Chinese General Practice

Expert Consensus on Risk Management of Polypharmacy in Elderly Endocrinology and Metabolism Branch of Chinese Association of Geriatric Research，Committee of Clinical Toxicology of Chinese Society of Toxicology

Endocrinology and Metabolism Branch of Chinese Association of Geriatric Research，Committee of Clinical Toxicology of Chinese Society of Toxicology

2018, 21(29): 3533-3544. DOI: 10.12114/j.issn.1007-9572.2018.00.225

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China has the largest elderly population in the world.Polypharmacy in the elderly with multiple diseases is inevitable and very common.In recent years，more and more medical and pharmaceutical experts appeal to pay attention to the risk of polypharmacy in elderly and put forward management to avoid damage caused by drug interaction in multi-drug combination therapy.To meet the needs of clinical practice and further to improve the level of drug safety in elderly，a group of clinical medicine and pharmaceutical experts in China have worked out the “Expert Consensus on the Risk Management of Polypharmacy in Elderly” for clinical reference to ensure the safety of drug use.

Relationship between the Mortality Rate of Cardio-cerebrovascular Disease and Air Quality：a Cross-sectional Study

BI Yuqing1，WANG Shasha1，YU Huihui1，ZHANG Jiping1，WANG Xiang1，LUO Sheng1，LI Wei2*

2018, 21(29): 3545-3550. DOI: 10.3969/j.issn.1007-9572.2018.00.148

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Objective　To investigate the relationship between the mortality rate of cardio-cerebrovascular disease and the emission of main air pollutants，and based on this，to explore the influence of air quality on the incidence of such kind of disease and people's health.Methods　We conducted this cross-sectional study in a simple random sample of 15 representative provinces （municipalities）.Using the mean mortality rates of coronary heart disease （CHD） and cerebrovascular disease （CD），mean emission of SO2，NOx and dust as variables of Y1，Y2，X1，X2，X3，respectively.We established multiple linear regression model 1 for investigating the relationship between mortality rate of CHD and air quality，and multiple linear regression model 2 for investigating the relationship of mortality rate of CD with air quality.SAS software was used to perform the analysis based on ridge regression model.Results　The formula for calculating the mortality rate of CHD was derived from model 1：Y1=0.022 08+0.287 93X1+0.188 73X2+0.272 63X3（R2=0.879 2，F=4.58，P=0.018 2），showing that the mortality rate of CHD was positively correlated with the emission of SO2，NOx and dust，and it was influenced the most by the emission of SO2，followed by the emission of dust and NOx.The formula for calculating the mortality rate of CD was derived from model 2：Y2=0.018 77+0.394 69X1+0.147 97X2+0.244 25X3（R2=0.897 4，F=5.68，P=0.008 4），indicating that the mortality rate of CD was positively correlated with the emission of SO2，NOx and dust，and it was affected the most by the emission of SO2，followed by the emission of dust and NOx.Conclusion　The mortality rate of cardio-cerebrovascular disease is closely related to air pollution.Air quality is an important factor associated with cardio-cerebrovascular disease and people's health.Therefore，it is urgent to control air pollution to promote people's health.

Air Pollutants and Cerebral Infarction：a Case-crossover Study　

LI Ning，JI Wei，YU Yanfeng，HAN Hangtao，FAN Mingsuo，ZHANG Liang

2018, 21(29): 3551-3556. DOI: 10.3969/j.issn.1007-9572.2018.00.255

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Objective　To explore the effects of air pollutants on the incidence of cerebral infarction using a case-crossover design.Methods　Data of visits for cerebral infarction（ICD10 I63） were collected from three grade A tertiary hospitals（Ningbo City Medical Treatment Center Lihuili Hospital，Ningbo First Hospital，and Ningbo NO.2 Hospital）.Air pollutants data were obtained from Environment Monitoring Center of Ningbo.Data concerning temperature stemmed from Ningbo Meteorological Bureau.All the aforementioned data cover a three-year period from January 1，2014 to December 31，2016.Based on a one-way retrospective 1∶3 case-crossover design，single pollutant and multi-pollutant（conditional Logistic regression） models combined with sex subgroup analysis were used.Results　A total of 22 837 visits were enrolled，except the data concerning sex of 4 329（18.95%） were missed，the other cases〔10 968 males（48.03%） and 7 540（33.02%） females，with a male-to-female ratio of 1.45∶1〕 were included in the sex subgroup analysis.Single-pollutant analyses showed that NO2 and CO levels appeared to be the associated factors for cerebral infarction〔OR=1.001，95%CI（1.000，1.003），P=0.034；OR=0.794，95%CI（0.723，0.873），P<0.001〕.When sex was considered as a stratification variable，NO2 and O3 levels were found to be the associated factors for cerebral infarction in males〔OR=1.003，95%CI（1.001，1.004），P=0.011；OR=0.999，95%CI（0.998，1.000），P=0.033〕，and NO2 and CO levels were identified to be the associated factors for cerebral infarction in females〔OR=1.002，95%CI（1.000，1.005），P=0.046；OR=0.826，95%CI（0.704，0.968），P=0.018〕.Multi-pollutant analyses revealed that PM10，NO2 and CO levels were associated factors for cerebral infarction〔OR=1.001，95%CI（1.000，1.002），P=0.019；OR=1.004，95%CI（1.002，1.006），P<0.001；OR=0.564，95%CI（0.490，0.650），P<0.001〕；PM10，NO2，O3 and CO levels were associated factors for cerebral infarction in males〔OR=1.002，95%CI（1.001，1.004），P=0.004；OR=1.004，95%CI（1.001，1.007），P=0.004；OR=0.999，95%CI（0.998，0.999），P=0.001；OR=0.580，95%CI（0.474，0.708），P<0.001〕，and NO2 and CO levels were associated factors for cerebral infarction in females〔OR=1.006，95%CI（1.003，1.009），P<0.001；OR=0.609，95%CI（0.480，0.773），P<0.001〕when sex was considered as a stratification variable.Conclusion　Under certain conditions，PM10 and NO2 levels might be the risk factors and CO level a protective factor associated with cerebral infarction，there might be gender differences in the effects of some air pollutants on cerebral infarction.

Association between Air Pollution and Cerebral Hemorrhage Occurrence in Dalian　

TAO Mengxing，WANG Yu，GUO Yan，YANG Xi，CAO Suhan，MAO Baoyi，FEI Fan，SUN Xiaopei*

2018, 21(29): 3557-3561.

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Objective　To explore the correlation between air pollutants and cerebral hemorrhage occurrence in Dalian.Methods　The data of 1 688 patients with initial cerebral hemorrhage were collected retrospectively from First Affiliated Hospital of Dalian Medical University，Second Affiliated Hospital of Dalian Medical University and Affiliated Zhongshan Hospital of Dalian University from 2014 to 2015.The information of air pollutants （PM2.5，PM10，NO2，SO2，O3） during the same period were collected from Dalian Environmental Protection Agency.A single retrospective crossover study was designed with a 1 to 1 matched case.Multivariate Logistic regression analysis was used to evaluate associations between air pollutants and cerebral hemorrhage.The hysteresis effect of PM2.5 and PM10 concentration on the 0-3 day before onset of cerebral hemorrhage was analyzed.The optimal hysteresis period was determined according to the OR value.Results　The result of multivariate Logistic regression analysis showed that the concentrations of PM2.5，PM10 and NO2 were correlated with the incidence of cerebral hemorrhage〔OR=1.022，95%CI（1.003，1.040），P=0.022；OR=1.014，95%CI（1.000，1.028），P=0.045；OR=1.006，95%CI（1.001，1.110），P=0.018〕.The result of hysteresis effect analysis showed that the incidence of cerebral hemorrhage was related to the concentration of PM2.5 on the day of onset and 1 day before onset〔OR=1.031，95%CI（1.008，1.054），P=0.007；OR=1.027，95%CI（1.004，1.050），P=0.023〕，and the maximum OR was on the day of onset.The incidence of cerebral hemorrhage was related to the concentration of PM10 on the day of onset〔OR=1.019，95%CI（1.003，1.036），P=0.020〕.Conclusion　The daily number incidence of cerebral hemorrhage is positively correlated to the concentration of PM10，PM2.5，and NO2.The particulate matter concentrations on the day of onset are significantly associated with the cerebral hemorrhage.

Multivariate Analysis of Risk and Prognostic Factors in Patients with Coronary Heart Disease　

WU Shuyao，LIU Yan，SONG Qian

2018, 21(29): 3562-3570. DOI: 10.3969/j.issn.1007-9572.2018.00.249

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Objective　To determine the risk factors associated with the development and prognosis of coronary heart disease （CHD） by retrospectively analyzing clinical data on patients with CHD in Shanghai City，to guide the prevention and treatment of CHD.Methods　A retrospective analysis was performed on 756 patients who underwent coronary angiography in the Department of Cardiology of Shanghai Ruijin Hospital，Shanghai Jiaotong University School of Medicine in 2009.There were 576 patients who were diagnosed with CHD by coronary angiography.Those patients were placed into a CHD group，and the other 180 patients without CHD were placed into a non-CHD group.General patient data were collected，and the CHD patients were followed up for 7 years by telephone or through re-hospitalization.The endpoint events were major adverse cardiac event （MACE）.Results　Logistic regression analysis showed that sex 〔OR=1.972，95%CI（1.240，3.138）〕，age 〔OR=1.371，95%CI（1.115，1.686）〕，smoking 〔OR=1.923，95%CI（1.168，3.165）〕，serum ereatinine （Scr）〔OR=1.138，95%CI（1.021，1.269）〕，total cholesterol （TC）〔OR=1.238，95%CI（1.016，1.509）〕，high-density lipoprotein cholesterol （HDL-C）〔OR=0.448，95%CI（0.239，0.842）〕were factors influencing the incidence of CHD （P<0.05）．The average follow-up time was （63.3±26.4） months．MACE occurred in 224 cases （38.9%）．Cox regression analysis showed that age 〔HR=1.197，95%CI（1.003，1.428）〕，diabetes 〔HR=1.824，95%CI（1.370，2.429）〕，diastolic pressure （DBP）〔HR=1.145，95%CI（1.000，1.312）〕，estimated glomerular filtration rate （eGFR）〔HR=0.903，95%CI（0.825，0.987）〕，use of anti-platelet drugs 〔HR=0.713，95%CI（0.532，0.956）〕，myocardial infarction 〔HR=1.401，95%CI（1.046，1.877）〕 were the factors influencing the occurrence of MACE in the CHD patients （P<0.05）．Conclusion　The development and prognosis of CHD are associated with multiple risk factors.Male sex，old age，history of smoking，elevated Scr and TC are risk factors for CHD；HDL-C may thus be a protective factor that reduces the risk of CHD.Patients with advanced age，high DBP，and a history of diabetes and myocardial infarction have a significantly higher risk for long-term MACE events.High eGFR and long-term administration of standard antiplatelet therapy significantly improved patient outcomes.

Effects of Antegrade Accessory Pathway Conduction on Terminal QRS Vectors among Pre-excitation Syndrome Patients　

LIU Ye，LIU Renguang，CHEN Qi，ZHANG Yingjie，XU Zhaolong，WANG Gaopin

2018, 21(29): 3571-3576. DOI: 10.12114/j.issn.1007-9572.2018.00.228

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Background　Pre-excitation syndrome affects terminal QRS vectors，which has not achieved enough attention.Objective　To discuss the effect of antegrade accessory pathway （AP） conduction on terminal QRS vectors，the relationship of changes in terminal QRS vectors with AP location and clinical significance among pre-excitation syndrome patients.Methods　From the First Affiliated Hospital of Jinzhou Medical University between January 2008 and December 2012，we enrolled 158 cases of preexcitation syndrome with an AP with antegrade conduction cured by radiofrequency catheter ablation （RFCA），including 150 with a manifest AP （manifest group） and 8 with a concealed AP（concealed group） detected by preoperative electrocardiogram （ECG）．We analyzed the manifest group in terms of the features of ECG before and after RFCA，effect of antegrade AP conduction on terminal QRS vectors，relationship of changes in terminal QRS vectors with AP location and the delta wave，and the concealed group in respect of the features of ECG before and after RFCA，ECG features of atrioventricular reentrant tachycardia（AVRT），effect of antegrade AP conduction on terminal QRS vectors，and the relationship of target spot V wave with the earliest onset of QRS complex on the intracardiac electrogram （IEGM） if the terminal QRS vectors had changed.Results　In patients with a manifest AP，the prevalence of changes in terminal QRS vectors was 100%，which was associated with the AP location.Moreover，both the trend of terminal QRS vectors changes and delta wave polarity varied by leads of V1，Ⅰ，Ⅱ，Ⅲ，aVL，aVF （P<0.001），indicating that the changes of the two were almost the same in different leads.Correlation analysis revealed that there were strong correlations between the trend of terminal QRS vectors changes and delta wave polarity in leads V1，Ⅰ，Ⅲ，and aVL （rs=0.812，0.701，0.771，0.762，P<0.05） and there were moderate correlations between them in leads Ⅱ and aVF（rs=0.569，0.647，P<0.05）．Two patients with a concealed AP were found with changes in terminal QRS vectors，and the target spot V wave via AP on IEGM appeared almost simultaneously with the earliest onset of QRS complex via AV node on the ECG.Conclusion　Both the initial and terminal QRS vectors can be changed by the antegrade conduction of AP in pre-excitation syndrome patients The appearance of delta wave indicates that the conduction via AP is faster than via AV node.The change of terminal QRS vectors is a sign of conduction to ventricle via AP，which is valuable for the diagnosis of atypical pre-excitation including unconspicuous delta wave and incomplete concealed pre-excitation syndrome.

Service Life and Risk Factors of Autogenous Arteriovenous Fistulas for Maintenance Hemodialysis　

WANG Bo，WEI Fang，SUN Guijiang，CHEN Haiyan，LU Zhi，JIA Lan，JIANG Aili

2018, 21(29): 3577-3581. DOI: 10.12114/j.issn.1007-9572.2018.00.097

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Objective　To explore the survival time and risk factors of autogenous arteriovenous fistula （AVF） for maintenance hemodialysis. Methods　A cohort study regarding 126 cases who underwent AVF creation in the Second Hospital of Tianjin Medical University for the first time from 2010 to 2011 was conducted. The clinical data of them from the creation of AVF to five years later were obtained from the hemodialysis patients database of the hospital. According to the functional patency of AVF，they were divided into nonfunctional AVF group （n=61） and functional AVF group （n=65）． Kaplan-Meier survival curves and multivariate Cox proportional hazard models were used to determine the service life of AVF and associated factors，respectively. Results　 The rate of AVF survival at 1 year，3 years，5 years after AVF creation for all the participants was 92.1%，69.8%，51.6%，respectively. The prevalence of diabetes，incidence of intradialytic hypotension （IDH） and mean serum phosphorus level differed significantly between the functional and nonfunctional AVF groups （P<0.05）． Multivariate Cox proportional hazard regression analysis showed that diabetes 〔HR=2.187，95%CI（1.303，3.670）〕，IDH 〔HR=1.703，95%CI（1.004，2.888）〕 and hyperphosphatemia 〔HR=1.893，95%CI（1.295，2.766）〕were risk factors for the service life of AVF （P<0.05）． Conclusion　 The service life of AVF among maintenance hemodialysis patients is short，and the risk factors associated with it included diabetes，IDH and hyperphosphatemia.

Changes in Insulin Resistance，Islet β-cell Function and Blood Glucose in Non-diabetic Patients with Chronic Kidney Disease　

ZHANG Yin，ZHOU Yilun，FENG Yiduo，DING Xia，WANG Dongxue，ZHANG Changqin，WU Yu，GONG Yong

2018, 21(29): 3582-3585. DOI: 10.3969/j.issn.1007-9572.2018.00.239

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Objective　To investigate changes in insulin resistance，islet β-cell function and blood glucose with decline in estimated glomerular filtration rate （eGFR） in non-diabetic patients with chronic kidney disease （CKD）.Methods　In this study，68 hospitalized non-diabetic CKD patients in the Department of Nephrology of Beijing Tiantan Hospital，Capital Medical University were recruited between January and July in 2017.The patients were divided into three groups according to their eGFR：eGFR <60 ml?min-1?（1.73 m2）-1 as group A （n=21），60 ml?min-1?（1.73 m2）-1≤eGFR <90 ml?min-1?（1.73 m2）-1 as group B （n=20），and eGFR ≥90 ml?min-1?（1.73 m2）-1 as group C （n=27）.A 75 g oral glucose tolerance test （OGTT） was performed to detect blood glucose （G0 and G120） and insulin （I0 and I120） levels fasting and 2 hours after sugar consumption.The insulin sensitivity index （ISI） and islet β-cell function index were calculated.Results　There were no significant differences in G0 and G120 levels among the three groups （P>0.05）.The ISI and islet β-cell function index in the three groups were statistically significant （P<0.05）.In group C，the ISI was higher than that in either group A or B.The islet β-cell function index in group C was lower than that in group A （P<0.05）.Pearson correlation analysis showed that eGFR was positively correlated with ISI （r=0.501，P<0.001）.There was a negative correlation between eGFR and the islet β-cell function index （r=-0.288，P=0.017）.There was no linear correlation between eGFR and G0 or G120 （r=0.006，P=0.962；r=-0.131，P=0.287）.Conclusion　In the non-diabetic CKD patients，insulin resistance worsened as eGFR decreased.Simultaneously β-cell function is well compensated thereby maintaining OGTT G0 and G120 levels when eGFR declined.

Clinical Study on MicroRNA Expression of Plasma and Tissues in Patients with Colorectal Cancer　

QU Xiao，PAN Cheng，YAN Xuebing，QIN Huanlong

2018, 21(29): 3586-3589. DOI: 10.12114/j.issn.1007-9572.2018.00.153

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Objective　To investigate the plasma microRNA（miRNA） expression changes in preoperative and postoperative patients with colorectal cancer（CRC），and the correlation between preoperative plasma and cancerous tissues.Methods　This study selected 32 patients with CRC who attended Department of Gastrointestinal Surgery at Shanghai Tenth People's Hospital of Tongji University from June 2014 to August 2016，and 33 healthy people were enrolled during the same period.Peripheral venous plasma of CRC patients was collected before and after surgery，as well as healthy people，and cancerous tissues and paracancerous tissues collected in CRC patients.Quantitative real-time polymerase chain reaction （qRT-PCR） was used to detect the expression of miR-21，miR-17，miR-145，miR-15b，miR-150 in plasma，cancerous tissues and paracancerous tissues.Results　Compared to healthy people，the expression of miR-21，miR-17，miR-145 and miR-15b in CRC patients were significantly higher（P<0.05）．Also，we found that the expression of miR-21，miR-17，and miR-15b decreased in postoperative plasma compared with preoperative plasma（P<0.05）；the expression of miR-21，miR-17，miR-145 and miR-15b were significantly higher in cancerous tissues than in paracancerous tissues （P<0.05），while the expression of miR-150 was lower（P<0.05）．Correlation analysis showed that there was a positive correlation between cancerous tissues and plasma of miR-21 （r=0.516，P=0.002） and miR-15b （r=0.526，P=0.001）．Conclusion　The expression levels of miR-21，miR-17，miR-145 and miR-15b are obviously imbalanced in plasma and cancerous tissues of patients with CRC.Moreover，plasma miR-21 and miR-15b are expected to be the new non-invasive markers for CRC diagnosis.

Effects of Maimendong Decoction on the Expression Levels of TGF-β1，MMP-9 and TIMP-1 in Lung Tissue of a Rat Model of Bleomycin-induced Pulmonary Fibrosis　

LIU Rui，HE Jia，LIANG Ziyang，LIU Xiufang，HOU Tibao，WU Juanjuan

2018, 21(29): 3590-3596. DOI: 10.12114/j.issn.1007-9572.2018.00.103

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Objective　To investigate the influence of maimendong decoction（MD） on the expression levels of TGF-β1，MMP-9 and TIMP-1 and pathological changes in lung tissue of a rat model of bleomycin-induced pulmonary fibrosis．Methods　This study was implemented from November 2016 to October 2017.80 male SD rats were equally randomized into the control group，model group，MD group，and prednisone group by random number table，with 20 in each.The control group received intragastric administration of distilled water 1.1 ml/100 g，and the latter three groups received intragastric administration of distilled water（1.1 ml/100 g），MD（1.1 g?ml-1?100 g-1），prednisone（5 mg/kg），once daily，respectively at 24 h after modeling pulmonary fibrosis with bleomycin.On the 7th and 14th days of intervention，half rats of each group were sacrificed for collecting lung tissue for detecting the severity of pulmonary alveolitis and the degree of pulmonary fibrosis using HE and Masson staining，and for determining the expression levels of TGF-β1，MMP-9 and TIMP-1 with immunohistochemical staining．Results　The MD group showed swelled epithelial cells in bronchioles and degenerative vacuoles in lung parenchyma and mild to moderate alveolitis on the 7th day of intervention，and presented aggravated alveolitis and pulmonary fibrosis on the 14th day of intervention.The model group demonstrated disorganized lung tissue，with massive deposition of deep blue mature collagen fibers around the small vessels，thickened alveolar septum and wall，and thickened collagen fibers in lung interstitium，which were more notable on the 14th day of intervention.Between the 7th and 14th days of intervention，the collagen fibers accumulated faster in the model group than in the MD group and prednisone group.On the 7th and 14th days of intervention，the pulmonary inflammation integral and degree of fibrosis in the MD group were milder than those of the model group（P<0.05）．The expression levels of TGF-β1，MMP-9 and TIMP-1 in the MD group were lower than those of the model group（P<0.05），but did not differ greatly from those of the prednisone group（P>0.05）．Conclusion　MD showed significant effects on alleviating the degree of bleomycin-induced pulmonary alveolitis and fibrosis，which may be related to the improvement of abnormal metabolism of extracellular matrix by inhibiting the expression levels of TGF-β1，MMP-9 and TIMP-1 in lung parenchyma.

Efficacy of ACEI or ARB in the Treatment of Non-alcoholic Fatty Liver Disease：a Meta Analysis　

LI Jinzhong，CHEN Ning，WANG Dan，GONG Xiaobing

2018, 21(29): 3597-3603. DOI: 10.3969/j.issn.1007-9572.2018.00.248

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Background　Non-alcoholic fatty liver disease （NAFLD） is the main cause of chronic liver disease in many regions of the world，and some cases gradually develop into liver cirrhosis and liver cancer.However，there are currently no consensus guidelines for drug therapy for NAFLD. In recent years，the drugs angiotensin-converting enzyme inhibitor （ACEI） and angiotensinⅡ receptor blocker （ARB） have been focused on for prevention and treatment of NAFLD.Objective　A meta-analysis was conducted to analyze the efficacy and safety of ACEI or ARB drugs in the treatment of NAFLD.Methods　We searched multiple databases including the Cochrane Clinical Controlled Trial Registration Database，EMBase，Medline，the China Biomedical Literature Database，CNKI，the Weipu Network and the Wanfang Database to retrieve literature in which RCT of ACEI/ARB in the treatment of NAFLD. The studies were published between 1978 and 2017. RevMan 5.3 was used for statistical analyses.The investigated indicators included liver pathology and laboratory tests〔alanine aminotransferase（ALT），aspartate aminotransferase （AST），serum total cholesterol （TC），triglyceride （TG） and low-density lipoprotein （LDL）〕．Results　A total of 8 articles that met the criteria and a total of 646 patients were included. Meta-analysis showed that the rate of improvement in liver histology between the experimental group and the control group was statistically significant〔OR=5.52，95%CI（1.78，17.06），P=0.003〕.The difference was not statistically significant in the levels of ALT and AST between the two groups 〔WMD= -6.90，95%CI （-15.68，1.88），P = 0.12；WMD = -3.96，95%CI（-8.64，0.72），P=0.10〕.There were no significant differences in the levels of TC，TG and LDL between the two groups〔WMD=-8.10，95%CI（-21.00，4.80），P=0.22；WMD=-15.36，95%CI（-46.38，15.66），P=0.33；WMD=-2.54，95%CI（-12.58，7.49），P=0.62〕.Conclusion　ACEI/ARB can improve liver histology and liver function in patients with NAFLD.However，there are few large-sample，high-quality RCTs investigating the treatment of NAFLD with ACEI or ARB. More high-quality RCTs are still needed for supplementation and evaluation of the efficacy of these drugs for NAFLD treatment.

Efficacy，Problems and Current Status of Two-way Referral from 1997 to 2017 in China：a Systematic Review　

SHEN Ying，HUANG Weiran，JI Shuyu，YU Jia，LI Mujun

2018, 21(29): 3604-3610. DOI: 10.12114/j.issn.1007-9572.2018.00.033

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Objective　This study aimed to understand the history and efficacy of the two-way referral in China from 1997 to 2017，as well as its current status，to analyze existing problems，and to propose suggestions for further improvement of the system.Methods　This study was conducted from May 2017 to January 2018.Systematic review was used，and multiple key words and key words combinations such as “two-way referral and current situation”“two-way referral and efficacy” and “two-way referral and problems” were used to search the Wanfang Data Knowledge Service Platform，the China Science and Technology Journal Database，CNKI，Baidu Scholar，and Google Scholar，as well as national and provincial health administrative websites.Chinese literature on the current status，efficacy and problems in the two-way referral was retrieved.Results　A total of 232 studies were included and further analyzed.The two-way referral in China has developed rapidly.The number of referred patients and the utility of primary health service have been steadily increasing for years.However，the quality of the two-way referral still had some problems，for example，upward-referred patients were much more numerous than downward-referred patients，referral standards and the accompanying insurance policies were insufficient，incentives and regulatory mechanisms were incomplete，and the competence of primary health care personnel needed improvement.Conclusion　More improvements are necessary in further development of the two-way referral，including adoption of more supportive policies，establishment of an appropriate incentive system and a utility system for the primary health workforce，improvement in the competence of primary health care personnel，and balancing the interests of all-level health institutes.

Analysis of the Impact of Bereavement on Health Outcomes and Associated Factors　

YE Ying，YANG Ke，FU Jing

2018, 21(29): 3611-3615. DOI: 10.3969/j.issn.1007-9572.2018.00.244

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Objective　To investigate the status and associated factors for health outcomes among the bereaved individuals，proving a theoretical reference for offering help for the bereaved.Methods　From November 2015 to June 2016，by convenience sampling combined with snowball sampling，we enrolled the bereaved individuals.We used a self-developed Sociodemographic Data Questionnaire and Chinese version of Impact of Event Scale-Revised （IES-R） to collect the sociodemographic characteristics and health outcomes，respectively.IES-R score was analyzed by sociodemographic characteristics and its associated factors were explored by multiple linear regression analysis.Results　441 of the totaled 500 participants returned responsive questionnaires，giving a response rate of 88.2%.The IES-R score was （33.2±16.9）. Post-traumatic stress disorder （PTSD） was found in 176 cases （39.9%）. The IES-R score varied significantly by age，educational level，marital status，the relationship with the deceased，intensity of feelings toward the deceased，causes of death of the deceased，age of the deceased，and length of period following the death of the deceased （P<0.05）. Multiple linear regression analysis revealed that death of a spouse（β=16.221），intensity of feelings toward the deceased（β=6.503），accident-induced death of the decreased（β=5.311），suicide of the decreased（β=9.776），died of old age（β=-6.435），length of period following the death of the deceased （β=-2.523） were associated factors of IES-R score of the bereaved individuals （P<0.05）. Conclusion　The relationship with the deceased，the emotional level of the deceased，the reason for the death of the deceased，and the time of the death of the deceased will affect the IES-R score of the bereaved.Targeted interventions can be developed based on the relationship between the bereaved and the deceased，and the conditions of the bereaved.

Research Progress in the Design of Rapid Rehabilitation Nursing Route for Artificial Hip Joint Replacement of the Perioperative Period　

YANG Hong，SHUANG Feng，TAN Jie

2018, 21(29): 3622-3626. DOI: 10.3969/j.issn.1007-9572.2018.00.179

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The therapeutic path of rapid rehabilitation nursing focuses on hospitals as the main treatment site，with patients at the core，and disease treatment as the goal.The concept of rapid rehabilitation nursing was applied during the perioperative period for unilateral hip joint replacement to improve the level of medical work，to optimize the perioperative care program，and to make full use of and further develop limited medical resources.The goals were to minimize the surgical stress response and to reduce the incidence of postoperative complications and readmissions，as well as hospitalization time for patients，and to improve the efficiency and satisfaction.This article reviewed the current implementation methods and steps of this new rapid rehabilitation nursing route to improve the health care service system as well as to create a new platform for the medical environment.

Effects of WeChat Video Follow-up on Home-based Functional Rehabilitation among Patients after Hip Arthroplasty　

JIANG Shangyan，LI Huiping，LI Lunlan，DING Ping，XIE Lunfang

2018, 21(29): 3627-3631. DOI: 10.3969/j.issn.1007-9572.2018.00.106

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Background　Home-based functional rehabilitation is of great significance to patients after hip arthroplasty for improving the prognosis.At present in China，most follow-ups for providing rehabilitation interventions for hip arthroplasty patients are conducted by telephone despite poor effects，and few studies about video follow-up have been carried out.Objective　To explore the effect of WeChat video follow-up on functional recovery，anxiety，compliance behavior and quality of life in patients after hip arthroplasty.Methods　196 patients received first hip arthroplasty in Department of Orthopedics，First Affiliated Hospital of Anhui Medical University from March 2014 to May 2016 were enrolled and divided into control group（102 cases） and experimental group（94 cases） in accordance with the random number table.Both groups received the conventional discharge guidance and telephone follow-ups，the experimental group additionally received WeChat video follow-ups，including the online assessment of hip function recovery status，online face-to-face rehabilitation instruction and demonstration education.Hip function was measured by Harris Hip Score，anxiety status was evaluated by Zung Self-Rating Anxiety Scale（SAS），compliance behavior was assessed by Questionnaire of Compliance with Doctors' Advice，and quality of life was assessed by 36-Item Short Form Health Survey（SF-36） on the day of discharge，and at 1，2 weeks，1，3，6 months after discharge，respectively.Results　Compared with the control group，the experimental group demonstrated much higher Harris Hip score and compliance behavior score at different time periods after discharge，and obviously higher SF-36 total score at 2 weeks，1，3，6 months after discharge，but substantially lower SAS score at 2 weeks，1，3，6 months after discharge（P<0.05）．Conclusion　Interventions given via WeChat video follow-up can improve the quality of life of patients after hip arthroplasty by alleviating the postoperative anxiety，improving the compliance behavior and functional recovery.

Clinical Characteristics of Anti-SSA Antibody Positive Patients　

GUO Yaping，ZHAN Qianli，CUI Jingjing，SONG Wenjie，WANG Yunli，ZHANG Zhiqiang

2018, 21(29): 3632-3635. DOI: 10.12114/j.issn.1007-9572.2018.00.032

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Objective　To explore the early characteristics of autoimmune diseases （AID） by investigating the clinical features of anti-SSA antibodypositive patients，in order to facilitate early detection and diagnosis and reduce misdiagnosis.Methods　We chose 3 143 patients as study subjects，who were treated or received physical examination in the Baoding No.1 Central Hospital between July 2011 and July 2017 and were confirmed to be anti-SSA antibody positive.The clinical symptoms and laboratory test results of the patients were collected and analyzed.Results　 Among the 3 143 anti-SSA antibody-positive subjects，there were 805 males and 2 338 females；the ratio of males to females was 1∶2.90.The incidence of joint swelling and pain，skin lesions，and dry mouth and eyes was higher in female patients than in male patients （P<0.05），and the incidence of lung disease was lower in female patients than in male patients （P<0.05）.Female patients had a higher rate of abnormal results in routine urine tests and a greater increase in erythrocyte sedimentation rate （ESR） than did male patients （P<0.05）.The incidence of elevated liver enzymes was lower in females than in males （P<0.05）.Conclusion　For patients with fatigue，abdominal discomfort，skin lesions，lymphadenopathy，and lung diseases，as well as abnormal laboratory test results including routine blood and urine tests，ESR，and liver enzymes，early testing of autoantibodies should be performed to avoid misdiagnosis and failure of diagnosis，especially in male patients.

Emergency Treatment of Renal Colic during Pregnancy：a Report of 18 Cases　

SUN Min，LIU Liang，NAN Yukui，QI Feibo，SHU Xing，ZHANG Zhiqiang，YAO Lizhong，WEN Bin

2018, 21(29): 3636-3638. DOI: 10.12114/j.issn.1007-9572.2018.00.016

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Renal colic during pregnancy（RCP） seriously affects the health of pregnant women and fetuses.There are no uniform prevention and treatment criteria for RCP.The diagnosis and management of 18 cases of RCP from Urology Department，People's Hospital of Xinjiang Uygur Autonomous Region during December 2011 to December 2017 were studied.All first received conservative drug treatment such as spasm relief，pain relief，anti-inflammation.Then 10 of them were relieved.Eight cases without unsatisfactory response were relieved by procedure later，specifically，6 by Double-J ureteral stenting following ureteroscopy，1 by ureteral lithotripsy with ureteroscopy，and 1 by percutaneous nephrostomy drainage.Seventeen delivered healthy newborns but 1 had stillbirth.Our experience supports that conservative drug treatment and procedures with the minimally invasive endoscopic technique are effective and safe for RCP and personalized treatment can greatly improve the success rate of procedure.

Chromoblastomycosis due to Fonsecaea monophora：a Case Report and Literature Review　

WANG Hongyan，WANG Hongwei

2018, 21(29): 3639-3643. DOI: 10.3969/j.issn.1007-9572.2018.00.194

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Objective　To diagnose a case of chromoblastomycosis（CBM） due to Fonsecaea monophora with a molecular biological method and to observe the patient response to the treatment with itraconazole plus terbinafine.Methods　We retrospectively analyzed the clinical data（including laboratory findings such as fungal culture，results of microscopy，pathological examination，DNA sequencing and antifungal susceptibility testing） of a case of CBM due to Fonsecaea monophora admitted to Department of Dermatology，Guangdong General Hospital at March 22，2015 receiving treatment with oral administration of itraconazole combined with terbinafine with reviewing the relevant studies.Results　A proliferative verrucous leukoplakia（PVL） was observed on the patient's left jaws of death which appeared after a trauma for over 11 years.Fungal culture produced dark brown or olivaceous to black colonies．Cladosporium-type and rhinocladiella-typeconidiogenous cells were observed on slide culture，which morphologically indicated the identification of Fonsecaea monophora.Histopathology of the skin biopsy showed brown sclerenchyma.Molecular identification of the isolated strain by ITS region sequencing confirmed the causative agent to be Fonsecaea monophora.The patient was diagnosed as CBM due to Fonsecaea monophora according to clinical features and laboratory findings．The results of antifungal susceptibility testing indicated that the isolated strain was sensitive to itraconazole and terbinafine.The patient was cured with a 9-month therapy of oral administration of itraconazole （200 mg/d） and terbinafine （250 mg/d）.No recurrence was found showed by a 6-month follow-up.During the treatment，the liver and renal functions were normal.Conclusion　This case of CBM due to Fonsecaea monophora was cured successfully with combination therapy of itraconazole plus terbinafine.

Mechanism of Association between Inflammation and Essential Hypertension in the Elderly　

LIU Fengmin，ZHANG Yanmin

2018, 21(29): 3644-3647. DOI: 10.3969/j.issn.1007-9572.2018.00.202

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Essential hypertension （EH） is a common circulatory system disease that severely threatens human physical and mental health.With the aging of the population，understanding of the pathogenesis of EH continues to improve.Inflammation has attracted much attention in studies of the pathogenesis of EH in the elderly.Structural remodeling of aging blood vessels is the structural basis for the increase in blood pressure with age.Inflammation-mediated blood vessel damage，which leads to changes in vascular function，is the pathological basis for the elevation in blood pressure occurring with age.The inflammatory response is involved in the pathogenesis and development of EH in the elderly.This article summarizes new discoveries in EH etiology，analyzes the associations among inflammation and EH in the elderly，and provides theoretical support for the prevention，treatment and control of EH in the elderly.

Clinical Development and Outcome of Hepatitis E Virus Infection in Immunocompromised Patients　

YANG Hongying，HUANG Wenxiang，JIA Bei

2018, 21(29): 3648-3653. DOI: 10.3969/j.issn.1007-9572.2018.00.233

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The clinical progress and outcome of hepatitis E virus（HEV） infected patients with immune insufficiency is an emerging issue in recent years.In patients with normal immune function，HEV infection usually manifests as acute self-limiting hepatitis.However，in solid organ transplant patients，HEV infection was susceptible to switch to chronic and could even rapidly develop into significant hepatic fibrosis and cirrhosis.Compared to the kidney transplant recipients with HEV infection，liver transplant recipients with HEV infection might be more likely to develop into chronic hepatitis，hepatic fibrosis，and cirrhosis.HEV infection was also easy to become chronic in patients with human immunodeficiency virus（HIV） infection and hematological malignancy，but further research is needed on whether infection or exposure of HEV can promote its to the progress of hepatic fibrosis or cirrhosis. The solid organ transplant recipients might be more likely to be infected by HEV than HIV infected patients and hematological malignancy patients，however，all of them with HEV infection had high risk of chronic infection development.In the immunocompromised patients，HEV infection requires early detection，early diagnosis and early treatment，and its diagnosis mainly dependents on the detection of HEV-RNA in serum or faeces.The detected HEV genotypes in chronic HEV infection patients are genotype HEV3 at present.

Interactions among Pain，Psychological Distress and Malnutrition in Cancer Patients　

LUO Di，ZHANG Xue，DENG Yaotiao

2018, 21(29): 3654-3658. DOI: 10.12114/j.issn.1007-9572.2018.00.007

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Cancer is a disease that has the highest morbidity and mortality.Cancer associated symptoms such as pain，psychological distress and malnutrition severely affect the quality of life of cancer patients.The interactions among the above three symptoms have not been comprehensively studied.In this article，we specifically analyze and discuss the close relationship and mechanisms of interaction among the three symptoms，from a perspective of clinical and molecular biology.

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