Chinese General Practice

Research Progress on Health Literacy of Stroke　

SUN Huijun，LU Jianping，ZHANG Jie，ZHANG Yaqing

2019, 22(36): 4409-4414. DOI: 10.12114/j.issn.1007-9572.2019.00.248

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Health literacy is an important basis for the health education and behavioral intervention，and it is also one of the hot topics in domestic and overseas researches.This paper summarizes the domestic and overseas researches on health literacy of stroke，involving the definition and connotation of health literacy，the evaluation and monitoring of stroke health literacy，the correlations to disease outcomes，and its influencing factors and related intervention researches in order to provide a reference for in-depth researches on health literacy of stroke in China.According to the research results，there is still no unified definition of health literacy up to now，and its connotation mainly includes public health perspective and clinical perspective.In view of the evaluation tools，universal health literacy evaluation tool is used to evaluate the health literacy level of stroke patients while that is affected by different demographic characteristics，and different levels and forms of health education can effectively enhance health literacy of stroke patients.The research on health literacy of stroke in China is still in its infancy.Therefore，we should refer to related overseas experience to develop health education methods of stroke health literacy and corresponding evaluation tools suitable for the cultural environment of China.

Advances in Risk Assessment of Post-stenting Ischemic and Bleeding Events Caused by Dual Antiplatelet Therapy　

ZHOU Suzhe，PAN Zhigang

2019, 22(36): 4415-4419. DOI: 10.12114/j.issn.1007-9572.2019.00.250

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The number of patients with coronary atherosclerotic heart disease in China is increasing rapidly.As interventional techniques continue to be improved，the application of drug-eluting stent placement in this group is becoming wider.Dual antiplatelet therapy（DAPT） reduces the risk of postoperative stent thrombosis，but increases the risk of bleeding.Related guidelines recommend that doctors develop personalized DAPT regimens，and perform an assessment of the risks of bleeding and ischemic events prior to develop the optimal DAPT regimen for a patient.In recent years，there has been a continuous analysis of the clinical features of patients receiving DAPT after stent implantation，and based on the results，risk assessment tools for ischemic events after stent implantation and bleeding events caused by DAPT have been developed.This article reviews the published high-quality risk assessment tools to provide help for further clinical application and research of such tools.

Interpretation of Multi-disciplinary Consensus Statement Document Vaccinal Prevention in Adult Patients with Diabetes Mellitus　

LI Xu，ZHANG Ziqiang

2019, 22(36): 4420-4423. DOI: 10.12114/j.issn.1007-9572.2019.00.415

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Diabetes is representatively one of the public health problems worldwide.The increasing morbidity and mortality due to chronic complications of diabetes has brought a huge burden to the society，national economy and public medical service.Although there are many guidelines for the management of diabetes，there is no consensus or guidelines for multiple vaccinations for adults with diabetes.In 2018 Italian Society of Hygiene，Preventive Medicine and Public Health，Italian Association of Medical Diabetologists，Italian Federation of General Practitioners，Italian Society of Diabetology and Italian Society of General Medicine & Primary Care jointly issued a multi-disciplinary consensus statement on vaccinations for adult diabetics——Multi-disciplinary Consensus Statement Document Vaccinal Prevention in Adult Patients with Diabetes Mellitus.This consensus statement describes the mechanism of predisposition to infection in adults with diabetes，as well as the significance and frequency of flu vaccination，pneumococcal vaccination，anti-herpes zoster vaccination，meningococcal vaccination，and anti-diphteria-tetanus-pertussis vaccination.It highlights the important role of diabetes-treating physicians and general practitioners in supervising adults with diabetes for vaccination.There are still no corresponding clinical guidelines or consensus in China up to now，but due to the increasing number of patients with diabetes and the heavy burden of health economics，here this paper tries to interpret this consensus statement issued by Italy to provide references for the formulation of vaccination policy and clinical management for infectious diseases of adult diabetics in China.

Relationship between Types of Serum Antibodies Against H.pylori and Gastric Diseases　

HE Yuan，ZHAO Jing，LIN Yong

2019, 22(36): 4424-4428. DOI: 10.12114/j.issn.1007-9572.2019.00.729

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Background　The prevalence of Helicobacter pylori（H.pylori）infection is high in China.But the clinical outcomes differ in the infectors，which may be associated with genetic and environmental factors，as well as the genotype of H.pylori.Objective　To explore the clinical significance of relationship between types of serum antibodies against H.pylori and gastric diseases.Methods　A total of 2 650 patients who underwent gastroscopy and H.pylori serum antibody test in Guangzhou First People's Hospital，Guangzhou Medical University，from January 2009 to December 2017 were enrolled after excluding those with previous H.pylori eradication treatment.Patients were divided into five groups based on gastroscopy and pathological results：chronic non-atrophic gastritis group（1 011 cases），chronic non-atrophic gastritis with erosion group（468 cases），gastric ulcer group（795 cases），chronic atrophic gastritis/dysplasia group（236 cases），and gastric cancer group（140 cases）.No H.pylori eradication therapy was performed in the selected patients.Serum H.pylori-specific antibodies CagA，VacA and Ure were detected by protein array.The associations of H.pylori prevalence and H.pylori types with different gastric diseases were compared among five groups.Results　The prevalence of H.pylori was 74.58%，74.34%，72.14%，71.58% and 64.49% for chronic atrophic gastritis/dysplasia，gastric ulcer，gastric cancer，chronic non-atrophic gastritis with erosion and chronic non-atrophic gastritis groups，respectively，showing a significant intergroup difference（P<0.05）.A total of 1 596 cases of H.pylori typeⅠ strains infection and 259 cases of type Ⅱ strains infection were detected.The prevalence of H.pylori type Ⅰ strains was significantly higher than that of type Ⅱ in all the groups（P<0.05）.The prevalence of H.pylori type Ⅰ differed significantly in each group（χ2=22.586，P<0.01）.The prevalence of H.pylori type Ⅰ strains in gastric ulcer group was higher than that in chronic non-atrophic gastritis/dysplasia group（P<0.005）.Among the 1 596 patients with H.pylori type Ⅰ strains，CagA+VacA antibody accounted for 60.15%（960/1 596），followed by VacA antibody，accounting for 34.27%（547/1 596），and CagA antibody accounted for 5.58%（89/1 596）.The prevalence of CagA+VacA antibody was higher than that of CagA and VacA antibody in each group，the prevalence of VacA antibody was higher than that of CagA antibody（P<0.05）.The prevalence of CagA antibody differed significantly in each group（χ2=19.054，P<0.01），and the gastric ulcer group was higher than the chronic non-atrophic gastritis group（P<0.005）.The prevalence of VacA antibody differed significantly in each group（χ2=20.204，P<0.01），and the chronic non-atrophic gastritis group was lower than the chronic non-atrophic gastritis with erosion group and gastric ulcer group（P<0.005）.The prevalence of Ure antibody differed significantly in each group（χ2=63.967，P<0.01），and the prevalence of Ure antibody in chronic non-atrophic gastritis group was higher than that in gastric ulcer group and chronic atrophic gastritis/dysplasia group and gastric cancer group（P<0.005）；chronic non-atrophic gastritis with erosion group was higher than gastric ulcer group，chronic atrophic gastritis/dysplasia group，gastric cancer group（P<0.005）.Conclusion　H.pylori infection is closely related to gastric lesions.Different types of H.pylori infection have different pathogenicity.Type Ⅰ strains are the main pathogenic strain of gastric diseases，while the co-expression of both CagA and VacA is most prevalent.

Value of Changes in Heart Rate Deceleration Capacity and Deceleration Runs in Children with Asymptomatic Vasovagal Syncope　

YAN Fei，WU Rui，HAN Yaqi，WANG Wentao，WANG Yaohan，ZHANG Xinyu

2019, 22(36): 4429-4434. DOI: 10.12114/j.issn.1007-9572.2019.00.599

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Background　Vasovagal syncope （VVS） is a common cause of unexplained syncope in children，whose occurrence is mainly associated with the imbalance of autonomic nerve system.Heart rate deceleration capacity（DC） and deceleration runs （DRs） are two new ECG indicators recently found for quantitative evaluation of cardiac autonomic responses to stress.But the application and changes of them in VVS children are rarely reported.Objective　To evaluate the clinical value of the changes in heart rate DC and DRs in children with asymptomatic VVS.Methods　Participants meeting the study criteria were recruited from Henan Provincial People's Hospital during December 2016 to December 2017，including 60 with VVS（study group），and sex-and age-matched 42 healthy physical examinees（control group）．All of them underwent 24-hour ambulatory ECG.Parameters of heart rate variability （HRV）（ SDNN，SDANN，RMSSD，LF and HF），DC and DRs were rerecorded，and were compared between groups.Pearson correlation analysis was conducted to examine the correlations of these parameters.Results　The study group had lower mean values of SDNN，SDANN，and LF，and higher mean values of RMSSD and HF than the control group（P<0.05）．The study group showed higher mean values of DC，DR4 and DR8（P<0.05），but similar mean value of DR2（P>0.05） compared with the control group.Pearson correlation analysis showed that the value of DC was positively correlated with SDNN，SDANN，RMSSD and HF （r values were 0.90，0.84，0.92，0.86，respectively），and negatively correlated with LF （r=-0.85）（P<0.05）．Conclusion　The values of DC and DRs in children with VVS were obviously increased，indicating that there were autonomic nervous system disorders.DC and DRs can quantitatively evaluate the vasovagal response to stress from different aspects.

Risk Factors of Microembolism in the Blood Supply Region of the Contralateral Carotid Artery after Unilateral Carotid Stenting　

CHEN Xuecong，KONG Wenting，ZHANG Yueqi，ZHU Xiaolong，ZHANG Shuyun，SHI Baolin

2019, 22(36): 4434-4438. DOI: 10.12114/j.issn.1007-9572.2019.00.295

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Background　After carotid artery stenting（CAS），microembolism occurs not only in the ipsilateral carotid artery blood supply area，but also in the contralateral carotid artery blood supply area and vertebrobasilar artery blood supply area.The risk factors，such as advanced age and carotid plaque ulceration，for microembolization in the carotid artery blood supply area ipsilateral to the stented carotid artery are relatively clear，but those for microembolization in carotid artery blood supply areas contralateral to the stented carotid artery are rarely mentioned in domestic studies.Objective　To investigate the occurrence of microembolism in the blood supply area of the contralateral carotid artery after unilateral CAS and analyze its risk factors.Methods　164 consecutive patients with carotid stenosis scheduled to undergo unilateral CAS from December 2013 to August 2018 in Department of Neurology，Weifang People's Hospital were enrolled.General data（sex，age，prevalence rates of hypertension，diabetes，hyperlipidemia，coronary heart disease，atrial fibrillation，and smoking，stroke history，preoperative carotid stenosis degree），postoperative clinical data（degree of carotid stenosis，degree of contralateral carotid stenosis，incidence of contralateral carotid occlusion，left carotid artery lesions，and type Ⅱ/Ⅲ aortic arch，and CAM score≥3），and use of closed-loop stent，and average number of catheters and/or guidewires used more than planned，as well as duration of surgery were collected and recorded.According to the results of MRI plain scan of brain within 3 days after CAS，patients with microembolism in posterior cerebral circulation blood area were excluded，the remaining ones were divided into two groups：ipsilateral group（with microembolization occurring at the ipsilateral side of carotid artery supply area）and contralateral group（with microembolization occurring at the contralateral carotid artery supply area or bilateral sides）．Results　163 of the 164 cases completed CAS.Plain MRI scan within 3 days after CAS found that 72 cases（44.2%）were newly microembolized，including 39 with ipsilateral microembolization（ipsilateral group），5 with contralateral microembolization and 13 with bilateral microembolization（contralateral group），and 15 with posterior circulation microembolization.Contralateral group showed higher incidence rate of left carotid artery lesions and higher rate of having CAM score ≥ 3 than ipsilateral group（P<0.05）．Multivariate Logistic regression analysis showed that the left carotid artery lesions〔OR=10.015，95%CI（2.728，42.680）〕，and CAM score≥ 3〔OR=9.137，95%CI（2.564，36.271）〕were associated with increased risk of microembolization at the contralateral carotid artery blood supply area after CAS（P<0.05）．Conclusion　Left carotid artery lesion and CAM score ≥ 3 are influencing factors for microembolization occurring at the contralateral carotid artery blood supply area after CAS，which suggests that complicated routes and severe aortic arch atherosclerosis can lead to significantly increased risk of microembolism in the contralateral carotid artery blood supply area after CAS.

Effects of Early Therapy of Somatostatin and/or Terlipressin Combined with Endoscopy Intervention for the Treatment of Bleeding Gastroesophageal Varices in Hepatic Cirrhosis　

GONG Min，WANG Guiliang，LIN Qiuman，QIU Ping，XU Linfang，HAN Ming，LI Xing，WEN Jianbo

2019, 22(36): 4439-4446. DOI: 10.12114/j.issn.1007-9572.2019.00.521

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Background　Bleeding gastroesophageal varices is a serious complication of portal hypertension in hepatic cirrhosis.The main treatments are endoscopic treatment and application of reducing-portal-pressure medicine.Somatostatin and terlipressin are classic reducing-portal-pressure medicines.Objective　To study the effect of early somatostatin and/or terlipressin combined with endoscopic treatment on patients with hepatic cirrhosis and bleeding gastroesophageal varices.Methods　From January 2010 to August 2018，a total of 173 patients with hepatic cirrhosis and bleeding gastroesophageal varices in Southern Medical University Affiliated Pingxiang Hospital were enrolled and randomly assigned into 4 groups according to 2×2 factorial design：placebo group；somatostatin group；terlipressin group；somatostatin+terlipressin group.Endoscopic treatment was performed after 48 hours of medicine treatment.Hemostasis time，recovery time of blood pressure，hemostatic effect，24 h hemostasis rate，48 h hemostasis rate，rebleeding rate and hemostasis rate within 2 weeks after endoscopic treatment，varicose veins alleviation effect，cost，cost-effectiveness ratio（C/E），ΔC/ΔE，sensitivity and incidences of adverse reactions of the 4 groups were analyzed.Results　The main effects of somatostatin and terlipressin on hemostasis time and recovery time of blood pressure were significant（P<0.001）．The interaction of somatostatin and terlipressin on hemostasis time and recovery time was not significant（P>0.05）．Compared with the placebo group，24 h hemostatic rate，48 h hemostasis rate，and the hemostasis rate within 2 weeks after endoscopic treatment of the somatostatin group，the terlipressin group，the somatostatin+terlipressin group significantly decreased（P<0.05）．There were significant differences between the efficacy of hemostasis and varicose veins between the 4 groups（Hc=10.914，P=0.012；Hc=9.708，P=0.021），but there were no significant differences between the efficacy of varicose veins of the somatostatin group，the terlipressin group and somatostatin+the terlipressin group（Hc=0.393，P=0.822；Hc=0.059，P=0.971）．Cost analysis showed that the cost of terliressin group and somatostatin+terlipressin group was higher than that of placebo group（P<0.05）．The cost-effectiveness ratio was calculated according to the 48 h hemostasis rate and the 2-week hemostasis rate.Compared with the placebo group，cost-effectiveness ratio of the somatostatin group significantly decreased，while increased significangly in the the terlipressin group and the somatostatin+terlipressin group（P<0.05）.In reference to somatostatin group，the incremental cost ratio ΔC/ΔE of the somatostatin+terlipressin group was lower than that of the terlipressin group（P<0.05）．Compared with the placebo group，the incidence of nausea significantly increased in the somatostatin group and the somatostatin+terlipressin group，and the incidence of abdominal pain significantly increased in the terlipressin group and the somatostatin+terlipressin group（P<0.05）．Compared with the placebo group，the incidences of intraoperative hemorrhage，fever，and ectopic embolization significantly decreased in the somatostatin group，the terlipressin group and the somatostatin+terlipressin group（P<0.05）.Conclusion　Early somatostatin or terlipressin combined with endoscopic treatment can effectively treat bleeding gastroesophageal varices in hepatic cirrhosis，and promote the varicose veins to allieviate.With the same effect，the cost of somatostatin is the lowest，followed by terlipressin，and somatostatin+terlipressin is the highest.Both somatostatin and terlipressin are safe for patients.There is no interaction between somatostatin and terlipressin，which can not further improve the efficacy.

Age-based Analysis of Spectral Characteristics of Sleep EEG in Patients with Severe Obstructive Sleep Apnea-hypopnea Syndrome　

MO Jianming，XU Ping，TANG Anjue，LI Wei，SONG Weidong

2019, 22(36): 4447-4452. DOI: 10.12114/j.issn.1007-9572.2019.00.677

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Background　Obstructive sleep apnea-hypopnea syndrome （OSAHS） is one of the common sleep disorders.Previous studies demonstrate that change of sleep structure and decline of cognitive function are more likely to appear in older patients，with reasons incompletely determined yet.Up to now，there are few studies focusing on the relationship of the sleep electroencephalogram （EEG） and sleep structure with OSAHS patients at different ages.Objective　To explore the characteristics of sleep EEG of patients with severe OSAHS by age，so as to further provide significant information about brain plasticity change for instructing clinical treatment.Methods　In the study，67 patients definitely diagnosed with severe OSAHS from June 2017 to March 2018 in the Sleep Disordered Breathing Diagnosis and Therapy Center，Peking University Shenzhen Hospital were selected and were divided into the younger group （18-40 years old，n=34） and the older group （41-65 years old，n=33） based on the latest national age classification standard.We compared the two groups in the aspects of apnea-hypopnea index （AHI），the lowest SpO2 （LSpO2） during the night，sleep efficiency，the percentage of sleep time during various non-rapid eye movement （NREM） sleep stages （N1，N2 and N3），and the percentage of rapid eye movement （REM） sleep period in the total sleep time，electroencephalograph power density of various waves 〔EEG-δ （0.5-4.0 Hz），EEG-θ（4.1-8.0 Hz），EGG-α（8.1-12.0 Hz） and EGG-β （12.1-30.0 Hz）〕 during NREM period，and analyzed the correlation of electroencephalograph power density during NREM，sleep time in REM period and sleep efficiency with AHI.Results　As for the percentage of the sleep time during various stages in the total sleep time，it was higher during N1 and N2 stages in the older group than in the younger group，while was lower in N3 and REM period in the older group than in the younger group （P<0.05）.During the stages of N1，N2 and N3，the power densities of EEG-δ of patients in the older group were lower than those of patients in the younger group （P<0.05）.The power density of EEG-θ of patients in the older group was lower than that of those in the younger group during N3 stage （P<0.05）.During the stages of N2 and N3，the power densities of EEG-α of patients in the older group were lower than those of patients in the younger group （P<0.05）.During the stages of N1，N2 and N3，the power densities of EEG-β of patients in the older group were higher than those of patients in the younger group （P<0.05）.For the patients in the younger group，the correlation of the power density of EEG-δ，EGG-θ and EEG-α，the sleep time during REM period and the sleep efficiency with AHI was negative （r=-0.338，-0.315，-0.383，-0.483 and-0.501，respectively，P<0.05）；the power density of EEG-β during NREM period of younger group patients had no linearity correlation with AHI（P>0.05）.For the patients in the older group，the power density of various waves during NREM period，the sleep time during REM period and the sleep efficiency had no linearity correlation with AHI （P>0.05）.Conclusion　There are significant differences between the EEG performance of the younger and older patients with severe OSAHS.The older patients have longer N1 and N2-stage sleep time with shorter N3 and REM-sleep time；compared to the younger group，the EEG-δ during NREM period，EEG-θ and EEG-αduring N3 stage are found to decrease while EEG-β during NREM period is found to increase.All the EEG changes lead to the reduction of deep sleep time and the increase of shallow sleep time for the older patients with severe OSAHS.Consequently，they are easier to wake when coming across external stimuli and intermittent hypoxia，which directly lead to the increase of sleep fragmentation.

Conditioned Medium Derived from Bone Marrow Mesenchymal Stem Cells with Inflammatory Pre-activation Regulates Inflammatory Response to Necrotizing Enterocolitis　

ZHU Xiaobo，MA Faxin，FENG Lin，ZHENG Yue，SHA Weihong，CHEN Hao

2019, 22(36): 4453-4459. DOI: 10.12114/j.issn.1007-9572.2019.00.726

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CHEN Hao，Physician，E-mail：mprmprvzdh@qq.com
Background　Bone marrow mesenchymal stem cells have a strong capacity of immunoregulation and anti-inflammation.Previous research identified that the conditioned medium derived from mesenchymal stem cells （MSC-CM） can downregulate various inflammatory responses and protect the small intestine.However，the effects and mechanisms of the MSC-CM in necrotizing enterocolitis（NEC） inflammation remain unknown.Objective　To investigate the role of MSC-CM with inflammatory pre-activation，in regulating NEC inflammatory response in an experimental newborn rat model of NEC.Methods　This study was carried out between July 2018 and April 2019.Eighty newborn SD rats（SPF grade） were randomly and equally divided into control group，NEC injury group，NEC injury+MSC-CMNOR group and NEC injury+MSC-CMTNF-α+IL-1β+NO group.DMEM-F12 medium，MSC-CMNOR and MSC-CMTNF-α+IL-1β+NO were given by intraperitoneal injection for the following 3 days to the NEC injury group，NEC injury+MSC-CMNOR group and NEC injury+MSC-CMTNF-α+IL-1β+NO group，respectively.The gross specimen of small intestine were observed，and the terminal ileum and blood samples were collected on the 4th day of intervention.H&E staining was used to observe the histological changes of the small intestine and determine the pathological scores.Inflammatory cytokines in small intestine tissue and serum samples were detected by ELISA.Results　Major changes in small intestine specimens：in the control group，the color of the tissue was ruddy and non-hyperemia with good elasticity，peristalsis，and no intestinal wall pneumatosis or necrosis.In both NEC injury and NEC injury+MSC-CMNOR groups，the color of the tissue was dull-red with distinct congestion，pneumatosis intestinalis，necrosis，low elasticity，and dilatation.In contrast，the NEC injury+MSC-CMTNF-α+IL-1β+NO group showed only mild congestion and fair elasticity，without pneumatosis intestinalis or necrosis.Intestinal histopathological score and incidence of NEC：the total intestinal histopathological scores for the control group，NEC injury group，NEC injury+MSC-CMNOR group and NEC injury+MSC-CMTNF-α+IL-1β+NO group were 16，51，43，and 16，respectively，showing a significant difference（H=41.70，P<0.01）.The control group showed lower mean intestinal histopathological score compared with NEC injury group and NEC injury+MSC-CMNOR group（P<0.01）.And NEC injury+MSC-CMTNF-α+IL-1β+NO group showed lower mean intestinal histopathological score compared with NEC injury group（P<0.01）.The incidence of NEC in the control group，NEC injury group，NEC injury+MSC-CMNOR group and NEC injury+MSC
-CMTNF-α+IL-1β+NO group was 0，85.0%（17/20），20.0%（4/20），and 80.0%（16/20），respectively，with a significant difference（χ2=44.00，P<0.01）.Mean levels of serum and intestinal pro-inflammatory and anti-inflammatory factors：the mean levels of serum TNF-α，IL-1β，IL-6，IL-8，IL-10 and IL-12 differed significantly across four groups（P<0.01）.The mean levels of intestinal TNF-α，IL-1β，IL-6，and IL-10 of four groups were significantly different（P<0.01）.Compared with the NEC injury group and NEC injury+MSC-CMNOR group，mean levels of serum TNF-α，IL-1β，IL-6，IL-8 and IL-12 decreased while mean level of serum IL-10 increased significantly in the NEC injury+MSC-CMTNF-α+IL-1β+NO group（P<0.01）；mean levels of intestinal TNF-α，IL-1β，IL-6 decreased while mean level of intestinal IL-10 increased significantly in the NEC injury+MSC-CMTNF-α+IL-1β+NO group（P<0.01）.Conclusion　The conditioned medium from pre-activated MSCs has protective effects on the intestinal tract of newborn rat model of NEC，which can regulate the balance of inflammatory and anti-inflammatory factors and reduce intestinal damage.

Clinical Characteristics of Acquired Thrombotic Thrombocytopenic Purpura　

HE Yang，JIN Jun，WANG Jun，YANG Haifei

2019, 22(36): 4460-4464. DOI: 10.12114/j.issn.1007-9572.2019.00.536

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Background　The pathogenesis of acquired thrombotic thrombocytopenic purpura （TTP） is not clear and the mortality rate is very high. Therefore，understanding the clinical characteristics of TTP can help medical workers to diagnose and treat TTP early and reduce its mortality.Objective　To comprehensively analyze the clinical characteristics，treatment strategies and outcome of patients with acquired TTP.Methods　We enrolled 82 inpatients with acquired TTP from the First Affiliated Hospital of Soochow University from January 2007 to July 2017 in accordance with the inclusion criteria，and retrospectively analyzed their clinical data，including precipitating factors，clinical manifestations，laboratory indicators，ADAMTS 13 activity and inhibitor titre，treatment and outcome.Results　Unapparent causes accounted for the largest percentage of the total precipitating factors （68.29%），followed by infections（10.98%，including 2 cases of systematic lupus erythematosis，1 case of erythroderma，1 case of psoriasis，and 1 case of Sjogren's syndrome），autoimmune disease （6.10%），and childbirth （6.10%）.Clinical manifestations：thrombocytopenia was mainly manifested as skin ecchymosis （58.54%），and hematuria （29.27%）；microangiopathic hemolytic anemia was mainly manifested as appearance of anemia （100.00%），yellowing appearance of skin and mucous membranes and sclera（43.90%）；neuropsychiatric symptoms mainly included coma （34.15%） and convulsions （26.83%）；renal dysfunction was manifested mostly as proteinuria （68.29%） and fever （54.88%）；typical pentalogy of TTP was found in 23.17%（19/82） of the total cases.Plasma ADAMTS 13 activity and inhibitor titre：ADAMTS 13 activity was detected in all cases，and 65 were found with activity <10%，38 with positive ADAMTS 13 inhibitor.Treatment and outcome：54 cases were improved after treatment，and were discharged，other 28 died.The died had higher mean temperature，ALT，AST，LDH，serum total bilirubin，creatinine，and urea，shorter time of PE，and less number of PEs than the survived （P<0.05）.Conclusion　The diagnosis of acquired TTP was based on comprehensive analysis of clinical data.Plasma ADAMTS 13 activity assay contributes to the clinical diagnosis.Plasma exchange has good efficacy，and its combined use with corticosteroids and immunosuppressive agents may further reduce the mortality and likelihood of recurrence of this disease.

Lung Protective Effect of Perioperative Intravenous Infusion of Lidocaine in Patients after Radical Resection of Esophageal Cancer　

YUAN Linfang，ZHAO Wenjing，LIU Yue，WU Bianliang，HUANG Yizhou

2019, 22(36): 4465-4470. DOI: 10.12114/j.issn.1007-9572.2019.00.175

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Background　Postoperative pulmonary complication（PPC）is common after esophagectomy，which is closely related with intraoperative one-lung ventilation.PPC not only increases hospitalization expense，but also increases the unplanned readmission rate after discharge.Moreover，it is an independent risk factor for poor prognosis of esphagectomy patients.However，PPC control after esophagectomy remains unsatisfied.Objective　To evaluate whether intravenous infusion of lidocaine can produce lung protection effect through the anti-inflammatory mechanism in esophagectomy patients，so as to reduce the possibilities of having lung injury and PPC，and improve patients' prognosis.Methods　Sixty adult patients who underwent elective open radical esophagectomy from November 2017 to June 2018 in the Affiliated Hospital of Xuzhou Medical University were selected as the subjects.They were randomly and equally divided into two groups，lidocaine group（group L）and control group（group C）．Both groups were treated with the same anesthesia induction and maintenance regimens，the difference was that group L received a loading dose of 2% lidocaine 1.5 mg/kg injected intravenously within 5 minutes at 5 minutes before anesthesia induction（T0），and then infused intravenously at the rate of 1.5 mg?kg-1?h-1 continuously until 1 hour after the end of the operation，while group C received an equal volume of 0.9% normal saline via the same administration procedure.General data were collected.Blood samples were collected at T0，admission to ICU（T1），12h after surgery（T2）and 36 h after surgery（T3），respectively，and oxygenation index（OI），interleukin（IL）-6，WBC，C-reactive protein（CRP），surfactant protein-A（SP-A）were measured.Postoperative indices were also recorded.Results　Intervention method and time had interaction effect on OI，IL-6，WBC，CRP and SP-A（P<0.05）．Intervention method and time had significant main effects on OI，IL-6，WBC，CRP and SP-A，respectively（P<0.05）．At T1，T2 and T3，group L showed higher OI but lower WBC，CRP and SP-A compared with group C（P<0.05）．IL-6 in group L was lower than that in group C at T1（P<0.05）．In both groups，OI was lower at T1，T2 and T3 than at T0，while IL-6，WBC and CRP were higher than at T0（P<0.05）．SP-A was higher at T1，T2 and T3 than at T0 in group C（P<0.05）．SP-A was higher at T1 and T2 than at T0 in group L（P<0.05）．There were no significant differences in ventilation time in the ICU，ICU length of stay，postoperative length of stay，atelectasis rate，pulmonary infection rate，pleural effusion rate and reintubation rate between the two groups（P>0.05）．Group L needed shorter time to have first passage of flatus，first passage of stool，and first oral fluid intake after the surgery than group C（P<0.05）．There were no lidocaine-related adverse events，respiratory failure，bronchospasm，aspiration pneumonia and pneumothorax happened in either group.Conclusion　Perioperative intravenous infusion of lidocaine may reduce IL-6，WBC，CRP and SP-A，reduce pulmonary inflammatory response，alleviate lung injury and improve patients' OI after esphagectomy，showing certain pulmonary protective effect.

The Analgesic Effect of Exogenous Oxytocin on Peripheral Nervous System　

LUO Yafan，HAN Yi，DI Chang，LI Guoping，CHEN Shaochun

2019, 22(36): 4471-4475. DOI: 10.12114/j.issn.1007-9572.2019.00.598

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Background　Chronic pain is one of the most common health problems.Exploring a variety of analgesic strategies and relevant mechanisms has always been the popular medical research field.Oxytocin （OT）is a self-secreting neurotransmitter.In addition to its well-known functions，such as strengthening the contraction of uterus during delivery and promoting lactation during lactation period，more and more attention has been paid to its analgesic role.Objective　To explore the analgesic effect of exogenous on peripheral nerve system （PNS）．Methods　A total of 40 adult male SD rats were randomly divided into 5 groups （n=8 in each） during March 2017 and January 2018，control group （NOR group）：with no treatment；model group （INF group）：carrageenan was injected in right hind foot paw；placebo group （NS group）：carrageenan was injected in right hind foot paw，followed by immediate intraperitoneal injection of 0.9% sodium chloride solution；oxytocin treatment group （OT group）：carrageenan was injected in right hind foot paw，followed by immediate intraperitoneal injection of oxytocin；positive control group （ASP group）：carrageenan was injected in right hind foot paw，and aspirin was injected immediately into the abdominal cavity.Except for the control group，the other four groups were successfully established without death or special injury.The rats in five groups were tested four hours after the establishment of the model.The hot-plate latency （HPL） and hindpaw withdrawal latencies （HWL） were measured by hot plate test and pressure plate test.The circumference of feet before and after modeling was measured and the swelling degree of hind feet was calculated.The levels of oxytocin，prostaglandin E2 （PGE2） in peripheral blood and PGE2 in inflammatory tissue were measured by ELISA.Results　Four hours after the models were made，HPL and HWL of INF，NS，OT，ASP groups were significantly shorter than those of NOR group （P<0.05）；HPL and HWL of OT，ASP groups were significantly longer than those of INF，NS groups （P<0.05）．HPL and HWL of the four groups （INF，NS，OT，ASP） four hours after model-making were significantly shorter than the ones before model-making （P<0.05）．The circumferences of right hind paw of INF，NS，OT，ASP groups were significantly longer than that of NOR group （P<0.05）；the circumferences of right hind paw of OT，ASP groups were shorter than that of INF，NS groups （P<0.05）．The swelling of inflammatory paw of OT and ASP groups was smaller than that of NOR and NS groups （P<0.05）．The oxytocin and PGE2 concentration in blood and the PGE2 concentration in inflammatory site of INF and NS groups were significantly higher than those of NOR group （P<0.05）.Conclusion　Exogenous oxytocin has significant analgesic effect，which can reduce PGE2 level in peripheral blood and inflammatory tissues and attenuate the swelling of inflammatory sites.This implicates that exogenous oxytocin plays analgesic role in the peripheral nervous system by anti-inflammatory effect and reducing pain-causing factors.

Self-rated Health Status and Influencing Factors in College Students　

YANG Xiulan，WANG Wanlu，WU Meng，YU Wanwan

2019, 22(36): 4476-4481. DOI: 10.12114/j.issn.1007-9572.2019.00.672

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Background　To achieve the goals towards building a healthy China，it is necessary to improve the health of all Chinese.College students，a group plays a role in promoting the prosperity of the nation and the country，whose health status deserves high level of focus.Objective　To investigate the self-rated health status and influencing factors in college students of China.Methods　From May to July 2018，3 000 college students from 11 universities in China were sampled by multi-stage stratified cluster sampling，and were surveyed in a face-to-face manner with a self-designed questionnaire，Self-rated Health Assessment for College Students，covering social demographic data（gender，major，household location，parental education level，parental occupational class，family economic status，family social status，financially strapped status），and the health status assessed by The Self-rated Health Measurement Scale（Version 1.0）（SRHMS V1.0） consisting of physiological，psychological and social health subscales.The influencing factors of the scale and subscale scores of the SRHMS V1.0 were explored by multiple linear regression analysis.Results　The survey obtained a response rate of 95.67%
（2 870/3 000）.The mean scale score for the SRHMS V1.0 was（66.56±6.13），and the mean scores for its physiological health，mental health social health subscales were（76.14±7.12）（54.10±6.27）（68.55±14.52），respectively.Multiple linear regression analysis showed that gender（β=0.767） and family social status（β=1.542） were associated with the score of the physiological health subscale（P<0.05）.Gender（β=-0.827），mother's occupational class（β=-0.582），family social status（β=0.864），and family economic status（β=0.758） were associated with the score of the mental health subscale（P<0.05）.Gender（β=1.350），father's education level（β=0.842），family social status（β=5.431），family economic status（β=2.966），and whether financially strapped（β=-1.863） were associated with the score of the social health subscale（P<0.05）.Mother's occupational class（β=-0.454），family social status（β=2.292），and family economic status（β=1.033） were associated with the scale score of the SRHMS V1.0（P<0.05）.Conclusion　On the whole，the self-rated health status in college students is fair.To improve the overall health status in this group effectively，it is essential to deliver diversified health management services and group counseling interventions，with special attention paid to sex，parental education level，parental occupational class，family economic status，family social status and financially strapped status.

Clinical Features of SAPHO Syndrome　

WANG Weitao，ZHENG Zhaohui，XIE Ronghua，WU Zhenbiao

2019, 22(36): 4482-4487. DOI: 10.12114/j.issn.1007-9572.2019.00.364

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Background　The cognition of the SAPHO syndrome，a rare disease，has made continuous progress in recent years.However，standardized diagnostic and therapeutic regimens for the disease need to be further explored，studied and summarized due to diversified manifestations.Objective　To analyze and summarize the clinical features，diagnosis and treatment of SAPHO syndrome.Methods　Twelve cases of SAPHO syndrome were retrospectively selected from the First Affiliated Hospital of Air Force Medical University during February 2012 to May 2018.Pathogenic characteristics，clinical features，imaging manifestations，serological makers，skin biopsy，treatment and follow-up results were analyzed.Results　In this group，there were 8 males and 4 females，with an average age of onset of （37.8±11.8） years （range 17-53），and the course of the disease ranged from 2 months to 25 years.All cases presented some lesions of the skin，bone and joint to varying degrees，with palmoplantar impetigo，sternoclavicular joint swelling and pain，and acromioclavicular joint pain as the main clinical manifestations.Whole body bone scintigraphy is an important detective approach，and the detection of bull's head sign，a typical sign of SAPHO syndrome on bone scintigraphy，is of great diagnostic significance.Serological examination showed no pathognomonic changes，but in the acute phase，elevated erythrocyte sedimentation rate and C-reactive protein levels were found.Typical pustules could be found in skin biopsy.Experiential therapies are the major treatments at present.Immunosuppressive agents combined with non-steroidal drugs can achieve good effectiveness.The conditions of most cases with regular pharmacological treatment were controlled and became stable.Conclusion　SAPHO syndrome can occur in both men and women.The early symptoms are not typical，and the initial symptoms are mostly skin or joint lesions.Bull's head sign on bone scintigraphy，a pathognomonic sign of SAPHO syndrome，in combination with inflammatory changes detected by skin biopsy，are important indicators for the diagnosis and differential diagnosis of this disease.Most patients with early diagnosis and treatment have a good prognosis.

Clinical Response and Changes in Serum 5-HT in Patients with Diarrhea-predominant Irritable Bowel Syndrome Treated with Anchang Decoction：a Study from the Perspective of Visceral Sensitivity　

CAI Linkun，HUANG Shi，PENG Zhuoyu，HUANG Yalan，TAO Lifen，LAN Siying

2019, 22(36): 4488-4492. DOI: 10.12114/j.issn.1007-9572.2019.00.533

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PENG Zhuoyu，Chief physician，Professor；E-mail：penazy@163.com
Background　Diarrhea-predominant irritable bowel syndrome（IBS-D） is one of the common diseases and frequently-occurring diseases of digestive system.Western medicine treatments have no significant therapeutic effects on such patients，especially in improving their visceral sensitivity.Moreover，after such treatment，the disease is easily recur.Therefore，it is particularly important to find a more effective treatment for IBS-D.Objective　To explore clinical response and changes in serum 5-HT in patients with IBS-D treated with Anchang Decoction from the perspective of visceral sensitivity.Methods　A total of 80 IBS-D gastroenterology inpatients and outpatients were enrolled from Ruikang Hospital Affiliated to Guangxi University of Chinese Medicine from January 2017 to January 2018.They were equally divided into control group and observation group by use of a random number table，receiving a 8-week oral administration of Trimebutine Maleate Capsule，Trimebutine Maleate Capsule with Anchang Decoction，respectively.The severity of clinical symptoms〔evaluated by Irritable Bowel Syndrome Severity Scale（IBS-SSS）〕，visceral sensitivity〔evaluated by Visceral Sensitivity Index（VSI）〕，parameters of rectal motility〔anal resting pressure（ARP），anal systolic pressure（ASP），anal maximal contraction pressure（AMCP），rectal resting pressure（RRP），inside rectal pressure（IRP）〕，visceral sensory parameters（first sensation threshold，first desire to defecate threshold，rectal maximum tolerable volume），and serum 5-HT levels were compared between the two groups before and after treatment.Results　After treatment，mean IBS-SSS and VSI scores of the observation group were significantly lower than those of the control group（P<0.05）．Posttreatment mean scores of IBS-SSS and VSI decreased in both groups compared with pretreatment（P<0.05）．After treatment，mean values of ARP，first sensation threshold，first desire to defecate threshold，and rectal maximum tolerable volume in，the observation group were significantly higher than those of the control group（P<0.05）．And the posttreatment values of these 4 parameters increased in both groups compared with pretreatment（P<0.05），After treatment，mean serum 5-HT level of the observation group was significantly lower than that of the control group（P<0.05）．Posttreatment mean serum 5-HT level declined in both groups compared with pretreatment（P<0.05）．Conclusion　From the perspective of visceral sensitivity，Anchang Decoction can improve the symptoms and visceral hypersensitivity of IBS-D patients as a whole.It may alleviate the symptoms of abdominal pain，diarrhea and abdominal distension and so on by lowering the serum 5-HT level，increasing ARP，first sensation threshold，first desire to defecate threshold，and rectal maximum tolerable volume，and relieving the visceral hypersensitivity.

Effects of Pingtusan Compounds on the Expression of MMP and TIMP in Retroocular Fibroblasts after CD40L Stimulation　

WAN Hong，CHEN Yalin，CUI Yaping，YU Dandan，YAN Shuxun

2019, 22(36): 4493-4498. DOI: 10.12114/j.issn.1007-9572.2019.00.734

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Background　Regarding thyroid-associated ophthalmopathy（TAO），although modern medicine has made some progress in basic and clinical research，and accumulated a certain amount of materials and evidence on pathogenesis，there are still few studies on TAO treatment，and there are still a lack of effective therapeutic methods and drugs in clinical practice.Furthermore，for TAO，TCM-based syndrome differentiation and treatment has a certain therapeutic effect with few side effects and low recurrence rate，but the mechanism of action is not clear，and the target of drug action is unclear.Objective　To observe the effects of CD40L on the expression of MMP-1，MMP-2，TIMP-1，TIMP-2 on the surface of retroocular fibroblasts（RFs） and the intervention results of three TCM composite drugs.Methods　In this experiment，the serum contained in three TCM composite drugs（xiehuopingtusan，huoxuepingtusan and yangmupingtusan） was derived from 35 male SPF SD rats in September 2016，and the human retrobulbar connective tissue was derived from two patients with ocular trauma（from Department of Ophthalmology，the First Affiliated Hospital of Zhengzhou University in 2014）.Successfully cultured RFs were randomly divided into 7 groups：blank group（cultured in a normal medium），serum group（cultured in a medium containing 10% normal rat serum），CD40L group（cultured in a culture medium containing 100 ng/ml CD40L），CD40L+serum group（cultured in a medium containing 100 ng/ml CD40L and 10% normal rat serum），xiehuopingtusan group（cultured in a medium containing 100 ng/ml CD40L and 10% xiehuopingtusan-containing rat serum with），huoxuepingtusan group（cultured in a medium containing 100 ng/ml CD40L and 10% huoxuepingtusan-containing rat serum），and yangmupingtusan group（cultured in a medium containing 100 ng/ml CD40L and 10% yangmupingtusan-containing serum）.Immunocytochemical staining was used to detect the expression of MMP-1，MMP-2，TIMP-1 and TIMP-2 in each group.Results　The activities of MMP-1 and MMP-2 in CD40L group were lower than those of the blank group（P<0.05）.The activities of MMP-1 and MMP-2 in CD40L+serum group were lower than those of serum group，and of the three TCM composite drug groups（P<0.05）.The activities of MMP-1 and MMP-2 in yangmupingtusan group were higher than those in xiehuopingtusan group and huoxuepingtusan group（P<0.05）.The activities of TIMP-1 and TIMP-2 in CD40L group were higher than those in blank group（P<0.05）.The activities of TIMP-1 and TIMP-2 in CD40L+serum group were higher than those in serum group，and those in three TCM composite drug groups（P<0.05）.The activities of TIMP-1 and TIMP-2 in yangmupingtusan group were lower than those in xiehuopingtusan group and huoxuepingtusan group（P<0.05）.Mean ratios of MMP-1/TIMP-1 and MMP-2/TIMP-2 in the CD40L group were lower than those in the blank group（P<0.05）.Mean ratios of MMP-1/TIMP-1 and MMP-2/TIMP-2 in CD40L+serum group were lower than those in serum group（P<0.05）.Mean ratios of MMP-1/TIMP-1 and MMP-2/TIMP-2 in three TCM composite drug groups were higher than those in CD40L+serum group（P<0.05）.Mean ratios of MMP-1/TIMP-1 and MMP-2/TIMP-2 in yangmupingtusan group were higher than those in the xiehuopingtusan group and huoxuepingtusan group（P<0.05）.Conclusion　The treatment of TAO by TCM composite drugs may be achieved by blocking the CD40-CD40L co-stimulatory pathway，subsequently leading to the imbalance of MMP/TIMP.

Research Progress of Effective Constituents in Traditional Chinese Medicine against Glioma and the Application of New Dosage Forms　

PANG Xiaochen，GAO Dandan，CHAI Zhongqiu，ZHANG Jingsha，ZHOU Bing

2019, 22(36): 4499-4503. DOI: 10.12114/j.issn.1007-9572.2019.00.661

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With the continuous deterioration of global environment，glioma has become a hot topic of social concern.At present，the main clinical treatment of glioma was surgery combined with chemotherapy and other means.Because of the high recurrence rate，the lack of obvious targets of chemotherapy drugs，and the difficulty of penetrating the blood-brain barrier，it is difficult to achieve the desired effect in the treatment of glioma.Therefore，how to enhance the targeted delivery of drugs through the blood-brain barrier and improve the therapeutic effect clinically is a problem to be solved.By reviewing related literatures in recent years at home and abroad，this paper introduced the characteristics of the blood-brain barrier and its targeting mechanisms，summarized the mechanism of action of traditional Chinese medicine against glioma and reviewed the application of new dosage forms.The author summarized the research progress of effective constituents in traditional Chinese medicine against glioma and the application of new dosage forms and prospected its development，in order to provide a more ideal clinical plan for the treatment of glioma in the future with the monomer of Chinese herb and Chinese herbal compound，which may develop ideas for deeper theoretical research and mechanism exploration.

Predictive Value of Cardiopulmonary Ultrasonography Parameters on Mechanical Ventilation Weaning Results in Elderly Patients with Sepsis　

JIANG Mingming，ZHANG Xuejia，CHEN Zhixin，SUN Bo，ZHANG Tianqing，HU Xuezhong，SUN Qin，XU Yulu，FANG Qiang

2019, 22(36): 4504-4511. DOI: 10.12114/j.issn.1007-9572.2019.00.426

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Background　The failure rate of mechanical ventilation weaning is high in elderly patients with sepsis.Although ultrasound has been widely used in the management of critically ill patients in recent years and its evaluation of cardiac and pulmonary function is increasingly used before weaning.However，it is rarely used in the process of weaning in elderly patients with sepsis.Objective　To investigate the predictive value of cardiopulmonary ultrasonography parameters on mechanical ventilation weaning results in elderly patients with sepsis.Methods　A retrospective case-control study was conducted to analyze the clinical data of 60 elderly patients with sepsis admitted to the intensive care unit（ICU） of Cixi Hospital Affiliated to Wenzhou Medical University from January 2013 to October 2018.Patients' basic information，including gender，age，body mass index（BMI），sequential organ failure score（SOFA），acute physiology and chronic health evaluation systemⅡ（APACHE Ⅱ）score，heart rate（HR） before the spontaneous breathing trial（SBT），and mean arterial pressure（MAP） was collected.Patients' underlying diseases and infection sites were also collected.Common predictors of weaning were recorded，including respiratory rate（RR），maximal inspiratory pressure（MIP），mouth occlusion pressure at 0.1s after onset of inspiratory effort（P0.1），and type B natriuretic peptide value（BNP） after SBT test.The rapid shallow breathing index（RSBI） was calculated.The results of cardiac ultrasonography before spontaneous breathing test（SBT） were recorded.Cardiac ultrasonography parameters included left ventricular septal thickness diamete（IVSTD），left ventricular posterior wall thickness diameter（LVPWTD），left ventricular end diastolic diameter（LVDd），left ventricular end systolic diameter（LVDs），mitral peak velocity of early filling（E），mitral peak velocity of late filling（A），and early diastolic mitral annular velocity（E'）．E/A，E/E' were calculated.Systolic left atrial area（LAA） was measured.Left ventricular ejection fraction（LVEF） was also calculated.Pulmonary ultrasonography parameters were lung ultrasound scores（LUS）．According to the results of the weaning，the patients were divided into the weaning success group and the weaning failure group.The differences of the parameters between the patients in the two groups were compared.The predictive value of the cardiopulmonary ultrasonography parameters in elderly patients with sepsis on results of weaning was evaluated with receiver operating characteristic curve（ROC）curve.Results　A total of 60 patients were enrolled，including 35 patients in the weaning success group and 25 patients in the failure group.There were no significant differences in the basic data between the two groups（P>0.05）．The incidence of coronary heart disease in the failure group was higher than that in the success group（P<0.05）．There was no significant difference in infection sites between the two groups（P>0.05）．The RSBI of the weaning failure group was higher than that of the weaning success group（P<0.05）．The cardiac ultrasound parameter E' of the success group was higher than that of the failure group，while the E/E' and the LAA was lower in the success group（P<0.05），and the pulmonary ultrasound parameter LUS was also lower in the success group （P<0.05）．The results of ROC curve analysis showed that E/E'，LUS and LAA had the predictive value for the result of weaning，and the area under curve（AUC） were 0.835，0.751，and 0.680，respectively.When the critical values were E/E'<8.22，LUS<15.50，and LAA<22.85 cm2，the sensitivity were 0.760，0.720，and 0.560，and the specificity were 0.857，0.724，and 0.829，respectively.Conclusion　The parameters of cardiopulmonary ultrasound have the predictive value for the outcome of weaning in elderly patients with sepsis，and the predictive value of the successful weaning in elderly patients with sepsis is high when E/E<8.22，and LUS<15.50 before SBT.

Analysis of Blood Flow Information for the Diagnosis of Benign and Malignant Thyroid Nodules with Coarse Calcification　

QIU Qianyi，OUYANG Jiabao，CHEN Qi，WU Changjun

2019, 22(36): 4511-4514. DOI: 10.12114/j.issn.1007-9572.2019.00.484

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Background　There have been several studies on the differential diagnosis of benign and malignant thyroid nodules with coarse calcification by gray-scale information and elasticity imaging，but few literatures have reported the diagnostic value of blood flow information.Objective　To explore the value of blood flow information in differential diagnosis of benign and malignant thyroid nodules with coarse calcification.Methods　A retrospective analysis of 103 patients with thyroid nodules（a total of 108 solid nodules with coarse calcification） from the First Affiliated Hospital of Harbin Medical University between October 2017 to December 2018 was performed.The internal blood flow grade of benign and malignant thyroid nodules and the blood flow distribution types in the internal nodules and peripheral glands were compared.Results　Among the 108 nodules，there were 59 malignant nodules and 49 benign nodules.The incidence of grade 0，grade 2，and grade 3 blood flow in benign and malignant thyroid nodules were not statistically significant（χ2=0.96，0.03，0.81，P>0.05），while the incidence of grade 1 blood flow in malignant thyroid nodules was higher than that in benign thyroid nodules（χ2=6.26，P<0.05）.There was significant difference in the blood flow distribution types in the internal nodules and peripheral glands （P<0.05）.The blood flow distribution type Ⅲ and Ⅳ were more frequently detected in malignant nodules，and typeⅠ，Ⅱ and Ⅳ were more frequently detected in benign nodules（P<0.05）.Conclusion　Blood flow grade 1 and distribution type Ⅰ，Ⅱ and Ⅳ are more common in benign nodules；type Ⅲ and Ⅳ are more common in malignant nodules.Observing the blood flow distribution types in the internal nodules and peripheral glands is helpful for the diagnosis of the benign and malignant thyroid nodules with coarse calcification.

Clinical Analysis and Differential Diagnosis of Non-conducted Premature Atrial Contractions Using a Lorenz-RR Scatter Plot and Reverse Technique　

WU Qiuhua，GONG Chun，WU Honglin

2019, 22(36): 4515-4519. DOI: 10.12114/j.issn.1007-9572.2019.00.587

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Background　The potential hazards of premature atrial contractions（PACs） have been recognized over the years.The ability of clinicians to detect PACs with high frequency and at an earlier stage is particularly important.Ambulatory electrocardiogram（ECG） is the preferred non-invasive examination for such arrhythmias.Although the traditional template-based method（template-based method） has been used for a long time in clinical settings，it cannot meet current clinical needs due to time-consuming.The Lorenz-RR scatter plot with reverse technique（scatter plot method） is a new diagnostic approach that can provide rapid detection and differential diagnosis of PACs.Objective　To summarize the characteristics of the Lorenz-RR scatter plot in patients with non-conducted premature atrial contractions（nPACs），and to further improve the diagnostic accuracy regarding PACs by combining reverse technique with differential diagnosis of type I second degree atrioventricular block（AVB）．Methods　Data obtained from 108 patients with arrhythmia who were treated in the Affiliated Wujin Hospital of Jiangsu University from January 2016 to June 2018 were analyzed retrospectively.Of them，those with nPACs （>100 times/24 h） were included in group A，and those with type I second degree AVB were included in group B.Ambulatory ECG data of group A were analyzed using both template-based and scatter plot methods.PACs，nPACs，paroxysmal atrial tachycardia，premature ventricular contraction，the fastest heart rate，the slowest heart rate，and the total heart rate were analyzed.The slopes of pre and post set lines of the non-conducted scatter plot in group A，along with those of blocked scatter plot in group B were compared，and the symmetry of pre and post set lines about 45 degree isovelocity was also compared for the two groups by using Geometer's Sketchpad.Results　The number of PACs，paroxysmal atrial tachycardia，and ventricular premature contractions detected using the template-based method was less than that detected using the scatter plot method，respectively（P<0.05）．The total number of heart beats detected using the template-based method was higher than that detected using the scatter plot method（P<0.05）．There was a significant difference in the slope of the point set before and after non-conducted PACs in group A or blocked scatterplot in group B（P<0.05）．There was no significant difference between the reciprocal slope of the pre point set and the slope of the post point set of the non-conducted scatter plot in group A（P>0.05）．However，a significant difference was seen between the reciprocal slope of the pre point set and the slope of the post point set of the blocked scatter plot in group B（P<0.05）．Conclusion　The scatter plot method can not only identify nPACs quickly，but can also count their number and improve the detection rate and diagnostic accuracy of PACs，and the ability to differentiate them from type I second degree AVB.

Integral Theory-based Trans-perineum Ultrasound Exploration of the Pathogenesis of Stress Urinary Incontinence during Pregnancy　

LUO Dan，CHEN Ling，YU Xiajuan，JIN Mei，CAI Wenzhi

2019, 22(36): 4520-4525. DOI: 10.12114/j.issn.1007-9572.2019.00.642

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Background　Stress urinary incontinence（SUI） is a disease often occurring during pregnancy，which impairs the quality of life greatly，but its pathogenic mechanism is unclear.The Integral Theory is a universally accepted theories that explains the mechanism of SUI，mostly in the surgical and non-pregnant populations，but whether it applicable to pregnant population remains to be explored.Objective　To perform a Integral Theory-based trans-perineum ultrasound exploration of the pathogenesis of SUI during pregnancy.Methods　Participants were women in the first and second trimesters recruited from those undergoing trans-perineum ultrasound in the Obstetric Clinic，Shenzhen Maternity & Child Healthcare Hospital and Shenzhen Hospital of Southern Medical University by convenience sampling.Among them，245（group A） were enrolled during October 2016 to January 2017，and their ultrasound parameters were analyzed and screened with homogeneity test，and common factors were extracted with exploratory factor analysis（EFA）．In accordance with the results，other 206 cases（group B） were enrolled during May to September 2017 based on a 1∶1-matched case-control design，and their ultrasound parameters were used to develop a structural equation model（SEM） of the mechanism of SUI during pregnancy.Results　Ten ultrasound parameters were screened out.And 3 common factors were extracted，explaining 73.339% of the total cumulative variance.The important indices of the improved SEM showed good fit.The SEM includes 9 observation variables，and two latent variables（changes in bladder-urethral junction and pelvic hiatal area）．And the standardized regression coefficients of path ranged from 0.19 to 0.92.Conclusion　The fitted well SEM developed based on the Integral Theory showed that SUI occurring during pregnancy may related with the changes in bladder-urethral junction and pelvic hiatal area.
Urinary incontinence，stress；Pregnancy；Integral theory；Ultrasonography

Research Progress in Cognitive Function Assessment Tools for Patients with Advanced Dementia　

2019, 22(36): 4526-4531. DOI: 10.12114/j.issn.1007-9572.2019.00.275

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Dementia is an irreversible neurodegenerative disease with a progressive course.The cognitive function of patients with dementia will gradually decrease as the disease progresses.At present，clinical medical staff and patients' families in China pay less attention to the late stage of dementia.The traditional cognitive function assessment tools have the floor effect and play a limited role in tracking cognitive function of patients with advanced dementia.Correct assessments of patients with advanced dementia can identify their residual cognitive functions and basic skills for survival，which provides medical staff useful information to track treatment outcomes，meanwhile increases caregivers' confidence and improves patients' quality of life.By reviewing the related researches on cognitive function assessment tools for patients with advanced dementia at home and abroad，we conducted a comparative analysis.The results showed that assessment tools have their own advantages and disadvantages and applicability in the evaluation of cognitive function of patients with advanced dementia，such as Severe Impairment Battery（SIB）scale，Severe Impairment Battery Short Version（SIB-S）scale，Severe Mini-Mental State Examination（SMMSE）scale，Baylor Profound Mental State Examination-cognitive（BPMSE-cog）scale，Test for Severe Impairment（TSI）scale，and Severe Cognitive Impairment Profile（SCIP）scale.This paper provides a basis for the selection of cognitive function assessment tools for patients with advanced dementia in China.

Using Beers Criteria to Manage Medication Regimens for Elder Patients with Multimorbidity in Primary Care：a Case Study　

QIU Shanjiao，HUANG Wenjing

2019, 22(36): 4532-4534. DOI: 10.12114/j.issn.1007-9572.2019.00.331

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It is increasingly common to treat elderly comorbid patients with polypharmacy in community-based general practice.How to formulate effective，safe and customized treatment plan for elderly comorbid patients is crucial for general practitioners in clinical practice.In this paper，the community general practitioner takes the polypharmacy for an elderly cerebral infarction patient with multiple diseases who is transferred from hospital to home-based care.This paper puts forward suggestions of treatment adjustment for the elderly patient by applying the medication use based on Beers criteria，so as to reduce the adverse drug reactions，and provide reference for community general practitioners to formulate multi-drug treatment programs for senile comorbidities.

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