Chinese General Practice

New Progress in Diagnosis and Treatment of Eating Disorders and Its Enlightenment to General Practitioners

CHEN Jue

2019, 22(8): 873-881. DOI: 10.12114/j.issn.1007-9572.2019.00.047

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The number of patients with eating disorders is increasing nowadays China. It influences more and more adolescents and young women in psychosomatic health. This review focuses on the domestic and overseas new progress of concepts and classification， epidemiology， diagnosis， prognosis， influential factors and treatment from the professional point-of-view in eating disorders. Finally it gives some suggestions to general practitioners， providing guidance of diagnosis and treatment for eating disorders in China.

Difficulties and Solutions for Hierarchical Diagnosis and Treatment of Elderly Patients with Chronic Pain in Community Hospitals

FU Lei，WANG Lin，LI Bin，WANG Qiaorong

2019, 22(8): 882-887. DOI: 10.12114/j.issn.1007-9572.2018.00.389

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In China，elderly people with chronic pain have a high demand of receiving healthcare from nearby medical facilities，but in community hospitals，the number of such patients is inadequate，although the implementation of the hierarchical medical system is ongoing vigorously.In this paper，we discussed the paradox.Moreover，we detailedly analyzed the reasons for the unsatisfactory development of pain medicine in community hospitals，such as insufficient treatment devices，lack of pain management professionals，difficulties for bi-directional referrals，inefficient community-based pain management，and insufficient incentives for community care development in medical insurance programs.In addition，suggestions based on the policies of the healthcare reform were put forward，for promoting the effective delivery of services for elderly people with chronic pain in community hospitals.

Recent Advances on Long-term Secondary Prevention and Risk Factors Control for ST-segment Elevation Myocardial Infarction Based on the Latest Evidence

LIANG Feng，HU Dayi，FANG Quan，SHEN Zhujun

2019, 22(8): 888-900. DOI: 10.12114/j.issn.1007-9572.2019.00.029

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In patients with ST-segment elevation myocardial infarction（STEMI），the key management is fast reperfusion therapy in the acute setting；after successful reperfusion，all patients are considered to be at sufficiently high risk to merit interventions for secondary prevention and risk factors based on the latest domestic and foreign evidence.Long-term management for STEMI includes noninvasive testing for ischemia，assessment of left ventricular function and risk for sudden cardiac death （SCD），cessation of smoking，exercise-based cardiac rehabilitation，diet advice and weight control，optimal blood pressure control，hyperglycemic management，lipid-lowering therapy，long-term antithrombotic therapy，beta-blockers，angiotensin-converting enzyme inhibitors（ACEI） and angiotensin Ⅱ receptor blockers（ARB），mineralocorticoid receptor antagonist （MRA） therapy，improvement of evidence-based treatment compliance，and system of care to promote care coordination.

Systematic Review of Guidelines on the Management of Refractory Gastroesophageal Reflux Disease

XIE Sheng，LI Jianfeng，LI Juan，CHEN Guangwen，LIU Lijian，LIU Yuanyuan，YANG Chengning，HUANG Xiaoyan，XIE Jieru，DAI Wenjie，CHEN Mingbing

2019, 22(8): 901-908. DOI: 10.12114/j.issn.1007-9572.2018.00.397

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Background　Currently，the incidence of refractory gastroesophageal reflux disease is increasing year by year. However，there has not been a unified consensus on the diagnosis and treatment of refractory gastroesophageal reflux disease，which makes the management of patients with refractory gastroesophageal reflux disease in clinical practice complicated，and the applicability of different guidelines for Chinese patients remains to be clarified.Objective　To systematically review the methodological quality of guidelines on the management of refractory gastroesophageal reflux disease （RGERD），so as to provide a reference for clinical use.Methods　Guidelines concerning refractory gastroesophageal reflux disease were electronically retrieved in PubMed，EMBase，Guidelines International Network（GIN），National Guideline Clearinghouse（NGC），National Institute for Health and Care Excellence（NICE），American Gastroenterology Association（AGA） and World Health Organization （WHO） website，CNKI，Wanfang Data，VIP，and Medlive from January 2004 to January 2018.Two researchers independently screened literatures and extracted data according to inclusion and exclusion criteria.AGREE Ⅱ system was used to evaluate the evidence quality and recommendation level of the RGERD guidelines.The AGREE Ⅱ evaluation system included scope and purpose，participants，rigor，clarity，application and editorial independence.Intra-group correlation coefficient （ICC） was used to test consistency among evaluators.Results　Five guidelines concerning RGERD were included，with publishing time ranging from 2009 to 2016.Among 5 guidelines，2 guidelines were made by USA，1 by China，1 by Japan and 1 by Asia-Pacific region.The scores of guidelines，according to the evaluation of AGREE Ⅱ，were “scope and purpose” of 88.33%，“clarity” of 86.66%，“rigor” of 72.08%，“participants” of 69.99%，“application” of 68.33%，and “editorial independence” of 20.00%.Five guidelines were Level B.The recommendations of different guidelines were fairly the same.Conclusion　The guidelines on RGERD should be improved in the aspect of “editorial independence” in the future.There is no independent guideline for RGERD in China，but only expert consensus which also needs to be further improved.It's also urgent to develop evidence-based guidelines in line withour national situation，in order to provide better implementation in clinical practice.

Inflammatory Cytokines and Clinical Effects of Folic Acid and Vitamin B12 in Treatment of First-episode Schizophrenic Patients

SU Zou，DING Ying，CHEN Tingting，XU Yan，WANG Chengqiang

2019, 22(8): 909-914. DOI: 10.12114/j.issn.1007-9572.2018.00.297

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Background　Inflammation is closely related to schizophrenia.Anti-inflammatory drugs have a good effect on improving schizophrenia.Folic acid has obvious anti-inflammatory effects，and the body's lack of folic acid and vitamin B12 （VitB12） are closely related to the occurrence of schizophrenia．Objective　To investigate the effect of folic acid and VitB12 in treatment of first-episode schizophrenic patients on serum inflammatory cytokines （IL-1β，IL-6 and TNF-α），nerve growth factor （NGF），brain-derived neurotrophic factor（BDNF），folic acid，VitB12，homocysteine （Hcy），scores of positive and negative syndrome scale （PANSS） and clinical effect．Methods　A total of 200 patients with first-episode schizophrenia who received routine treatment in Wuhan Second Mental Hospital from 2016 to 2017 were selected and divided into control group （100 cases） and intervention group （100 cases）．All 200 first-episode schizophrenic patients were randomized to receive 16-week treatment of risperidone with either 2 mg of folic acid and 400 μg of VitB12 capsule （intervention group，n=100） or placebo （control group，n=100）．Serum levels of IL-1β，IL-6，TNF-α，NGF，BDNF，folic acid，VitB12 and Hcy were measured by enzyme-linked immunosorbent assay （ELISA）．The PANSS was used to assess the change of clinical psychiatric symptoms，the adverse effects and the clinical effect were recorded.Results　Before treatment，no significant differences were noted in the levels of serum IL-1β，IL-6，TNF-α，NGF，BDNF，folic acid，VitB12 and Hcy between two groups（P>0.05）.After 16 weeks treatment of folic acid and VitB12，the levels of serum IL-1β，TNF-α and Hcy in intervention group reduced and were significantly lower than those in the control group，and the levels of NGF，BDNF，folic acid and VitB12 increased and were higher than those in the control group （P<0.05）．However，there was no significant difference in total PANSS score，positive symptom score，negative symptom score and general pathological score between two groups before treatment （P>0.05）．After treatment，there was no significant difference in PANSS positive symptom score between two groups （P>0.05）；total PANSS score，negative symptom score and general pathological score in intervention group were lower than those in control group （P<0.05）．The total score of PANSS，positive symptom score，negative symptom score and general pathological score after treatment in control group and intervention group were lower than those before treatment （P<0.05）．There were 10 cases of marked effect，41 cases of effective and 19 cases of ineffective in the control group，56 cases of marked effect，35 cases of effective and 9 cases of ineffective in the intervention group，and the clinical effect of the intervention group was better than that of the control group （u=2.540，P=0.011）.There was no significant difference in the incidence of adverse reactions between two groups （P>0.05）．Conclusion　Folic acid combined with VitB12 intervention can effectively reduce levels of inflammatory factors and Hcy in patients with first-episode schizophrenia，which can also increase the serum NGF and BDNF levels to improve patients' PANSS score and participate in the adjuvant treatment of first-episode schizophrenia.

Clinical Study of Immune Functions in Patients with Primary Liver Cancer Complicated with Diabetes

WANG Huming，XU Jie，ZHOU Ning，LIU Xianfeng

2019, 22(8): 915-919. DOI: 10.12114/j.issn.1007-9572.2018.00.311

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Background　Liver cancer is one of the most common malignant tumors in clinic. The prognosis of liver cancer patients with diabetes mellitus is poor. Diabetes mellitus is associated with primary liver cancer （PLC），but whether diabetes mellitus increases the risk of PLC and becomes an independent risk factor for PLC is still unclear. Objective　To investigate the immune functions in patients with PLC complicated with diabetes. Methods　From 2016 to 2017，40 PLC inpatients （PLC group） from Department of General Surgery and Department of GI，Baotou Cancer Hospital were enrolled in this study. They were matched with a diabetes group，and a PLC with diabetes group at a ratio of 1︰1. All of them measured CD3＋，CD4＋，and CD8＋ cell counts，carbohydrate antigen 199 （CA199），carcinoembryonic antigen （CEA），a-feto-protein （AFP） and α-L-fucosidase （AFU） on admission or during receiving outpatient treatment，and CD4＋/CD8＋ ratio was calculated. Results　Three groups had significantly different prevalence rates of positive CD3＋ and CD8＋ cells，and abnormal CD4＋/CD8＋ ratio （P<0.05） . Pairwise comparisons showed that，compared with PLC with diabetes group，the prevalence rates of positive CD3＋ and CD8＋ cells were lower in diabetes group and PLC group （P<0.05），and abnormal CD4＋/CD8＋ ratio was lower in diabetes group（P<0.05）. The prevalence rate of positive CD8＋ cells differed significantly in PLC with diabetes patients by PLC stage （P<0.05）. In particular，it was lower in those with advanced-stage PLC than in those with early-stage or intermediate-stage of PLC （P<0.05）. Three groups showed obviously different mean levels of CA199，CEA and AFU （P<0.05）. Diabetes group demonstrated lower mean levels of CA199，CEA and AFU compared with other two groups （P<0.05）. The mean levels of CA199，CEA，AFP and AFU in both PLC group and PLC with diabetes group did not differ obviously by PLC stage （P>0.05）. Conclusion　PLC with diabetes patients showed decreased positive CD3＋ and CD8＋ cells，increased CD4＋/CD8＋，CA199，CEA and AFU，indicating that they had declined immune functions.

Correlation between Homocysteine and Different Types of Coronary Heart Disease

LIU Xianghong，SHI Zhiyun，LIU Huiling，WANG Lixin

2019, 22(8): 920-924. DOI: 10.12114/j.issn.1007-9572.2018.00.294

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Background　The latest study found that homocysteine （Hcy） is a newly discovered risk factor of atherosclerosis and is closely related to the occurrence of cardiovascular disease．Objective　To investigate the correlation between serum Hcy and different types of coronary heart disease （CHD）．Methods　A total of 1 303 patients with CHD admitted to General Hospital of Ningxia Medical University were retrospectively analyzed from 2015 to 2017，which included 311 cases of ST-elevation myocardial infarction （STEMI），254 cases of non ST-elevation myocardial infarction （NSTEMI），503 cases of unstable angina pectoris （UAP），235 cases of stable angina pectoris （SAP） and 242 cases of control group.General information and laboratory indexes of each group were compared，and Pearson linear correlation analysis was used to analyze the correlation between Hcy level and other laboratory indexes.Results　There were significant differences in sex，age，smoking history，hypertension and diabetes detection rate，Hcy，triglyceride （TG），total cholesterol （TC），high-density lipoprotein cholesterol （HDL-C），low-density lipoprotein cholesterol （LDL-C），lipoprotein（a）〔Lp（a）〕，glycosylated hemoglobin （HbA1c），C-reactive protein （CRP）（P<0.05）；Pearson linear correlation analysis showed that Hcy in STEMI group was positively correlated with HbA1c （P<0.05），Hcy in NSTEMI group positively correlated with TG （P<0.05），Hcy in UAP group negatively correlated with HDL-C （P<0.05） and positively correlated with Lp（a）（P<0.05），and Hcy in SAP group positively correlated with TC （P<0.05）．Conclusion　Hcy is closely related to the severity of CHD and has important clinical diagnostic value.

Effect of HAART on the Progression of Liver Fibrosis in Patients with both HIV and HBV Infection

JIANG Zhongsheng，CHEN Tao，HU Jiaguang，ZHANG Peng，LI Minji

2019, 22(8): 925-930. DOI: 10.12114/j.issn.1007-9572.2018.00.302

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Background　Current studies have confirmed that the risk of hepatic fibrosis in human immunodeficiency virus（HIV）and hepatitis B virus（HBV）co-infected patients is higher than that in HBV-infected patients alone. Anti-HBV therapy can significantly improve hepatic fibrosis in HBV-infected patients. However，whether highly active antiretroviral therapy（HAART）can also improve hepatic fibrosis in HIV and HBV co-infected patients and whether there is difference between different schemes is still uncertain. Objective　To investigate whether HAART can improve liver fibrosis of patients infected with HIV and HBV and whether there is difference between different HAART schemes.Methods　A total of 128 patients with HIV and HBV infection initially treated in Liuzhou General Hospital from 2011 to 2017 were selected in this experiment.Patients were divided into TDF group（n=90） and non-TDF group（n=38）.Subjects in TDF group had not osteoporosis with normal renal insufficient whose treatment scheme included TDF.Non-TDF group members had osteoporosis and/or renal function whose treatment scheme did not include TDF.Gender，age，baseline indexes〔HIVRNA，HBVDNA，CD4 cell count，alanine aminotransferase（ALT），aspartate aminotransferase（AST），platelet count（PLT） and fibrosis-4（FIB-4）〕 and follow-up indexes（FIB-4 of the 3rd，6th，9th，12th，18th，24th，30th，36th，42th and 48th months after treatment） were recorded.The effects of different antiviral schemes and different time points for antiviral treatment on hepatic fibrosis in patients with HIV and HBV infection were compared by generalized estimating equation.Results　Age，AST in TDF group were higher than those in non-TDF group（P<0.05）.At baseline and after 9th，12th months of antiviral treatment，FIB-4 in TDF group was higher than that in non-TDF group（P<0.05）.The comparison results showed that the estimated marginal means of non-TDF group and TDF group were 0.308 3 and 0.435 0，respectively.The difference between both groups had statistical significance（P=0.033）.The results of repeated measures showed that the estimated marginal means of all patients' baseline after the 3rd，6th，9th，12th，18th，24th，30th，36th，42th and 48th month of antiviral treatment were 0.929 4，0.492 7，0.354 0，0.371 9，0.322 8，0.256 1，0.288 1，0.272 3，0.299 6，0.278 8 and 0.222 5，respectively.The time difference had statistical significance（Wald χ2= 35.078，P<0.001）.Conclusion　HAART can improve liver fibrosis of patients infected with HIV and HBV，and TDF scheme is better than non-TDF scheme.

Protective Effects and Mechanism of α-lipoic Acid in Graves' Disease Complicated with Liver Damage

XI Yue，WANG Yuanyuan，CUI Xiuling

2019, 22(8): 931-935. DOI: 10.12114/j.issn.1007-9572.2018.00.277

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Background　Liver damage is common in patients with Graves' disease（GD），and a few of them even have liver failure。The mechanism of GD-induced liver injury remains unclear. Existing studies have found that thyroid hormone can induce oxidative stress in rat liver，and α-lipoic acid（ALA）has the effect of anti-oxidative stress. Objective　To investigate the protective effects and mechanism of ALA in GD complicated with liver damage.Methods　A total of 90 patients who first diagnosed as GD combined with liver damage or had recurrence after one year of initial diagnosis with GD combined with liver damage in the Third Affiliated Hospital of Jinzhou Medical University between May 2015 and December 2016 were selected and divided into three groups：conventional group，hormone group and ALA group，each with 30 cases.Conventional group was given compound diisopropylamine dichloroacetate，silybin capsule combined with methimazole treatment.Hormone group was given methylprednisolone treatment on the basis of treatment in conventional group.ALA group was given ALA treatment on the basis of treatment in conventional group.Alanine aminotransferase （ALT） and aspartate aminotransferase （AST） were detected before treatment and on the 14th and 28th day after treatment；free triiodothyronine （FT3），free thyroxine （FT4），thyroid stimulating hormone （TSH），thyroglobulin antibody （TgAb），thyroid peroxidase antibody （TPOAb），superoxide dismutase （SOD），malondialdehyde （MDA） and total antioxidant capacity （T-AOC） were detected before treatment and on the 28th day after treatment.Results　ALT and AST on the 14th and 28th day of treatment in three groups were lower than those before treatment （P<0.01）．The ALT and AST on the 14th and 28th day of treatment in hormone group and ALA group were lower than those in conventional group （P<0.01）．The ALT and AST of hormone group on the 28th day of treatment were lower than those of ALA group （P<0.01）．TSH level on the 28th day of treatment in three groups were higher than those before treatment，and FT3，FT4，TgAb and TPOAb levels were lower than those before treatment （P<0.01）；TSH level in hormone group and ALA group was higher than that in conventional group on the 28th day，TSH level in ALA group was lower than that in hormone group on the 28th day，FT3，TgAb，TPOAb level in hormone group was lower than that in conventional group and ALA group on the 28th day（P<0.01）．SOD and T-AOC levels on the 28th day of the three groups were higher than those before treatment （P<0.01），and MDA level was lower than that before treatment （P<0.01）．The levels of serum SOD and T-AOC on the 28th day of treatment in hormone group and ALA group were higher than those in conventional group，and MDA was lower than that in conventional group；the levels of SOD and T-AOC on the 28th day of treatment in hormone group were higher than those in ALA group，and MDA level was lower than that in ALA group （P<0.01）．Conclusion　ALA have a protective effect on liver damage by reducing oxidative stress in patients with GD.

Hypoglycemia and Its Influential Factors in Outpatients with Type 2 Diabetes Mellitus

KONG Yuxia，DONG Aimei，ZHENG Jiatang，FEI Xiuwen

2019, 22(8): 936-941. DOI: 10.12114/j.issn.1007-9572.2019.00.034

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Background　Hypoglycemia is a common and easily neglected complication of diabetes mellitus.Mild hypoglycemia reduces the quality of life and treatment compliance of patients，and serious hypoglycemia can induce cardiovascular and cerebrovascular events and even become a threat to life.The risk of hypoglycemia is also an important influential factor in the individualized treatment scheme and the blood glucose control of patients.Objective　To investigate the hypoglycemia and its influential factors of type 2 diabetes mellitus（T2DM） in outpatients in medical institutions at different levels in the same area，with the expectation of finding the hypoglycemia risk population，so as to take measures to reduce the risk.Methods　This study was a cross-sectional study.A questionnaire survey was conducted among T2DM patients in a community general outpatient clinic（the community group） and an endocrine outpatient department（the hospital group） in a tertiary，level A hospital in Beijing from August 2017 to March 2018 by convenient sampling method.The survey included demographic characteristics，diabetes management such as lifestyle，drug use，health education，blood glucose monitoring，the knowledge of blood glucose control targets and the occurrence of hypoglycemia in the last 1 year.Univariate analysis and multivariate Logistic regression analysis were used to analyze the influential factors of hypoglycemia in T2DM patients.Results　A total of 388 questionnaires were sent out，and 380 questionnaires were collected，of which 369 were valid questionnaires，including 180 in the community group and 189 in the hospital group.Of 369 patients，180（48.8%） had hypoglycemia in the last year.The incidence of hypoglycemia in the community group was 58.3%（105/180），which was higher than that in the hospital group（39.7%）（75/189）（χ2=12.836，P<0.001）．Univariate analysis result showed that age≥60 years，BMI<24.0 kg/m2，abdominal circumference <85 cm，course of disease≥10 years，education level below junior high school，exercise，use of insulin，oral insulin secretion agent，poor drug compliance，lack of health education，no self-monitoring of blood glucose，unsatisfactory self-evaluation of blood glucose control，and visits in the community were related to the incidence of hypoglycemia（P<0.05）．The results of multivariate Logistic regression analysis showed that course of disease≥10 years（OR=2.497），exercise（OR=3.028），use of insulin（OR=3.252），oral insulin secretion agent（OR=3.072） were risk factors of hypoglycemia；BMI≥24.0 kg/m2（OR=0.234），good drug compliance（OR=0.280），receiving health education（OR=0.354），self-monitoring of blood glucose（OR=0.505），satisfactory self-evaluation of blood glucose control（OR=0.387），visit in a hospital（OR=0.354） were protective factors of hypoglycemia（P<0.05）．Conclusion　The incidence of hypoglycemia in patients with T2DM is high，and the incidence of hypoglycemia in patients who visited community health centers is higher than those who visited hospitals.We should pay more attention to patients with T2DM who have a long course of disease，low BMI，using insulin or insulin secretion agent and few exercise.Improving drug compliance，strengthening self-monitoring of blood glucose and health education can reduce the risk of hypoglycemia，which could be controllable factors of hypoglycemia.

Molecular Mechanism of H19-mediated miR-let-7 and Its Role in Gestational Diabetes Mellitus

MA Jing，TANG Dan，ZHANG Yan，JING Xiaotao

2019, 22(8): 942-946. DOI: 10.12114/j.issn.1007-9572.2018.00.434

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Background　Gestational diabetes mellitus（GDM） is a gestational complication commonly seen in clinical practice，which seriously threatens the life and health of the mother and the fetus.The analysis of the molecular mechanism of miR-let-7 mediated by H19（an imprinted gene） and its role in the development of GDM can provide a basis for targeted therapy for this disease.Objective　To study the molecular mechanism of H19-mediated miR-let-7 and its role in GDM.Methods　This experiment was conducted from January 2017 to January 2018.The 50 SPF grade experimental mice were purchased from Peking University Health Science Center.After 7 days of free diet，the mice were divided into normal-fat group （20 cases） and high-fat group （30 cases） according to their blood glucose and lipid levels.RT-qPCR was used to analyze the relative mRNA expression levels of H19，let-7，target genes LPL，INSR-β in the liver and IRS-2 in mice of the two groups.At the same time in mice myoblast cell lines，through cell transfection technique，small interfering RNA （siRNA） was transfected for the knockdown of the H19，and antisense strand iLet-7 was transfected for specifically blocking the let-7 to combine with target genes.3 and 6 weeks after transfection，cells were harvested，The relative mRNA expression levels of H19，let-7 and target genes LPL，INSR-β，IRS-2 and INSR were observed at different time points.And the same experimental procedure was carried out in human ovarian teratoma-derived cell line PA-1．Results　The normal-fat group showed significantly lower mRNA expression levels of H19，let-7 and LPL，and much higher mRNA expression levels of INSR-β，IRS-2 and INSR compared with the high-fat group （P<0.05）．The mRNA expression levels of the above-mentioned 6 indicators at baseline，and at the end of 3 weeks and 6 weeks of intervention were all significantly different in mice myoblast cell lines（P<0.05），as did they in human ovarian teratoma-derived cell line PA-1（P<0.05）．Conclusion　H19 mediates the molecular mechanism in miR-let-7 and plays a vital role in the development of GDM.Clinical detection of relevant indicators such as H19 and miR-let-7 in pregnant women should be strengthened in order to identify GDM as early as possible.

Efficacy and Safety of Bushenxiezhuo Therapy versus Allopurinol in the Treatment of Gouty Nephropathy：a Meta-analysis

ZHENG Qiyan，SUN Luying，ZHAO Qing，ZHANG Xiaoxiao，WANG Yahui，JIN Huanan，ZHANG Wen

2019, 22(8): 947-953. DOI: 10.12114/j.issn.1007-9572.2018.00.259

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Background　With the improvement of living standards，the prevalence of gout is increasing.Inappropriate treatment of gout may lead to gouty nephropathy （GN）.In its treatment，western medicine advocates the use of allopurinol，which can reduce the level of serum uric acid，but cannot improve the pathological changes related to gouty nephropathy.In recent years，many physicians have achieved good clinical efficacy in the treatment of gouty nephropathy by Bushenxiezhuo，which means nourishing kidney and discharge waste.However，current studies are mainly based on small samples and there is still no evidence of evidence-based medicine to prove it．Objective　To compare the efficacy and safety between Bushenxiezhuo therapy and allopurinol for GN．Methods　 We searched CNKI，Wanfang Data，VIP，CBM，PubMed，Cochrane Library，EMBase，and printed conference proceedings as well as back issues of magazines collected in Library，Beijing University of Chinese Medicine for studies evaluating the efficacy and safety of Bushenxiezhuo therapy and allopurinol for GN published as of October 2017.Studies screening and data extraction were performed by two researchers separately.Meta-analysis was conducted with RevMan 5.3.The quality of evidence for outcome was evaluated by the GRADE system with GRADEprofiler 3.6.Results　A total of 11 randomized controlled trials were included，involving 721 individuals.Meta-analysis showed that mean serum uric acid levels were similar in both Bushenxiezhuo-treated group and allopurinol-treated group 〔MD=-18.24，95%CI（-51.06，14.58），P=0.28〕；Bushenxiezhuo-treated group demonstrated much lower levels of mean serum creatinine 〔MD=-27.34，95%CI（-43.10，-11.58），P=0.000 7〕，mean blood urea nitrogen 〔MD=-1.68，95%CI（-2.15，-1.21），P<0.000 01〕，mean serum β2-microglobulin（β2-MG）〔MD=-0.81，95%CI（-1.02，-0.59），P<0.000 01〕，and mean 24-hour urine total protein（24 hUTP）〔MD=-0.73，95%CI（-0.80，-0.67），P<0.000 01〕compared with the allopurinol-treated group；the incidence of side effects in Bushenxiezhuo-treated group was significantly lower than that of the allopurinol-treated group 〔OR=0.22，95%CI（0.07，0.67），P=0.008〕；the qualities of 24 hUTP，serum creatinine，serum β2-MG，blood uric acid，serum urea nitrogen for outcome，indicators（side effects） for safety，were moderate，low，low，very low，very low，very low，respectively.Conclusion　 Our analysis found that although both Bushenxiezhuo therapy and allopurinol have similar effects on lowering blood uric acid level of GN patients，the former can better improve the renal function and reduce the urine protein level with higher safety.The qualities of indicators for outcome（24 hUTP，serum creatinine，β2-MG） and for safety need to be further verified by higher quality studies.

Relationship between Sleep Disorders and Vitamin D Deficiency： a Meta-analysis

WANG Chaoya， WANG Liecheng， XU Shengchun

2019, 22(8): 954-959. DOI: 10.12114/j.issn.1007-9572.2018.00.160

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Background　The diagnosis of sleep disorders has been lack of objective indicators and basis. It usually relies on patients ' subjective expression and traditional evaluation scale to diagnose sleep disorders. It is often affected by patients' psychological state and subjective assumptions, which reduces the accuracy of clinical diagnosis. In recent years, many studies have shown that sleep disorders are correlated with vitamin D levels, but some studies have found that there is no relationship between them, and it is necessary to systematically evaluate the correlation between sleep disorders and vitamin D levels. Objective　To explore the correlation between sleep disorders and vitamin D deficiency from the perspective of evidence-based medicine.Methods　From November 2017 to February 2018， we searched CBM， CNKI， Wanfang Data Knowledge Service Platform， VIP， Medline， EMBase， Web of Science， Cochrane Library （Issue 2，2018） until February 2018 to identify articles evaluating the correlation between sleep disorder and vitamin D deficiency.Data extraction and quality assessment were conducted.Results　A total of 15 articles were included， involving a sample of 15 622 individuals.Meta-analysis showed that sleep disorders were associated with vitamin D deficiency〔RR=1.20， 95%CI（1.03，1.39）， P=0.02〕.Subgroup analysis showed the following results： sleep disorders were associated with vitamin D deficiency in the Mongolian and Negroe populations（P<0.05）， but not in the European populations （P>0.05）； sleep disorders were associated with vitamin D deficiency in the Asian population（P<0.05）；two types of sleep disorders， sleep debt and obstructive sleep apnea hypopnea syndrome were associated with vitamin D deficiency（P<0.05）； sleep disorders diagnosed by PSG were associated with vitamin D deficiency （P<0.05）， but those diagnosed by PSQI and ESS were not （P>0.05）； sleep disorders were associated with vitamin D deficiency in the population consisting of both males and females （P<0.05）， but were not in female population （P>0.05）； sleep disorders were found to be associated with vitamin D deficiency measured by immunoassay（P<0.05）．Conclusion　There is a correlation between sleep disorders and vitamin D deficiency， which varies by race，areas，types of sleep disorders，diagnostic methods of sleep disorders，detection methods of vitamin D and other factors.

Epidemiological Characteristics and Prognostic Factors of Inpatients in Emergency Center from 2007 to 2016

BUZUKELA·Abuduaini，YALIKUN·Sailai

2019, 22(8): 960-965. DOI: 10.12114/j.issn.1007-9572.2018.00.352

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Background　There are few epidemiological studies on the disease spectrum，cause of death and discharge prognosis of hospitalized patients in emergency centers.Therefore，it is important to take a large scale epidemiological survey in emergency centers to understand epidemiological feature，which is of great significance for early detection of patients and high-risk groups and comprehensive prevention and control.Objective　To evaluate the epidemiological distribution of inpatients in emergency centers over the ten years，to explore the influencing factors of prognosis，and to provide clinical evidence for improving quality and safety of diagnosis and treatment in emergency centers.Methods　The demographic characteristics and disease status of inpatients in the Emergency Center of the First Affiliated Hospital of Xinjiang Medical University from 2007 to 2016 were retrieved by hospital information system （HIS），including gender，age，allergy history，length of stay，admission department，discharge department，hospitalization expenses，number of re-admissions within 30 days，number of operations，first hospitalization diagnosis，combined disease and prognosis.Multivariate Logistic regression analysis was used to assess factors influencing prognosis of inpatients in emergency center by SPSS 19.0 statistical software.Results　A total of 16 367 inpatients were hospitalized in emergency centers from 2007 to 2016，15 686 （95.84%） survived and 681 （4.16%） died.The number of inpatients in emergency center in 2016 was 45.59% higher than that in 2007.The results of multivariate Logistic regression analysis revealed that the age 〔OR=1.326，95%CI（1.067，1.648）〕，admission department 〔OR=0.668，95%CI（0.564，0.790）〕，discharge department 〔OR=1.608，95%CI（1.309，1.975）〕，hospitalization expenses 〔OR=3.589，95%CI（2.826，4.559）〕，30-day unplanned readmission 〔OR=4.527，95%CI（1.023，5.183）〕，operation frequency 〔OR=3.353，95%CI（2.901，3.877）〕，mental disorder 〔OR=2.988，95%CI（1.047，8.530）〕，heart disease 〔OR=13.146，95%CI（3.647，47.371）〕，hypertension 〔OR=0.518，95%CI（0.258，0.941）〕，recovery period of cerebrovascular accident 〔OR=1.805，95%CI（1.091，2.989）〕，liver disease 〔OR=1.938，95%CI（1.230，3.056）〕，chronic poisoning 〔OR=2.162，95%CI（1.261，3.691）〕，and concomitant diseases 〔OR=2.322，95%CI（1.270，4.250）〕 had regression relationships with the prognosis of inpatients in emergency center （P<0.05）.Conclusion　The number of patients in emergency center is increasing year by year，and the quality and safety of diagnosis and treatment also attract attention.Age，unit of admission and discharge，hospitalization expenses，the number of operation，30-day unplanned readmission，and combined diseases are independent prognostic factors，influencing survival of inpatient in emergency center.Therefore，we should improve emergency mode and intervene preventable factors to improve the quality and safety of inpatient diagnosis and treatment in emergency centers.

Mortality and Years of Life Lost Due to Stroke among Residents in Pudong New Area of Shanghai between 2002 and 2017

CHEN Yichen，SUN Lianghong，LI Xiaopan，CHEN Hanyi，ZHANG Ge，QU Xiaobin，CHEN Hua，ZHOU Yi，LIN Tao，SUN Qiao

2019, 22(8): 966-972. DOI: 10.12114/j.issn.1007-9572.2019.00.002

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Background　Stroke is a disease threatening human health globally.At present，the epidemiological data of stroke mortality among residents in Pudong New Area is absent.Objective　To explore the epidemiological characteristics and the potential years of life lost due to stroke among residents in Pudong New Area of Shanghai from 2002 to 2017，so as to provide a reference for establishing intervention measures.Methods　Records of stroke mortality data of residents in Pudong New Area of Shanghai from 2002 to 2017 were derived from the death surveillance system.Crude mortality among different populations was compared by Z test to Poisson distribution，and standardized mortality was compared by Mantel-Haenszel test.The annual percentage change （APC） of stroke mortality was calculated by Joinpoint 4.0.4.Indicators of life loss included potential years of life loss （PYLL），potential years of life loss rate （PYLLR），average years of life loss （AYLL），standardized potential years of life loss （SPYLL） and standardized potential years of life loss rate （SPYLLR）.The contribution of demographic and non-demographic factors to the change of stroke mortality was assessed by the rate difference decomposition method.Results　The crude mortality and standardized mortality of stroke among residents in Pudong New Area between 2002 and 2017 were 129.85/100 000 and 47.03/100 000，respectively，with 56 180 stroke deaths in total.The crude mortality rate of stroke kept stable （Z=1.362，P=0.195），and the standardized death rate of stroke declined over the years （APC=-3.78%，Z=-14.950，P<0.001）.The crude mortality rate of ischemic stroke increased year by year （APC=3.62%，Z=14.055，P<0.001），and the standardized mortality rate showed a downward trend （APC=-0.74%，Z=4.639，P<0.001）；the crude mortality rate and standardized mortality rate of hemorrhagic stroke decreased year by year （APC=-1.46%，Z=-5.739，P<0.001；APC=-5.43%，Z=-13.409，P<0.001）.The crude mortality rate of stroke in male residents was lower than that in female residents （Z=-5.465，P<0.001），and the standardized death rate was higher than that in female residents （Z=-35.779，P<0.001）.Mortality rates of the children group，the youth group，the middle-aged group，the younger aged group and the older aged group were 0.15/100 000，2.52/100 000，27.86/100 000，248.02/100 000 and 2 019.20/100 000，respectively.The trend analysis of mortality in age groups showed that the mortality of stroke in all age groups showed a downward trend （P<0.001）.PYLL of stroke was 87 302 years，PYLLR was 2.02‰ and AYLL was 1.55 years per person.The mortality rate of stroke in Pudong New Area in 2017 was higher than that in 2002，and demographic factors contributed to the increase of stroke mortality，and non-demographic factors reduced the mortality.Conclusion　The stroke mortality in Pudong New Area keep stable during 2002—2017，which cause heavy burden of disease.As population aging is the major contributor，comprehensive prevention and control measures should be taken.

Recent Advances in Psychological Flexibility of Patients with Chronic Pain　

XIE Chanjuan，XU Xianghua，OU Meijun，LI Juan，CHEN Yongyi

2019, 22(8): 973-977. DOI: 10.12114/j.issn.1007-9572.2018.00.357

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Psychological flexibility is the core of acceptance and commitment therapy （ACT）.This article reviews the origin，concept，theoretical framework，and assessment tools of psychological flexibility，and the impact factors and main interventions for psychological flexibility in chronic pain patients.It is recognized that the future research is to explore the concept of psychological flexibility for Chinese patients and to develop a Chinese version of Psychological Inflexibility in Pain Scale （PIPS）.Furthermore，targeted interventions for such patients with psychological inflexibility need to be formulated on the basis of the results of qualitative interviews regarding mental and emotional experiences.

Prevalence of Kinesiophobia in Patients with Chronic Low Back Pain and Its Influential Factors　

PAN Li, SHI Baoxin

2019, 22(8): 978-982. DOI: 10.12114/j.issn.1007-9572.2019.00.007

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Background　Chronic pain has become one of the most sensitive and most concerned symptoms for patients. Pain can cause fear of functional rehabilitation and daily activities, which in turn affects the quality of life for patients. Objective　To investigate the prevalence of kinesiophobia in patients with chronic low back pain and to explore its influential factors. Methods　This study was a cross-sectional study. A questionnaire survey was conducted among patients with chronic low back pain aged over 18 years in spine surgery clinics and wards of Tianjin Medical University General Hospital and Tianjin Hospital from November 2017 to March 2018. The survey included social demography questionnaire, pain-related data survey, general self-efficacy scale （GSES）, Tampa Scale for Kinesiophobia （TSK）（≥38 scores for kinesiophobia）, social support rating scale （SSRS）, simple chronic pain acceptance questionnaire （CPAQ-8）, hospital anxiety and depression scale （HADS）． Multivariate Logistic regression analysis was performed to analyze factors influencing kinesiophobia. Results　A total of 255 valid questionnaires were collected. The TSK score of patients was （46.2±10.2） points. Among them, 118（46.3%） had more than 38 points and 137（53.7%） had less than 38 points. The GSES score was （2.3±0.5） points, the SSRS score was （30.1±5.8） points, the CPAQ-8 score was 21 （15，29） points, the anxiety score was 9.5 （8.0，11.0） points, and the depression score was 8.0 （6.0，12.0） points. There were significant differences in family monthly income, pain degree, GSES score, SSRS score, CPAQ-8 score, anxiety score and depression score between patients with TSK score <38 and those with TSK score ≥38 points （P<0.05）． The results of multivariate Logistic regression analysis showed that the per capita monthly income level 〔OR=0.371，95%CI（0.185，0.744）〕, average pain degree 〔OR=1.413，95%CI（1.059，1.885）〕, SSRS score〔OR=0.892，95%CI（0.823，0.968）〕, CPAQ-8 score〔OR=0.864，95%CI（0.804，0.928）〕, degree of anxiety 〔OR=1.177，95%CI（1.045，1.275）〕, and degree of depression 〔OR=1.168，95%CI（1.071，1.275）〕 were influential factors of kinesiophobia in patients with chronic low back pain （P<0.05）． Conclusion　The incidence of kinesiophobia in patients with chronic low back pain is high. The degree of kinesiophobia is mainly affected by factors such as monthly income level, social support level, average pain degree, anxiety and depression. Researchers suggest the degree of kinesiophobia should be assessed in the process of treatment and medical workers need to carry out targeted health education and interventions for guiding patients to reduce the degree of kinesiophobia and increase activity participation.

Relationship of Repetitive and Stereotyped Behaviors with Cognitive Flexibility and Inhibitory Control Ability in Children with High-functioning Autism　

YANG Yulu，LI Xue，LIU Jing，WANG Hui，MA Zenghui，JI Zhaozheng，XU Lingzi，TANG Xinzhou，MEI Ting，YANG Liu，WANG Feifei

2019, 22(8): 983-988. DOI: 10.12114/j.issn.1007-9572.2019.00.051

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Background　The repetitive and stereotyped behavior （RSB），one of the core symptoms of autism，is closely associated with the response to rehabilitation therapy and prognosis in children with autism.Foreign studies have found that cognitive flexibility and inhibitory control ability may be correlated with the severity of RSB，while related studies in China are very few.To improve the prognosis of children with autism，it is of great significance to explore highly effective interventions for autism on the basis of active discussion of the pathogenesis of RSB.Objective　To investigate the relationship of RSB with cognitive flexibility and inhibitory control ability in children with high-functioning autism （HFA）．Methods　46 outpatient pediatric patients with HFA（IQ≥70） aged 6-17 years were recruited during October 2014 to October 2016 from Peking University Sixth Hospital.The Trail-Making Test （TMT） and Stroop color-word test were used to assess cognitive flexibility and inhibitory control ability，respectively.The high-functioning Autism Spectrum Screening Questionnaire （ASSQ） was adopted to identify HFA.Aberrant Behavior Checklist （ABC） was employed to assess the autistic behaviors.Spearman correlation and multiple linear regression analyses were performed to examine the correlation between results of ASSQ restricted and repetitive behavior subscale / ABC stereotypic behavior subscale and TMT/ Stroop test.Results　Spearman correlation analysis found that the score of item 9 in ASSQ was positively correlated with the number of errors made in connecting the numbers and letters in part B of TMT （P<0.05）．The score of ASSQ item 10 was negatively correlated with the time used for naming the color of the words in experiment 3 （P<0.05）．The score of ASSQ item 18 was positively correlated with the time used for connecting numbers and letters in part B of TMT，the difference between the time used for completing part A and that for part B in TMT，time used for naming the color of the patches in experiment 2，time used for naming the color of the words in experiment 3，number of errors in naming the color of the words in experiment 4，and color interference time in performing the Stroop test （P<0.05）．The score of item 22 of ASSQ was positively correlated with the number of number-letter connection errors in part B of TMT and the number of errors made in naming the color of the words in experiment 3 during performing the Stroop test （P<0.05）．The score of ASSQ item 23 was negatively correlated with the time used for reading the written color names of the words in experiments 1，time used for naming the color of the patches in experiment 2，time used for naming the color of the words in experiment 4，and the semantic interference time（P<0.05）．The score of ABC item 17 was positively correlated with the number of number-letter connection errors in completing part B of TMT （P<0.05）．The score of ABC item 27 was positively correlated with the number of errors in reading the written color names of the words in experiment 1 and in naming the color of the words in experiment 3 during performing the Stroop test （P<0.05）．The score of ABC item 49 was positively correlated with the number of errors in reading the written color names of the words in experiment 1 and the time of color interference of the Stroop test （P<0.05）．The stereotypic behavior subscale score of ABC was positively correlated with the time used for connecting the numbers and letters in part B of TMT and the number of errors during the process，and the difference between the time used for completing part A and that for part B in TMT （P<0.05）．Multiple linear regression analysis showed that the number of errors in completing part B of TMT was associated with the score of ASSQ restricted and repetitive behavior subscale（β=0.302，β'=0.397，t=2.330，P=0.027）．The color interference time during the Stroop test was associated with the score of ABC stereotypic behavior subscale（β=0.162，β'=0.366，t=2.152，P=0.040）．Conclusion　RSB is associated with cognitive flexibility and inhibitory control ability in children with HFA.The worse the cognitive flexibility is，the more severe RSB becomes.But the relationship between inhibitory control ability and RSB is complex and contradictory.

Effects of HELP on Medication Safety at Home for Family Caregivers with Low-level Health Literacy of Neonate　

LU Qi，NI Qianqian，WANG Liping，ZHOU Lihua，ZHANG Hailing

2019, 22(8): 983-993. DOI: 10.12114/j.issn.1007-9572.2018.00.292

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Background　The health literacy level of the parents with correct drug administration was 6 times that of the parents with wrong drug administration，and 79.2% of the parents of discharged children with medicine have low health literacy level.Low health literacy is a major risk factor for medication errors occurred.Prescription medication errors family events will have serious adverse consequences for children，so there is an urgent need to through the intervention of health literacy of children caregivers，improve children family medication safety level.Objective　To explore the effects of health education and literacy for parents（HELP）on medication safety at home for newborn caregivers with low-level health literacy.Methods　A total of 100 neonatal caregivers with low-level health literacy went to NICU of Anhui Provincial Hospital in 2017 were selected as research subjects by using convenient sampling method，with 50 neonatal caregivers from January to June 2017 as control group and 50 from July to December 2017 as intervention group by time grouping method.The control group received conventional health education and intervention group received 2-week HELP intervention.The content of HELP included medication instruction and log sheets，teach-back method，and provision of a standardized dosing instrument.Chinese version of Newest Vital Sign（NVS），doses of medication，Safe Medicine Knowledge Scale，Morisky Medication Adherence Scale were used before and after intervention to evaluate the level of health literacy，difference of dosage，understanding of medication and medication compliance.Results　Calculating ability，reading comprehension ability and Chinese version of NVS total score of neonatal caregivers in intervention group were higher than those in control group，and the incidence of dosage difference was lower than that in the control group.The basic knowledge of drugs，the characteristics and principles of medication in children，the understanding and treatment of adverse drug reactions，drug compliance，quality identification and storage score and the total score of Safe Medicine Knowledge Scale in intervention group were higher than those in control group（P<0.05）.After intervention，calculating ability，reading comprehension ability and Chinese version of NVS total score of neonatal caregivers in intervention group were higher than those before intervention.In control group and intervention group，the incidence of drug dose difference among newborn caregivers and the quality identification and storage score of control group were lower than those before intervention.The basic knowledge of drugs，the characteristics and principles of medication for children，the understanding and treatment of adverse drug reactions，drug compliance，the quality indentification and storage score and the total score of Safe Medicine Knowledge Scale in intervention group were higher than those before the intervention （P<0.05）．Sixteen cases （32.0%） in intervention group and 6 cases （12.0%） in control group had good drug compliance.The drug compliance in intervention group was better than that in control group（χ2=5.828，P=0.016）．Conclusion　HELP can improve medication security and health literacy level.

Subjective and Objective Assessment of the Therapeutic Effect of Activity-induced Pain after Thoracic Surgery　

ZHOU Lijuan，ZHANG Lan

2019, 22(8): 994-998. DOI: 10.12114/j.issn.1007-9572.2019.00.018

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Background　At present，most of domestic studies about postoperative pain evaluate the pain in general without explaining whether it is rest pain or activity-induced pain.Studies about postoperative activity-induced pain in China are very limited.Recently，it has been widely pointed out in studies at home and abroad that the relief of activity-induced pain can ensure maximal postoperative recovery of physical function.In addition，most of the pain assessment methods used in some studies are only subjective self-evaluation from patients，which is not comprehensive enough.Objective　To subjectively and objectively evaluate the therapeutic effect of postoperative activity-induced pain in patients with thoracic surgery.Methods　We selected 15 patients who underwent video-assisted thoracoscopic surgery under general anesthesia in Department of Thoracic Surgery，the First Affiliated Hospital of Jinzhou Medical University during August to September，2018.All of them received an intraoperative frozen section diagnosis of lung cancer.We adopted four grade Functional Activity Score （FAS） to evaluate the patient's ability to cough effectively within 30 minutes before or after taking flurbiprofen axetil 4 times daily （namely at 10：00，11：30，
16：00，and 17：30） and used Numerical Rating Scale （NRS） to evaluate the intensity of pain during effective coughing，on the 1st day after surgery，the day of extubation，the 1st day after extubation，and the discharge day，respectively.Results　There were no significant differences between the average NRS scores of the patients at 10：00 and 11：30，and between the average NRS scores at 16：00 and 17：30 on the 1st day after surgery，the day of extubation，the 1st day after extubation，and the discharge day（P>0.05）．The average NRS scores of the patients at 10：00，11：30，16：00 and 17：30 were similar on the 1st day after surgery，and they were also similar on the 1st day after extubation，and the discharge day（P>0.05）．The average NRS score of the patients at 10：00，11：30，16：00 and 17：30 on the day of extubation varied notably（P<0.05）．The average NRS score of the patients at 10：00，11：30，16：00 and 17：30 differed significantly on the 1st day after surgery，the day of extubation，the 1st day after extubation，and the discharge day（P<0.05）．Conclusion　The activity-induced pain control for the patients is stable at present.However，the stimulation of the drainage tube is still an obvious factor causing pain for patients.

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