperlipidemia，and brain trauma.The prevalence of MCI among the elderly people was investigated，and associated influencing factors were analyzed.Results　A total of 1 033 questionnaires were distributed，and 1 033 valid questionnaires were returned，with an effective recovery rate of 100.00%.There were 430 MCI cases among the 1 033 respondents.There were differences in the education duration，career features，tea drinking history，exercise，hobbies，rate of complaints of memory decline，rate of complaints of decreased work and study ability，and hyperlipidemia between the respondents with MCI and without MCI （P<0.05）．The complaints of memory decline〔OR=2.324，95%CI（1.538，3.511）〕 and decreased work and study ability〔OR=1.667，95%CI（1.258，2.209）〕 were risk factors for MCI in the elderly people in the community （P<0.05）．The education duration〔OR=0.953，95%CI（0.913，0.996）〕，career features〔OR=0.695，95%CI（0.501，0.964）〕，hobbies〔OR=0.723，95%CI（0.533，0.981）〕，and history of hyperlipidemia〔OR=0.706，95%CI（0.536，0.929）〕 were protective factors against MCI in the elderly people in the community （P<0.05）．Conclusion　The prevalence of MCI among elderly people in the Shanghai community is relatively high，and the risk factors include complaints of memory decline and decreased work and study ability，whereas the protective factors include education duration，career features，and hobbies.In addition，the history of hyperlipidemia may be a protective factor against MCI，but its association with MCI remains unclear and requires further research.

Clinical Application of Fecal Microbiota Transplantation in Gastrointestinal Diseases and Non-gastrointestinal Diseases：a Literature Review　

LI Tian-tian，LI Dong-ying，LI Jian-sheng

2018, 21(24): 2916-2921. DOI: 10.3969/j.issn.1007-9572.2018.00.220

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Fecal microbiota transplantation （FMT） is the transfer of fecal bacteria from a healthy donor into the colon of a patient whose disease is a result of an altered microbiome，with the goal of restoring the normal microbiota and thus curing the disease.We mainly reviewed and summarized the clinical application of FMT recently：so far，sufficient evidences show that FMT is the most effective treatment for recurrent Clostridium difficile infection.Moreover，it is being exploratorily used as a potential therapy for other gastrointestinal diseases such as inflammatory bowel disease，irritable bowel syndrome and so on.Furthermore，although there is no adequate evidences supporting FMT for chronic fatigue syndrome，Parkinson's disease，metabolic disorders，multiple sclerosis and other non-gastrointestinal diseases，relevant studies are increasing rapidly. This article mainly reviewed the current evidences of clinical application of FMT.

Bibliometric Analysis of the Correlation between Hypertension and Gut Microbiota　

LIU Jing，ZHENG Li-wei，YANG Chen-chen，CHEN Zu-sen，WANG Mei，MENG Ming，LIU Wei-hua

2018, 21(24): 2922-2926. DOI: 10.12114/j.issn.1007-9572.2018.00.055

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Objective　To analyze and evaluate the literature on the correlation between hypertension and gut microbiota collected in SCI from 2008 to 2017，and to provide a reference for further research in this field.Methods　The Web of Science Core Collection Databases were used as the data source，and the "Advanced Search"feature was used to retrieve the related literature.The synonym and hyponym or hypernym keywords related to "hypertension" and "gut microbiota" combined with the Boolean operator "OR"，or the Boolean operator "AND" were used in the search，and "Topic"（TS） was chosen as the field tag.The searching period was 2008—2017，and the searching date was 2017-11-01.A descriptive statistical analysis was conducted on the literature on the correlation between hypertension and gut microbiota.Results　A total of 62 papers were included.The number of published papers increased from 2015；the journal Current Hypertension Reports published the highest number（five papers），and Circulation had the highest impact index （19.309）．There were 14 highly cited papers（cited ≥9.02）．The degree of literature cooperation was 7.29，and the rate of literature cooperation was 91.94%.Authors who had two or more papers were mainly from the United States.There were 48 papers sponsored by funds （77.42%）．The present study used 88 keywords.The research fields were primarily the cardiovascular system and cardiology，and the research content mainly focused on the relationship between intestinal dysbacteriosis and hypertension.Conclusion　Research on the correlation between hypertension and gut microbiota is still in an early stage.There are some shortages，for example，academic influence is not strong.It is necessary to continue exploring and verifying key issues such as the causality and mechanisms underlying connections between hypertension and the gut microbiota.Research scope and quality must also expand and improve.

Alterations and Influences of Gut Microbiota in Chronic Kidney Disease　

BAO Wen-han，WANG Yue

2018, 21(24): 2927-2931. DOI: 10.3969/j.issn.1007-9572.2018.00.168

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加速CKD进展。肠道菌群参与CKD发生发展的机制尚不明确，本文就CKD患者肠道菌群的变化及影响做一综述，希望通过调节肠道菌群延缓CKD进展以降低病死率。Normally the gut microbiota and the human body are mutually beneficial.Chronic kidney disease（CKD） contributes to the intestinal dysbiosis and impaired intestinal barrier resulting in bacterial translocation，increased production of uremic toxin and systemic inflammation，which accelerates the progression of CKD.The exact pathogenesis by which gut microbiota participates in the development of CKD is not clear.This paper reviews literature on the alterations and influences of gut microbiota in CKD in order to provide basis for delaying the progression of CKD and decreasing its mortality by modulating gut microbiota.

Safety and Efficacy of Paclitaxel in the Treatment of Anaplastic Thyroid Cancer　

LANG Ran，JIN Jian-jun，ZHANG Peng-hui，BIAN Jing

2018, 21(24): 2932-2936. DOI: 10.3969/j.issn.1007-9572.2018.00.151

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Objective　To evaluate the safety and efficacy of paclitaxel in the treatment of anaplastic thyroid carcinoma （ATC）.Methods　Thirty-two patients preliminarily diagnosed with ATC in the First Affiliated Hospital of Henan University of Science and Technology between April 2013 and March 2017 were selected.Twenty-one patients were confirmed with pathological examination.During the treatment，5 patients died from disease progression，and 2 patients withdrew treatment.Fourteen patients（9 females and 5 males） completed the entire treatment.The patients were administered paclitaxel （80 mg/m2），and each course lasted 3 weeks.The relative dose intensity and incidence of adverse reactions were analyzed.Adverse reaction events were recorded and graded on the basis of Common Terminology Criteria for Adverse Events v4.0.The overall survival（OS） of the patients was evaluated through follow-up，and the objective response rate was evaluated according to Response Evaluation Criteria In Solid Tumors.Results　The median number of courses completed was 10.The relative dose intensity of paclitaxel during the first two courses was more than 80.0%；there were no severe adverse reactions.Common adverse reactions included anemia（85.7%），leucopenia（71.4%），and hair loss（71.4%）.Six （42.9%） patients experienced adverse events grade 3 or above.The median OS of 14 ATC patients was 10.4 months，and the 6-month and 12-month survival rates were 85.7% and 42.9%，respectively.The 12-month survival rates of stage Ⅳa，Ⅳb，and Ⅳc patients were 80.0%，16.7%，and 0，respectively；Ⅳb and Ⅳc patients had poorer survival than did Ⅳa patients（χ2=7.627，10.317，P<0.001）.Three patients （21.4%） showed partial response，and 5 patients （35.7%） exhibited stable disease.Progressive disease （PD） occurred in 6 patients （42.9%）.The objective response rate was 21.4%.The progression time of the PD patients was 0.4-26.3 months，with a median time of 1.6 months.Four Ⅳa patients and 2 Ⅳb patients received postoperative radiotherapy，and their survival time was 15.5 months，which was significantly longer than the survival time （8.5 months） of those who did not receive radiotherapy（P=0.016）.Conclusion　Paclitaxel chemotherapy for the treatment of ATC can achieve a relatively high objective response rate and low incidence of adverse reactions.The treatment is effective and safe for ATC patients.

Prognostic Value of Two CT Angiography Collateral Circulation Score in Patients with Middle Cerebral Artery Occlusion Stroke　

ZHANG Ying，WANG Hua，LU Feng，ZHANG Long-zhen

2018, 21(24): 2937-2942. DOI: 10.3969/j.issn.1007-9572.2018.00.141

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Objective　To investigate the values of CT angiography（CTA） collateral circulation score in evaluating the prognosis of patients with middle cerebral artery occlusion stroke.Methods　From September 2015 to November 2016，66 patients with middle cerebral artery occlusion stroke who were examined in Department of Radiology of Wuxi Second People's Hospital and met the inclusion criteria were selected as study subjects.The patients were followed up for 3 months.Four patients were lost in visits，and two patients died during the follow-up period.Patient prognosis was scored according to the National Institutes of Health Stroke Scale（NIHSS）．According to NIHSS scores，the patients were divided into good prognosis group（NIHSS score<16，n=32） and poor prognosis group（NIHSS score≥16，n=28）．Within 12 h after disease onset，CTA collateral circulation was scored，and magnetic resonance diffusion weighted imaging（DWI） infarct volume was calculated.Logistic regression was used to analyze the risk factors associated with patient prognosis.The correlation between DWI infarct volume and the CTA collateral circulation score was analyzed with Spearman rank correlation.The value of the DWI infarct volume and two CTA collateral circulation score in predicting the prognosis of the patients with middle cerebral artery occlusion stroke were assessed.Results　The DWI infarct volume in the poor prognosis group was greater than that in the good prognosis group，and the Maas and Tan scores were lower in the poor prognosis group than the good prognosis group（P<0.05）．The DWI infarct volume and two CTA collateral circulation scores were prognostic factors for the patients with middle cerebral artery occlusion stroke（P<0.05）．The DWI infarct volume showed a negative correlation with the Maas and Tan scores（rs=-0.886，-0.713，P<0.001）．DWI infarct volume predicted the prognosis of AUC=0.892 with a critical value of 30.2 cm2, sensitivity and specificity of 75.0%, and 100.0%, respectively, and the Maas score predicted AUC=0.852, the critical value was 3, the sensitivity and specificity were 64.3% and 75.0%, and the Tan score predicted the prognosis of AUC=0.815, with a critical value of 2, sensitivity and specificity were 71.4%, 78.1%，respectively .Conclusion　Both the Maas and Tan score have value in prognostic prediction in patients with acute middle cerebral artery occlusion stroke.The Tan score has higher sensitivity and specificity than the Mass score.

Influencing Factors of Serum Transforming Growth Factor-β1 in Han，Uyghur，and Kazak Patients in the Xinjiang Uygur Autonomous Region　

TANG Rui，ZHANG Jun-shi，LIU Hai-ming，LI Hai-xia，YAN Fei，ZHANG Ya-ling，XU Xin-juan

2018, 21(24): 2943-2947. DOI: 10.3969/j.issn.1007-9572.2018.00.126

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Objective　To investigate the influencing factors of serum transforming growth factor-β1（TGF-β1） in Han，Uyghur，and Kazak individuals with essential hypertension in the Xinjiang Uygur Autonomous Region.Methods　A total of 271 patients（Han，129 cases；Uyghur，70 cases；Kazak，72 cases） with hypertension admitted to the First Affiliated Hospital of Xinjiang Medical University from September 2014 to May 2016 were recruited for the study.The clinical data of the patients were collected.The correlation between serum TGF-β1 and clinical indices in the three ethnic groups were analyzed，the related factors of TGF-β1 were analyzed using multivariate linear regression.Results　Serum TGF-β1 levels were positively correlated with systolic blood pressure，diastolic blood pressure，and heart rate in the Han patients（r=0.216，0.236，0.194，P<0.05）；serum TGF-β1 level was positively correlated with creatinine，serum cystatin C，and urinary microalbumin in the Uygur patients（r=0.429，0.446，0.446，P<0.05），and negatively correlated with eGFR in the Uygur patients（r=-0.446，P<0.05）．In the Kazak patients，serum TGF-β1 levels showed positive correlations with triglyceride and fasting blood glucose（r=0.446，0.384，P<0.05）．Multivariate linear regression analyses showed that the serum TGF-β1 level was independently associated with diastolic blood pressure （β=0.216）in Han patients，and serum cystatin C（β=0.531），eGFR（β=-0.448），and urinary microalbumin（β=0.603） in the Uygur patients. Triglyceride （β=0.469），fasting blood glucose（β=0.248），creatinine（β=0.315），and urinary sodium/urinary potassium（β=0.528）， were associated with TGF-β1 levels in the Kazak patients.Conclusion　Diastolic blood pressure was independently associated with TGF-β1 levels in Han patients；serum cystatin C，eGFR，and urinary microalbumin were independently associated with TGF-β1 levels in Uighur patients；triglyceride，fasting blood glucose，creatinine，and urinary sodium/urine potassium were independently associated with serum TGF-β1 levels in Kazak patients.

Investigation of the Role of CDH1 Promoter Methylation in Ovarian Endometriosis　

FAN Xia，AN Dong，LI Yan，KANG Shan

2018, 21(24): 2948-2951. DOI: 10.12114/j.issn.1007-9572.2018.00.054

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Objective　To investigate the methylation status of the promoter region of the E-cadherin gene（CDH1） and its role in ovarian endometriosis.Methods　We selected 50 patients with ovarian endometriosis who were diagnosed surgically and treated in Fourth Hospital of Hebei Medical University between October 2011 and August 2013，and 50 control cases who underwent hysterectomy or uterine exploration due to gradeⅢ cervical intraepithelial neoplasia during the same period.The methylation status of the CDH1 promoter in eutopic endometrium tissues（eutopic endometrium group） and ectopic endometrium tissues（ectopic endometrium group） in the patients with ovarian endometriosis and in the control subjects（control endometrium group） was detected through methylation-specific PCR （MSP）．RT-PCR and flow cytometry were used to detect the expression levels of CDH1 mRNA and E-cadherin in CDH1 promoter methylation positive tissues and CDH1 promoter methylation negative tissues.Results　The positive methylation rate of the CDH1 promoter was 26.0%（13/50） in the eutopic endometrium group，and 32.0%（16/50） and 8.0%（4/50） in the ectopic endometrium group and control endometrium group，respectively；the positive methylation rates in the eutopic endometrium group and ectopic endometrium group were significantly higher than those in the control endometrium group（P=0.017，0.003）．The levels of CDH1 mRNA and E-cadherin protein in methylation-positive samples〔（0.4±0.2），（129.0±17.5）〕 were significantly lower than those in the methylation-negative samples〔（0.6±0.1），（158.0±51.0）〕（P=0.023，0.035）．Conclusion　The CDH1 promoter region in eutopic and ectopic endometrium tissues is abnormally methylated，and the expression levels of CDH1 mRNA and E-cadherin in methylation positive and negative tissues were significantly different，thus suggesting that abnormal methylation of the CDH1 promoter may be involved in the development of ovarian endometriosis.

Promoter Methylation Status of GSTP1，BRCA1 and MGMT in Breast Cancer Tissues and Its Correlation with Clinical Pathological Features　

QIAN Xiao-ying，LIN Hai-feng，ZHOU An-xi，ZHUO Man-yun

2018, 21(24): 2952-2956. DOI: 10.12114/j.issn.1007-9572.2018.00.141

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Objective　To analyze the promoter methylation status of GSTP1，BRCA1 and MGMT in breast cancer tissues and its correlation with clinical pathological features.Methods　According to the inclusion criteria，we enrolled 100 cases of breast cancer from the Second Affiliated Hospital of Hainan University from January 2015 to June 2016.The promoter methylation status of GSTP1，BRCA1 and MGMT in breast cancer tissues and tissues adjacent to breast cancer was detected by methylation-specific PCR and its relationship with clinical pathological features was analyzed.Cox regression analysis was performed to investigate the relationship between the promoter methylation status and prognosis of the patients.Results　Promoter methylation level of GSTP1，BRCA1 and MGMT in breast cancer tissues was higher than that in tissues adjacent to breast cancer（P<0.05）.The proportion of methylated genes in breast cancer tissue was higher than that of the methylated breast cancer adjacent tissue （P<0.05）.The promoter methylation level of these genes differed significantly by breast cancer staging and prevalence of lymphatic metastasis（P<0.05）.Patients with breast cancer of≥20 mm in maximum diameter showed higher methylation level in the promoter region of GSTP1 compared with those with breast cancer of <20 mm in maximum diameter（P<0.05）.Moreover，breast cancer patients with lymphatic metastasis presented higher methylation level in the promoter region of GSTP1 compared with those without（P<0.05）.Younger than 50 years old and estrogen receptor negative were associated with higher methylation level in the promoter region of BRCA1（P<0.05）.Patients with histological Ⅲbreast cancer，stage Ⅱ-Ⅳ breast cancer or breast cancer with lymphatic metastasis demonstrated higher methylation level in the promoter regions of MGMT compared with those with histological Ⅰ-Ⅱ breast cancer，stage Ⅰ breast cancer or breast cancer without lymphatic metastasis（P<0.05）.Cox regression analysis showed that the methylation in the promoter regions of GSTP1，BRCA1 and MGMT genes were associated with the prognosis of breast cancer （P<0.05）.Conclusion　The promoter regions of GSTP1，BRCA1 and MGMT in breast cancer tissue was higher than that of the methylated breast cancer adjacent tissue.The methylation of GSTP1，BRCA1 and MGMT genes are correlated with clinicopathological characteristics and progression of breast cancer.

Clinical Characteristics of Acute Ischemic Stroke Patients with Family History　

LI Jie-jie，ZHAO Xing-quan，WAND Yi-long，LIU Li-ping，WANG Chun-xue，YAN Hong-yi，WANG Yong-jun

2018, 21(24): 2957-2960. DOI: 10.12114/j.issn.1007-9572.2018.00.182

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Objective　To investigate the clinical characteristics of acute ischemic stroke patients with family history.Methods　Data was derived from the China National Stroke Registry（CNSR）study.A total of 11 031 patients who had acute ischemic stroke with available information of family history from April to May 2018 were included in this study.They were divided into the group with family history（1 406 cases）and group without family history（9 625 cases）.The baseline data and clinical characteristics were collected and compared.Results　The group with family history had lower proportion of female patients and smoking rate and younger age than group without family history（P<0.05）.Systolic pressure，diastolic pressure，drinking rate，incidence rates of ischemic stroke，cerebral hemorrhage，subarachnoid hemorrhage，diabetes，hypertension，asthma，arthritis，wake-up stokes，and headache，National Institutes of Health Stroke Scale（NIHSS）score，incidence rates of upper limb weakness，numbness of limbs，facial paralysis，dysarthria，diplopia and dysphagia in group with family history were significantly higher than those in group without family history（P<0.05）.Conclusion　Acute ischemic stroke patients with family history had more cardiovascular risk factors and neurological deficits were more common in them.

GATA-4 Overexpressed Mouse Bone Marrow Mesenchymal Stem Cells Increase Anti-apoptosis by Secreting Exosome　

HE Ji-gang，LI Bei-bei，HAN Jin-xiu，LI Hong-rong，SA Ya-lian，YAN Dan，YANG Xiao-hua

2018, 21(24): 2961-2966. DOI: 10.12114/j.issn.1007-9572.2018.00.068

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Objective　To explore the role of GATA-4 overexpressed mouse bone marrow mesenchymal stem cells （BMSCs） in the improvement of cardiac function after myocardial infarction repair by enhancing the anti-apoptotic capability of BMSCs via secreting Exosome.Methods　This study was conducted between January and December 2017.60 healthy SPF C57BL/6 mice aged 4 weeks were selected.GATA-4 overexpressed mouse BMSCs were constructed by transfecting the BMSCs with lentiviral vector GV308 carrying GATA-4.Doxycycline was added to induce the gene.Then，SBI ExoQuick-TC was adopted to extract the Exosome secreted by the transfected BMSCs.Exosome purity was determined by SBI Exosome Antibodies，Array，and ELISA Kits and observed by an electron microscope.In vitro experiments：coculture was performed between Exosome secreted by GATA-4 overexpressed BMSCs and myocardial cells（group A），between Exosome secreted by GATA-4-free-vector-BMSCs and myocardial cells（group B），and between Exosome secreted by BMSCs and myocardial cells （group C）．For the positive control group（group D），myocardial cells alone were subjected to hypoxia culture and serum-free culture to induce apoptosis.Meanwhile，for the negative control group（group E），myocardial cells alone were cultured under normal conditions.All these 5 groups were cultured for 48 h to induce apoptosis.The cell apoptosis rate was determined through flow cytometry，and Caspase-3，Caspase-8，Caspase-9，and cytochrome C were measured through Western blot.In vivo experiments：48 h after the establishment of mouse model of myocardial infarction in 30 mice，Exosomes secreted by GATA-4 overexpressed BMSC，and GATA-4-free-vector-BMSCs and BMSCs were injected into the tail veins of group A，group B，group C，respectively.Treatment-free 3 mice models of myocardial infarction（group D） and 3 normal mice receiving normal feeding（group E） were used as the control groups.The cardiac function was evaluated by Philips EPIQ 7 C Cardiac Ultrasound at 48 h after intervention.After that，the number of apoptotic cells in myocardial infarction focus was detected through immunohistochemistry with in situ hybridization methods.Results　In vitro experiments：Electron microscopy showed that the size of Exosome ranged from 40 nm to 100 nm，and expression amount of Exosome was 0.272 5，the purity of Exosome was 5.25×108 .Flow cytometry results showed that the proportion of apoptotic cells in myocardial infarction focus after intervention and adoption for 48 h in group A was lower than that of groups B，C，D，but higher than that of group E（P<0.05）．Western blotting results indicated that the expression levels of Caspase 8 and cytochrome C in group A were lower than those of other groups（P<0.05）．In vivo experiments：Cardiac ultrasound results revealed that group A had better EF and FS D-value than other groups（P<0.05）．Analysis of immunohistochemical examination with in situ hybridization showed that the number of apoptotic cells in myocardial infarction focus after intervention and adoption for 48 h in group A was more than that of group E，but less than that of groups B，C and D（P<0.05）．Conclusion　Exosome secreted by GATA-4 overexpressed mouse BMSCs can enhance the anti-apoptotic capability of BMSCs to effectively improve the cardiac function after myocardial infarction.

Implementation Status of Hierarchical Diagnosis and Treatment Covered by the New Rural Cooperative Medical Scheme in Huining County，Gansu Province　LI

Shi-ya，WANG Xiao-hui，NAN Xiao-qiang，MIAO Jing，WU Yu-pan，GAN Ting，BAI Yi-bo，WU Hui，ZHANG Ben-zhong

2018, 21(24): 2967-2973. DOI: 10.12114/j.issn.1007-9572.2018.00.147

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Objective　To analyze the status of hierarchical diagnosis and treatment（HDT） covered by the New Rural Cooperative Medical Scheme （NRCMS） in Huining County，Gansu Province，providing suggestions for the improvement of HDT in this county.Methods　From October 2016 to November 2017，we collected 246 461 records of hospitalization expenses reimbursed by the NRCMS in Huining County，Gansu Province during 2012 to 2016.We compared the rate of seeking inpatient healthcare in and outside of this county，average cost and length of a hospitalization，and average real reimbursement for a hospitalization before and after 2014 （the implementation of HDT） in this county.Results　After the implementation of HDT，the overall rate of seeking inpatient healthcare within the county increased significantly〔79.18%（131 275/165 792） vs 77.04%（62 134/80 655），χ2=147.64，P<0.01〕.The average cost of a hospitalization declined significantly in township health centers within the county and in county-level medical institutions outside the county，but increased obviously in county-level medical institutions and all medical institutions within the county and in hospitals at municipal，provincial and above levels as well as all medical institutions outside the county（P<0.05）．The average real reimbursement for a hospitalization decreased substantially in township health centers within the county，county-level medical institutions，hospitals at municipal，provincial and above levels as well as all medical institutions outside the county，but increased significantly in county-level medical institutions and all medical institutions within the county（P<0.05）．The median length of hospitalization in medical institutions within the county differed significantly before and after the implementation of HDT〔7（5，11）d vs 7（5，10）d，Z=21.483，P<0.05〕.Conclusion　The implementation of HDT in Huining county promoted the reasonable flow of inpatients，improved the service efficiency and controlled the cost of hospitalization in medical institutions，which is contributive to reducing the patients' medical burden.

Fuxing Hospital，Capital Medical University Optimizes the Bidirectional Referral Model to Improve the Service Capabilities of Family Doctors　

YAN Wei，DU Xue-ping，HUANG Xuan，SONG Yan，LI Qian，ZHANG Hong-bo，WU Wei，WANG Fei，WANG Jie-ping

2018, 21(24): 2974-2979. DOI: 10.12114/j.issn.1007-9572.2018.00.139

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Family doctor contractual service plays an important role in safeguarding the health of the Chinese people in the new era，which is in the exploratory stage.Bidirectional referrals connect the services delivered by the grassroots medical institution and tertiary general hospital，and provide strong support for family doctors offering continued care for contracted residents.Therefore，optimizing the bidirectional referral system can improve the service capabilities of the family doctor so as to provide high-quality continued care and enhance the development of hierarchical medical system.The implementation of bidirectional referral system in China faces many challenges，but has obtained some achievements，for example，the internet-based bidirectional referral model optimizes the bidirectional referral process and improves medical resources sharing.Fuxing Hospital，Capital Medical University uses the internet-based bidirectional referral model，and established an internet-based bidirectional referral platform.From 2015 to 2017，it provided bidirectional referral services for 5 400 patients via the platform being perfected while in use.Although the bidirectional referrals increased significantly in this period，the percentage of downward referrals increased unnotably，indicating that the platform needs further improvement.The latest optimized platform has been put into operation in January 2018，and the downward referrals implemented via it show a fair growth.

Intervention Effect of Aerobic Exercise Combined with Situ Squats Resistance Training Program on Middle-aged Patients with Type 2 Diabetes　

CHANG Feng

2018, 21(24): 2980-2986. DOI: 10.12114/j.issn.1007-9572.2018.00.135

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Objective　To investigate the effective programs and intervention effect of aerobic exercise combined with situ squats in middle-aged patients with type 2 diabetes.Methods　A total of 56 middle-aged patients aged 45-59 years with type 2 diabetes were enrolled from the Hospital of Hubei University between March and September 2016.They were divided into the control group（20 cases，maintaining the original exercise habit），the aerobic exercise group（18 cases，aerobic exercise program）and the aerobic exercise combined with situ squats group（18 cases，aerobic exercise combined with situ squats resistance training program，and aerobic exercise plan was the same as the aerobic exercise group，situ squats resistance training scheme was determined by orthogonal tests）on the premise of gender，age，course of disease，BMI，medication and so on.Patients' general information was collected，and situ squat number of different loads，heart rate，intermittent time，sports time，time-glucose area under the curve（GAUC）of different squat combinations were examined.Fasting plasma glucose（FPG），glycosylated hemoglobin（HbA1c），insulin，C peptide and blood lipid were also determined before and after the intervention.Results　The number of squats，heart rate of patients in medium load and higher load groups were significantly higher，and their interval time and exercise time were also significantly longer than those in low load group（P<0.05）．The number of squats，heart rate in higher load group were significantly higher，and its interval time and exercise time were significantly longer than those in medium load group（P<0.05）．GAUC of M-5-45"（45 min after meal with medium load 5 groups）and L-5-60"（60 min after meal with low load 5 groups）was less than that in the control group（sitting after meal），L-3-30"（30 min after meal with low load 3 groups），M-3-45"（45 min after meal with medium load 3 groups），H-3-60"（60 min after meal with higher load 3 groups），L-4-45"（45 min after meal with low load 4 groups），M-4-60"（60 min after meal with medium load 4 groups），H-4-30"（30 min after meal with higher load 4 groups）and H-5-30"（30 min after meal with higher load 5 groups）（P < 0.05）．To sum up，the training program of aerobic exercise with situ squats was determined as the following：the exercise intensity was 30% or 50% of the maximum number of situ squats，5 groups；the exercise time was 20-30 min，and the interval time was 2-3 min；the exercise frequency was twice a week（Tuesday，Thursday）；the starting time of exercise was 30 to 45 minutes before the peak of blood glucose.After the intervention，FPG of the aerobic exercise group and aerobic exercise combined with situ squats group was lower than that of the control group（P<0.05）．FPG in the aerobic exercise group was significantly lower after intervention than before intervention（P<0.05）．FPG and c-peptide in the aerobic exercise combined with situ squats group after intervention were significantly lower than those before intervention（P<0.05）．After intervention，triglyceride（TG）and cholesterol（CHO）in the aerobic exercise group and aerobic exercise combined with situ squats group were much lower than those in the control group（P<0.05）．After intervention，high-density lipoprotein cholesterol（HDL-C）in the aerobic exercise combined with situ squats group was higher than that in the control group and the aerobic exercise group（P<0.05）．TG and CHO in the aerobic exercise group after intervention were much lower than those before intervention（P<0.05）．After intervention，TG and CHO in the aerobic exercise combined with situ squats group were lower than those before intervention，and HDL-C was higher than that before intervention（P<0.05）．Conclusion　Aerobic exercise combined with M-5-45"，L-5-60" situ squats in middle-aged patients with type 2 diabetes can be used as effective therapy when combined with resistance training in terms of improving the patient's FPG，blood lipid and enhancing the effect of islet cell function.Moreover its function in increasing HDL-C effect was much better than simple aerobic exercise.

Construction and Application of a VR Platform Based on the Omaha System for Rehabilitation Management of Breast Cancer Patients　

JIN Ai-xiang，CHEN Xiao-min，ZHANG Xiao-fei，CHEN Jie

2018, 21(24): 2987-2993. DOI: 10.12114/j.issn.1007-9572.2018.00.026

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Objective　To build a virtual reality （VR） model for a breast cancer combined rehabilitation program based on breast cancer rehabilitation principles and the Omaha system，and to explore its clinical application.Methods　According to the operation type and stage of postoperative recovery，combined with the natural language processing of the Omaha system and feedback from patient information，the core physical and psychological rehabilitation functions of the VR platform were developed and implemented.A total of 120 breast cancer patients treated in the Zhejiang Province People's Hospital between January 2016 and May 2017 were selected and divided into observation group （VR group，n=60） and control group（conventional rehabilitation group，n=60） with a random number table method.The scores of various dimensions and average scores of quality of life scales（SF-36） between the two groups were compared.Results　A VR platform for postoperative rehabilitation of breast cancer patients based on the Omaha system was developed.After a 3-month application，the scores of various dimensions and average scores of SF-36 in the observation group were significantly higher than those in the control group（P<0.05）.Conclusion　The VR platform based on the Omaha system for rehabilitation management is easy to operate and apply.It is an effective physical and psychological postoperative rehabilitation model for breast cancer patients，and it provides a new option for personalized rehabilitation of breast cancer patients.

Dietary Behaviors and Dyslipidemia in Full-time Employees of Functional Institutions in Beijing　

ZHANG Jing-bo，WU Zhi-yuan，LIU Xiang-tong，ZHAO Zhan，ZOU De-chun，ZOU Xiao-ping，MU Yong-min，LIU Feng，CHEN Shuo，GUO Xiu-hua

2018, 21(24): 2993-2996. DOI: 10.12114/j.issn.1007-9572.2018.00.080

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Objective　To investigate the relationship between dietary behaviors and the prevalence of dyslipidemia in full-time employees of functional institutions in Beijing.Methods　This cross-sectional survey was conducted among 14 448 full-time employees of functional institutions in Beijing who underwent physical examination at the Beijing Physical Examination Center from April 2014 to April 2015 with a self-developed questionnaire for collecting the data concerning sociodemographic characteristics，dietary behaviors and prevalence of dyslipidemia.Multivariate Logistic regression analysis was implemented to examine the association between dietary behaviors and prevalence of dyslipidemia.Results　The prevalence of dyslipidemia was 9.7%（1 399/14 448）.Multivariate Logistic regression analysis found that，after adjusting for sex and age，having a sweet tooth was negatively correlated with the prevalence of dyslipidemia 〔OR=0.783，95%CI（0.629，0.975）〕，while skipping breakfast 7 days（all days） per week 〔OR=2.811，95%CI（1.649，2.884）〕，eating breakfast 1-3 times per week 〔OR=1.761，95%CI（1.404，2.209）〕，eating breakfast 4-5 times per week 〔OR=1.396，95%CI（1.142，1.707）〕，eating breakfast relatively fast 〔OR=1.777，95%CI（1.401，2.254）〕，eating breakfast very fast 〔OR=1.899，95%CI（1.386，2.602）〕 were positively correlated with the prevalence of dyslipidemia（P<0.05）.Conclusion　Many bad eating behaviors，in particular，bad breakfast eating habits and fast eating speed，were found in the full-time employees of functional institutions in Beijing，which were associated with the prevalence of dyslipidemia.In view of this，eating breakfast regularly and eating slowly are recommended for the prevention of dyslipidemia.

Characteristics and Clinical Significance of Preoperative CT Perfusion Imaging in Patients with Carotid Stenosis　

CUI Yong，JIN Guang-yu，SUN Sheng-jun，LI Liang，JIN He，SUI Bin-bin

2018, 21(24): 2997-3000. DOI: 10.12114/j.issn.1007-9572.2018.00.122

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Objective　To discuss the preoperative value of CT perfusion imaging （CTP） on patients with carotid artery stenosis in forecasting the risk of postoperative cerebral hyperperfusion syndrome（CHS） and Cerebral hyperperfusion（CH）．Methods　The retrospective study was performed on 64 patients admitted to Beijing Tiantan Hospital，Capital Medical University from January to December 2015.Subjects had undergone unilateral carotid artery stenting（CAS） / carotid endarterectomy （CEA），and preoperative CT perfusion imaging was performed to determine the blocked carotid artery.These patients were divided into 5 groups by carotid stenosis; Group A: carotid occlusion group （stenosis 100%） of 10 cases; Group B: severe carotid stenosis group （stenosis 75%-99%） of 17 cases; Group C: moderate carotid stenosis group （stenosis 50%-74%） of 7 cases; Group D: mild carotid stenosis group （stenosis< 50%） of 4 cases; Group E: normal carotid artery group of 26 cases.Preoperative CT perfusion parameters were collected and compared，including local cerebral blood volume（rCBV）index，local cerebral blood flow（rCBF）index，local mean transit time （rMTT）index and local time to peak （rTTP）index.Results　Cerebral hyperperfusion occurred in 33 cases （high blood pressure，mild headache，dizziness），and cerebral hyperperfusion syndrome occurred in 1 case，with symptoms of elevated blood pressure，obvious headache，nausea，and intracranial hemorrhage.Thirty cases showed no excessive perfusion.The incidence of high blood pressure after the operation was 51.6% （33 cases）.The levels of rCBV index and rTTP index in Group A and B were significantly higher than those in Group C，D and E（P<0.05）.The rCBF index and rMTT index levels among different groups were not statistically significant（P>0.05）.Conclusion For patients with mild and severe stenosis in internal carotid artery （blocked blood vessel） with contralateral carotid artery occlusion or severe stenosis，if the preoperative rCBV index and rTTP index significantly increased，especially when rCBV index >0.20 and rTTP index >0.25，CHS and CH are more likely to occur after the operation; therefore，the preoperative rCBV index and rTTP index provide a potential value in predicting CHS after the CAS/CEA surgery on patients with unilateral internal carotid artery stenosis.

Application of 3D-CT Reconstruction Combined with Indocyanine Green Fluorescence in Anatomical Thoracoscopic Segmentectomy　#br#

WANG Kang-wu，WANG Zu-yi，DUAN Gui-xin，CHEN Liu-cheng，WANG Guo-wen，WANG An-sheng，CHEN Xiao

2018, 21(24): 3001-3004. DOI: 10.12114/j.issn.1007-9572.2018.00.060

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Objective　To investigate the feasibility and efficacy of three-dimensional CT（3D-CT） reconstruction combined with indocyanine green fluorescence（ICGF） in anatomical thoracoscopic segmentectomy.Methods　Twenty patients who underwent anatomical thoracoscopic segmentectomy in the Department of Thoracic Surgery，the First Affiliated Hospital of Bengbu Medical College between January and December 2017 were selected as study subjects，including 18 cases of primary lung cancer and 2 cases of metastatic lung cancer.The target segment of the pulmonary artery was evaluated preoperatively，and the virtual segment plane was reconstructed with 3D-CT.During the operation，when the target segment pulmonary artery and bronchus were separated，ICG （0.25 mg/kg） was intravenously injected.ICGF in the non-target segments（NTS） was observed，and the boundaries between target segments and NTS were marked with an electrical burn.Patient 's baseline characteristics，and the time of first appearance of fluorescence，the duration of ICGF and the duration of effective contrast and other surgical indicators were observed and recorded.Results　ICGF provided a clear mark delineating segments，and its fluorescence duration was sufficient to complete the labeling.Lung surface labeling and anatomical thoracoscopic segmentectomy were successfully completed in all 20 patients.The operation time was（186.0±41.5）min，and the blood loss was（30.0±17.8）ml.After the injection of ICG，the time of first appearance of fluorescence was（20.0±10.5） s，and the duration of fluorescence was（180.0±30.8） s；the duration of effective contrast was（70.0±11.6） s，which was sufficient for clinicians to perform labeling.The methods did not cause side effects in the patients.Conclusion　3D-CT reconstruction combined with ICGF allows for full preoperative evaluation and clearly shows the segmental boundary，thus providing a reliable technique for anatomical thoracoscopic segmentectomy.It is a safe and effective method worthy of further clinical use.

Eosinophilic Gastroenteritis：a Case Report and Literature Review　

XU Hui-ying，LI Yue-hong，ZHUANG Zhen

2018, 21(24): 3005-3009. DOI: 10.3969/j.issn.1007-9572.2018.00.212

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The pathogenesis of eosinophilic gastroenteritis is usually associated with allergy，characterized by infiltration of eosinophils in the stomach or the intestinal tract accompanying with peripheral blood eosinophilia.The clinical manifestations include nausea，vomiting，abdominal pain，diarrhea and other non-specific gastrointestinal symptoms.Clinical symptoms are often related with the sites and depth of eosinophils infiltration.We reported one case of eosinophilic gastroenteritis and reviewed the relevant literature.

Analysis of a De Novo Mutation of the PHEX Gene in a Pedigree with Familial Hypophosphatemic Rickets　

LI Yuan，MA Xiao-xue

2018, 21(24): 3010-3014. DOI: 10.3969/j.issn.1007-9572.2018.00.117

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Familial hypophosphatemic rickets is a rare hereditary rickets representing a group of diseases characterized by excessive phosphate excretion and hypophosphatemia caused by defects of renal phosphate transport.The most common form of the disorder is X-linked hypophosphatemic rickets（XLH），which has an X-linked dominant inheritance.XLH is caused by the PHEX gene mutation and has an incidence of 1/20 000.The clinical manifestations of the disease include disproportionate short stature，rickets，lower extremity deformity，hypophosphatemia，and normal serum calcium.In this study，we reported an XLH family and performed sequencing analyses on the proband and main family members.We found that a c.2066C>T（p.Ala689Val） heterozygous missense mutation of the PHEX gene occurred in four family members，moreover，the variation had not been included in the ESP6500，dbSNP，and 1 000 genomes databases.Our finding provides valuable information for genetic counseling and prenatal diagnosis of the disease.

Recent Advances in Extravascular Lung Water Monitoring　

YAO Yu-Long，LEI Ming，LI Wen-fang2

2018, 21(24): 3015-3019. DOI: 10.3969/j.issn.1007-9572.2018.00.219

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Extravascular lung water（EVLW） is the amount of fluid accumulating in the spaces outside the pulmonary vessels，which is a parameter commonly monitored for evaluating the severity of pulmonary edema in ICU patients.EVLW achieves increasing attention for it can be applied to assess pulmonary pathophysiological conditions，pulmonary circulation as well as the outcome of critically ill patients.Therefore，correctly monitoring EVLW is of great significance in the diagnosis and treatment of critically ill patients.In order to improve healthcare providers' understanding of EVLW monitoring，we introduced some currently used methods for monitoring EVLW，focusing on comparing the monitoring principles，procedure of use，limitations and developments between them.

Recent Advances in Bronchial Asthma in Adults　

WANG Shi-qiang，WANG Xiong-biao

2018, 21(24): 3019-3024. DOI: 10.3969/j.issn.1007-9572.2018.00.171

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We introduced the characteristics and clinical manifestations of bronchial asthma in adults（BAA），compared the differences between BAA and asthma in adolescents，summarized the risk factors for BAA，reviewed the recent advances in BAA，and put forward that the pathogenesis of BAA may be related to air pollution，obesity and occupational exposure，so in order to achieve good control of BAA，occupational exposure should be avoided，control of infection and self-management，should be implemented successfully.Moreover，we came to a conclusion that the determination of asthma phenotype mainly depends on clinical characteristics，rather than biomarkers，which provides relevant information for treating asthma with new methods.

Recent Developments in Using Olfactory Stimuli in Preterm Care　

WEN Yan，WEI Qin

2018, 21(24): 3025-3028. DOI: 10.3969/j.issn.1007-9572.2018.00.139

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Fetus can smell the amniotic fluid in the womb.They have response to the external olfactory stimulation after birth.The olfactory stimulus response is one item of behavior assessment in premature infants.We introduced the recent advances in olfactory stimuli used for improving apnea and pain，reducing the impact of pain on heart rate and SPO2 as well as enhancing feeding in premature infants，in order to increase healthcare providers' understanding of olfactory stimuli for premature infants，and to provide new ideas for improving the neonatal clinical care mode.

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