Chinese General Practice

Active Screening，Comprehensive Evaluation，Tiered Diagnosis and Management of Diabetic Foot：Essentials of Screening，Diagnostic and Therapeutic Strategies　

WANG Aihong，ZHAO Weibo

2021, 24(24): 3013-3018. DOI: 10.12114/j.issn.1007-9572.2021.00.564

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Diabetic foot is a major cause of diabetes-related disability and mortality，which imposes a tremendous social and economic burden on individuals and society due to high recurrence rate and healthcare expenditure. Diabetic foot ulcer is the most common manifestation of diabetic foot，and the main reason of limb amputation. Complicated disease state，poor general physical conditions，severe infection，and poor outcomes are the features of Chinese patients with diabetic foot ulcer．Moreover，inadequate screening and evaluation，as well as nonstandard diagnosis and treatment still exist clinically. This commentary highlights the value of active screening and early intervention for patients with a high risk of diabetic foot，comprehensive evaluation for diabetic foot patients，using a multidisciplinary approach for tiered diagnosis and treatment，and new model for the management of diabetic foot under regular containment of COVID-19.

Diabetes Management in China：Types and Reflections　

WANG Junwei，LIU Yun，LI Lianxi

2021, 24(24): 3019-3025. DOI: 10.12114/j.issn.1007-9572.2021.00.551

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Diabetes management plays very important roles in delaying the progression of diabetes，decreasing the risk of diabetes complications and reducing diabetes-related medical expenditure. Currently，the types of diabetes management in China mainly include hospital management，community management，hospital-community integrated management and information technology-assisted management. However，limitations of various types of diabetes management have become increasingly prominent as the increase of diabetes incidence，such as non-uniform criteria，low management efficiency，and formality. Therefore，it is urgently necessary to develop a standardized information technology-assisted hospital-community integrated management model for diabetes，which will finally reduce the harm of diabetes and its chronic complications via effective，efficient and long-term diabetes management.

Frailty and Multimorbidity in the Elderly：Challenges for General Medical Services Delivered by Healthcare Facilities in a Compact Medical Consortium and Recommended Solutions　

XU Haihong，WANG Yongli，YAN Wei

2021, 24(24): 3026-3031. DOI: 10.12114/j.issn.1007-9572.2021.00.509

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Multimorbidity in the elderly is a global public health problem. Most elderly people with multimorbidity have cognitive impairment，mental and psychological problems with much higher risks of falls，disability and even death. Multimorbidity coexisting and interacting with frailty may worsen the conditions of elderly people，increasing the risk of adverse outcome，which brings new challenges to general practice. Regarding frailty and multimorbidity in the elderly in China，we proposed the recommendation：developing a general practitioners-led multidisciplinary team formed by professionals working in healthcare facilities in a compact medical consortium to deliver holistic management services，including standardized pharmacological treatment，cognitive improvement treatment，psychotherapy，in combination with exercise rehabilitation and nutritional support. We hope the recommendation could treat multimorbidity with reversing or delaying frailty，and improve the quality of life and reduce medical burden of these people.

Prevalence and Influencing Factors of Frailty among Elderly People in the Community　

FENG Qingqing，BIAN Meng，DU Yufeng

2021, 24(24): 3032-3038. DOI: 10.12114/j.issn.1007-9572.2021.00.530

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Background　Frailty is a term that describes a decrease in physiological function that results in dependency，which can be dynamic and reversible. Frailty is closely correlated with adverse health outcomes in older people，so it is particularly important to early identify frailty，and deliver interventions targeting its influencing factors in this group in a rapidly ageing world. Objective　To investigate the frailty prevalence and influencing factors in the elderly in the community，providing evidence for the development of interventions for frailty in this population. Methods　This household survey was carried out from June 2018 to June 2019 by eligible physicians with relevant trainings with the help of the neighborhood committee. Participants（n=600） were randomly selected from a random sample of 6 moderate-income communities with the assistance of Taiyuan Health Commission. The questionnaire used for collecting data includes three parts：general information，geriatric syndrome-related assessment〔Mini Nutritional Assessment-short Form（MNA-SF），Mini-mental State Examination（MMSE），Zung Self-rating Anxiety Scale（SAS），Zung Self-rating Depression Scale（SDS），Athens Insomnia Scale，Activities of Daily Living（ADL） Scale〕，and the FRAIL Scale. Multivariate ordinal Logistic regression analysis was adopted to analyze the influencing factors of frailty. Results　Altogether，513（85.5%） cases who responded to the survey effectively were included in the final analysis. Of the respondents，431（84.0%） were robust，63（12.3%） were pre-frail，and 19（3.7%） were frail. The prevalence of frailty among the respondents differed significantly by age，education level，living environment，swallowing function，number of chronic diseases，nutritional status，cognitive function，anxiety status，depression status，sleep status，and level of independence in ADLs（P<0.05）. Multivariate ordinal Logistic regression analysis found that number of chronic diseases〔OR=1.455，95%CI（1.071，1.974）〕，cognitive function 〔OR=0.915，95%CI（0.855，0.979）〕，depression〔OR=2.563，95%CI（1.185，5.540）〕，level of independence in ADLs 〔some dependency：OR=2.487，95%CI（1.310，4.721）；very dependant：OR=11.485，95%CI（4.424，29.815）〕 were the influencing factors of frailty（P<0.05）. Conclusion　The frailty of elderly in the community are affected by the number of combined chronic diseases，cognitive function，depression，and ability to perform ADL. Interventions for reducing the risk of frailty may be delivered based on the above-mentioned frailty-related factors.

Prevalence and Associated Factors of Frailty in Elderly Hospitalized Patients with White Matter Hyperintensity　

WANG Jing，WANG Xiuhong，DENG Kaisheng，WANG Zhenmin，LIU Haiyan，FANG Wen

2021, 24(24): 3039-3047. DOI: 10.12114/j.issn.1007-9572.2021.02.050

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Background　White matter hyperintensity （WMH） is more likely to occur in the elderly. It is hidden-onset，and its progression eventually leads to poor prognosis. Frailty is a common geriatric syndrome，which is strongly associated with adverse health events in the elderly. Few studies have focused on frailty in elderly WMH inpatients. Objective　To investigate the prevalence and influencing factors of frailty in elderly hospitalized patients with WMH. Methods　By use of purposive sampling method，totally 321 neurology inpatients with WMH aged 60 years or above were selected from the Affiliated Hospital of Guizhou Medical University，and Guizhou Provincial People's Hospital from December 2019 to June 2020. A self-designed General Data Questionnaire was used to collect general data. The FRAIL Scale，Barthel Index，and Morse Fall Scale were used to assess frailty，functional independence，and risk of falling，respectively. Early morning fasting venous blood samples were obtained to test laboratory indicators. WMH was detected by brain MRI，and quantified by the Fazekas Scale. Binary Logistic regression analysis was used to investigate the influencing factors of frailty. Results　Of the 321 cases，129 （40.2%） were found with frailty，and the other 192 （59.8%） without. Binary Logistic regression analysis showed that older age〔80 or older：OR=3.597，95%CI （1.330，9.730）〕，high risk of falling〔>45 points：OR=12.509，95%CI（6.460，24.221）〕and Fazekas grade of WMH〔grade 2：OR=5.503，95%CI （2.638，11.479）；grade 3：OR=6.981，95%CI （2.977，16.368）〕were associated with increased risk of frailty（P<0.05），while hemoglobin〔male≥120 g/L，female≥110 g/L：OR=0.260，95%CI （0.092，0.732）〕，and prealbumin〔≥180 mg/L：OR=0.221，95%CI （0.078，0.625）〕were associated with decreased risk of frailty （P<0.05）. Conclusion　The prevalence of frailty in this population was high. In view of this，healthcare workers should pay attention to frailty assessment in elderly hospitalized patients with WMH，especially those who are older，having high risk of falling，Fazekas grade over 1，abnormal level of hemoglobin and/or prealbumin，so as to develop a more scientific and rational management plan. Early prevention and timely intervention may be a scientific approach to improving frailty and other health-related management of such patients.

Prevalence and Risk Factors of Sarcopenia in Obese Elderly Adults　

GUO Yushu，XUE Qian，WEI Yanan，LIU Jie，WANG Jingtong

2021, 24(24): 3048-3053. DOI: 10.12114/j.issn.1007-9572.2021.00.405

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Background　The coexistence and interaction of obesity and sarcopenia in some elderly adults will easily lead to multiple adverse clinical outcomes. But there are few reports about risk factors of sarcopenia in obese elderly adults. Objective　To examine the prevalence and risk factors of sarcopenia in obese elderly adults. Methods　Totally 140 obese elderly patients were consecutively recruited from Department of Geriatrics，Peking University People's Hospital，and Beijing Zhanlanlu Community Health Center，from August 2018 to August 2019，including 115 with simple obesity and 25 also with sarcopenia. General clinical information，biochemical and metabolic indicators，comprehensive geriatric assessment results and body composition were compared between the two groups. Multivariate Logistic regression analysis was conducted to explore the risk factors of sarcopenia in obese elderly patients. Results　The prevalence of sarcopenia with obesity in all the participants，male and female participants was 17.9%（25/140），21.4%（18/84）and 12.5%（7/56），respectively. Compared to those with simple obesity，patients with sarcopenia and obesity had greater mean age，systolic blood pressure and visceral fat area as well as lower mean BMI（P<0.05）. Moreover，they had higher prevalence of fatty liver and serum creatinine（P<0.05）. Furthermore，they had lower mean levels of hemoglobin，albumin，triacylglycerol，fasting insulin，blood calcium，25-hydroxy vitamin D，estimated glomerular filtration rate，incidence of depression，muscle content，protein content and inorganic sulfate content（P<0.05）. Multivariate Logistic regression analysis demonstrated that，older age，greater visceral fat area，lower BMI and albumin were independent risk factors of sarcopenia in obese elderly patients（P<0.05）. Conclusion　The prevalence（17.9%）of sarcopenia was relatively high in this group of obese elderly patients，which may be independently associated with older age，greater visceral fat area，lower BMI and albumin.

Distribution of TCM Constitution and Associated Factors of the Severity of Clinical Symptoms in Patients with Chronic Prostatitis　

MAO Dandan，ZHAO Yan，LIU Qinghua，ZHOU Jianping，ZHENG Junzhuang

2021, 24(24): 3054-3059. DOI: 10.12114/j.issn.1007-9572.2021.00.532

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Background　The risk factors for the degree of clinical symptoms of chronic prostatitis （CP） are unclear. TCM constitution has been found to be strongly associated with the development，progression，outcome and prognosis of many diseases，but whether it also affects the development of CP is unknown. Objective　To investigate the distribution of TCM constitution and associated factors of the severity of clinical symptoms in CP patients. Methods　Convenience sampling was used to select 357 first-visit patients with CP from Andrology Clinic，Ningbo Municipal Hospital of TCM from October 2018 to December 2019. They were invited to attend a survey using two self-administered questionnaires，the TCM Constitution Classification and Determination Table for assessing TCM constitution，and Chinese version of NIH-CPSI for evaluating the severity of CP clinical symptoms. The questionnaires were returned immediately after being completed. Multivariate Logistic regression analysis was used to explore the factors associated with the severity of CP clinical symptoms. Results　In all，357 cases（100.0%）who returned responsive questionnaires were included for final analysis. The distribution of TCM constitution was as follows：66 （18.5%） with damp-heat constitution，65（18.2%） with qi-stagnation constitution，44（12.3%） with phlegm-dampness constitution，41（11.5%） with qi-deficiency constitution，37 （10.4%） with balanced constitution，37（10.4%） with yang-deficiency constitution，35 （9.8%） with yin-deficiency constitution，26（7.3%） with blood stasis constitution，and 6（1.6%） with special constitution. The severity of clinical symptoms：142 were mild （39.8%，Chinese version of NIH-CPSI score of 4 to 14），199 were moderate（55.7%，Chinese version of NIH-CPSI score of 15 to 29），and 16 were severe（4.5%，Chinese version of NIH-CPSI score of 30 to 43）. The severity of clinical symptoms differed significantly by monthly income，work stress，sexual satisfaction，sleep time，number of hours of cycling per week，and TCM constitution（P<0.05）. Multivariate Logistic regression analysis showed that monthly income〔<10 000 yuan：OR=0.629，95%CI（0.503，0.785）〕，sleep time 〔OR=0.686，95%CI（0.484，0.971）〕 and TCM constitution 〔damp-heat constitution：OR=3.177，95%CI（1.310，7.702）；qi-stagnation constitution：OR=4.902，95%CI（1.897，12.666）〕 were associated with the severity of clinical symptoms of CP（P<0.05）. Conclusion　Damp-heat constitution and qi-stagnation constitution were the two most common abnormal TCM constitution in CP patients. Low monthly income，insufficient sleep，qi-stagnation constitution and damp-heat constitution were risk factors for the exacerbation of clinical symptoms.

Intermediary Role of Autonomic Dysfunction in the Relationship between Rapid Eye Movement Sleep Behavior Disorder and Severity of Parkinson's Disease　

ZHANG Xinnan，HUANG Ying，QIN Yao，CUI Jing，GE Xiaoyan，HAN Hongjuan，LIU Long，YU Hongmei

2021, 24(24): 3060-3065. DOI: 10.12114/j.issn.1007-9572.2021.00.601

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Background　Previous studies have showed that the rapid eye movement sleep behavior disorder（RBD） and autonomic dysfunction are associated with the severity of the Parkinson's disease（PD），but there is a lack of studies on whether autonomic dysfunction plays a role in the relationship between RBD and PD severity. Objective　To examine whether autonomic dysfunction plays an intermediary role in the relationship between RBD and PD severity，and whether the role is influenced by age. Methods　A total of 669 PD patients meeting the inclusion criteria were selected from the Parkinson's Progression Markers Initiative database from January to December 2018. General socio-demographics，RBD prevalence（assessed by the REM Sleep Behaviour Disorder Screening Questionnaire），autonomic dysfunction prevalence（assessed by the Scales for Outcomes in Parkinson's Disease-Autonomic questionnaire），and PD severity 〔assessed by the modified Hoehn and Hahr （H-Y） staging〕 were collected. Using the RBD as the independent variable，severity of PD as the dependent variable，the autonomic dysfunction as the intermediate variable，and age as the subgroup variable（less than 56 years，56-65 years and greater than 65 years），a model for investigating the intermediating effect size of autonomic dysfunction between RBD and PD severity was constructed. Results　Those aged above 65 years had a higher mean modified H-Y staging than those aged less than 56 or 56-65 years（P<0.05）. Pearson correlation analysis showed that the severity of PD was positively correlated with RBD and autonomic dysfunction（r=0.200，0.299，P<0.01），and RBD was positively correlated with autonomic dysfunction（r=0.384，P<0.01）. In all participants，autonomic dysfunction partially played an intermediary role between RBD and PD severity，with an effect size of 0.031 with Bootstrap 95%CI（0.022，0.041），accounting for 50.00% （0.031/0.062） of the total effect.For those aged less than 56 years，autonomic dysfunction fully played an intermediary role between RBD and PD severity，with an effect size of 0.034 with Bootstrap 95%CI（0.016，0.056）. For those aged between 56-65 years，autonomic dysfunction partially played an intermediary role between RBD and PD severity，with an effect size of 0.028 with Bootstrap 95%CI（0.014，0.046），accounting for 39.43% （0.028/0.071） of the total effect. For those older than 65 years，autonomic dysfunction fully played an intermediary role between RBD and PD severity，with an effect size of 0.027 with Bootstrap 95%CI（0.012，0.046）. Conclusion　Autonomic dysfunction may produce intermediating effect on the relationship between RBD and PD severity，and the effect size may be impacted by age.

Discrimination Ability in Maternal and Infant Health Information and Influencing Factors in Pregnant Women　

ZHANG Juan，ZHANG Zhili，WANG Qian，GUO Xiaoqin，ZHANG Xuejuan，HU Xianming

2021, 24(24): 3065-3070. DOI: 10.12114/j.issn.1007-9572.2021.00.592

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Background　Due to current backward supervision of explosively increased maternal and infant health information，the discrimination of such information has become a major challenge to pregnant women. Objective　To explore pregnant women's ability of discriminating maternal and infant health information and associated factors. Methods　From November 2016 to August 2017，the survey was conducted among pregnant women recruited from Children's Hospital of Shanxi，Boai Hospital of Shanxi Province and Taiyuan Jinyuan District Jinsheng Town Health Center. A questionnaire designed by our research group was used in the survey to collect data including demographic information，frequency of active access to maternal and child health information，the impact of Internet information，level of general maternal and child health knowledge/information，experience of learning in the school for pregnant women，ways to access to health information，ability of discriminating health information，interpersonal communication network for maternal and child health information，etc. Multivariate Logistic regression analysis was used to explore the influencing factors of discrimination ability in maternal and infant health information. Results　A total of 1 100 cases attended the survey，and 858（78.00%） of them who returned responsive questionnaires were included for analysis. Of the respondents，345（40.21%） had self-reported difficulty in discriminating maternal and infant health information. Multivariate Logistic regression analysis showed that higher ability in discriminating maternal health information was associated with strong health awareness〔OR=1.354，95%CI（1.015，1.805）〕，active access to maternal and infant health information〔OR=1.364，95%CI（1.073，1.733）〕，having general maternal and infant health knowledge/information〔OR=1.523，95%CI（1.106，2.097）〕，and large-scale maternal and infant health information exchange network〔OR=1.461，95%CI（1.092，1.955）〕（P<0.05）. Internet information was found to be related to decreased ability to discriminate maternal and child health information〔OR=0.509，95%CI（0.340，0.762），P<0.05〕. Conclusion　Our survey indicates that there may be still great space to improve the ability of discriminating health information in pregnant women. To improve the ability of them，it is essential to promote the publicity and education of general maternal and infant health information，motivate them to actively acquire such information，encourage them to seek extensive and professional social support，and strengthen the supervision of health information quality.

Clinical Efficacy and Safety of Methotrexate with Hydroxychloroquine versus Methotrexate with Hydroxychloroquine and Leflunomide in Treating Active Rheumatoid Arthritis：a Head-to-head Comparative Trial　

CHEN Meiqing，WU Bin，LIU Fuan，CHEN Ziqing，LIN Qingyan，GAO Yisang，SUN Yuechi，CHEN Shiju，TANG Guobao

2021, 24(24): 3071-3076. DOI: 10.12114/j.issn.1007-9572.2021.00.442

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Background　Traditionally synthetized disease-modifying antirheumatic drugs are the cornerstone of rheumatoid arthritis（RA）treatment. Methotrexate（MTX）with hydroxychloroquine（HCQ），as well as MTX with HCQ and leflunomide（LEF）are common clinical combination therapies for active RA，but there is lack of head-to-head research. Objective　To compare the clinical efficacy and safety of MTX with HCQ versus MTX with HCQ and LEF in treating active RA. Methods　A total of 100 inpatients and outpatients with active RA were selected from Department of Rheumatology and Immunology，the First Affiliated Hospital of Xiamen University and Xiamen Xianyue Hospital Affiliated to Xiamen University from January 2017 to December 2019，and simply randomized into dual therapy（treated by MTX with HCQ）and triple therapy groups（treated by MTX with HCQ and LEF）in a 1∶1 ratio. The treatment for both groups lasted for 24 consecutive weeks. ACR70，ACR50，and ACR20 responses，proportion of patients using NSAIDs，dose of prednisone at 12 and 24 weeks of treatment，as well as incidence of adverse reactions during treatment were compared between the two groups. Results　A total of 88 patients were involved in efficacy evaluation，including 42 with dual therapy and 46 with triple therapy. Both groups had no significant differences in ACR70，ACR50 and ACR20 responses，proportion of patients using NSAIDs or dose of prednisone at 12 and 24 weeks of treatment（P>0.05）. A total of 94 patients were involved in safety evaluation，including 45 with dual therapy and 49 with triple therapy. The incidence of severe gastrointestinal reactions in dual therapy group was significantly higher than that in triple therapy group（P<0.05），but there was no significant intergroup difference in incidence of dizziness，elevated ALT or AST（less than 2 times the upper limit of the reference range），allergic dermatitis，hypertension，loss of vision，dental ulcer or emaciation（P>0.05）. Conclusion　Both therapies have similar clinical efficacy in treating active RA，with relatively high safety and tolerance，but the triple therapy is more helpful to reduce the risk of severe gastrointestinal reactions.

Expression of MOS Gene and Its Correlations with Clinicopathological Features and Prognosis of Patients with Colorectal Cancer　

PENG Junfu，PENG Jisheng，WANG Rui，LIU Chao，WANG Zhenbiao

2021, 24(24): 3077-3081. DOI: 10.12114/j.issn.1007-9572.2021.00.434

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Background　The specific pathogenesis of colorectal cancer is not completely clear at present，and there are few reports about the relationship of MOS gene with biological characteristics and prognosis of colorectal cancer patients. Objective　To examine the expression of MOS gene and its correlations with clinicopathological features and prognosis of patients with colorectal cancer. Methods　Data of 86 newly diagnosed colorectal cancer patients were selected from Beijing Shijitan Hospital，Capital Medical University from October 2009 to June 2019. The expression of MOS gene and its correlations with clinicopathological features and prognosis of colorectal cancer patients were analyzed. Results　The relative expression quantity of MOS gene was（4.56±2.17）in colorectal cancer tissues，which was significantly higher than that（3.12±1.65） in paracancerous tissues（P<0.001）. Subgroup analysis based on MOS expression found that，high and low MOS expression subgroups（stratified equally by the mean value of relative expression quantity of MOS gene）had no significant differences in gender ratio，distributions of age，cancer differentiation，prevalence of lymphatic metastasis or distant metastasis（P>0.05）. High MOS expression subgroup had much higher proportion of T3-4 colorectal cancer patients（P<0.05）. The median survival for high and low MOS expression subgroups was 101 months〔95%CI（92.4，112.6）〕and 116 months〔95%CI（105.6，128.7）〕，respectively，with significant intergroup difference in Kaplan-Meier survival curve（P=0.029）. Cox proportional hazards regression analysis showed that，high expression of MOS gene〔HR=7.695，95%CI（1.377，43.003）〕，lymphatic metastasis〔HR=28.585，95%CI（1.401，583.297）〕and distant metastasis〔HR=47.852，95%CI（3.527，649.257）〕were independently associated with increased risk of poor prognosis of patients with colorectal cancer（P<0.05）. Conclusion　As one of the independent risk factors of poor prognosis of patients with colorectal cancer，high expression of MOS gene may be closely correlated with the degree of colorectal cancer infiltration and prognosis，which may be a valuable predictive and prognostic biomarker，and a potential therapeutic target for colorectal cancer.

Relationship between Abnormal Methylation of GSTM1 Promoter Region and Ovarian Endometriosis　

WANG Lixian，LI Yan，KANG Shan

2021, 24(24): 3082-3086. DOI: 10.12114/j.issn.1007-9572.2021.00.591

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Background　Evidence has shown that many differentially methylated genes exist in eutopic and ectopic endometrium of endometriosis（EMT） patients，which may be closely associated with the development of EMT. Objective　To investigate the relationship between abnormal methylation of GSTM1 promoter region and ovarian EMT. Methods　Participants were selected from Department of Gynecology，the Fourth Hospital of Hebei Medical University from September 2013 to December 2015，including 65 with pathologically confirmed ovarian EMT using laparoscopic surgical treatment，and a control group of 53 with CINⅢ using total hysterectomy. The eutopic and ectopic endometriotic tissues of ovarian EMT patients and endometrial tissues of controls were collected aseptically during the operation. Pyrosequencing and RT-qPCR were employed to detect the average methylation levels in the first fragment （including-116，-111，-104，-98 CpG sites） and second fragment （including-40，-23，-16 CpG sites） of GSTM1 promoter region and mRNA expression levels，and their correlations were analyzed. Results　The average methylation level of the first fragment in the eutopic or ectopic endometrium was significantly lower than that in the control endometrium（H=2.588，P=0.046；H=6.496，P<0.001）. The average methylation level of the first fragment in the ectopic endometrium was significantly lower than that in the eutopic endometrium（H=4.213，P<0.001）. The average methylation level of the second fragment in the ectopic endometrium was significantly lower than that in the eutopic endometrium or control endometrium（H=7.693，P<0.001；H=8.257，P<0.001），but there was no significant difference between the eutopic endometrium and control endometrium（H=0.682，P=0.504）. The average mRNA expression level in the eutopic or ectopic endometrium was significantly higher than that in the control endometrium（H=6.994，P=0.011；H=3.414，P<0.001）. Moreover，the average mRNA expression level in the ectopic endometrium was significantly higher than that in the eutopic endometrium（H=3.846，P<0.001）. The expression level of GSTM1 mRNA was significantly negatively correlated with the average methylation level of the first or second fragment in GSTM1 promoter region（rs=-0.61，P<0.001；rs=-0.52，P<0.001）. Conclusion　There were abnormal hypomethylation and high mRNA expression in eutopic and ectopic endometrium in GSTM1 promoter region in patients with ovarian EMT，suggesting that abnormal hypomethylation of GSTM1 promoter region may play an important role in the development of ovarian EMT.

Recent Developments in Postpartum Blood Glucose Screening among Patients with Gestational Diabetes Mellitus　

ZHANG Dengyan，ZHU Qingshuang

2021, 24(24): 3087-3095. DOI: 10.12114/j.issn.1007-9572.2021.00.425

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Gestational diabetes mellitus（GDM）is defined as diabetes diagnosed in pregnancy although the patient's pre-pregnancy glucose metabolism is normal. The prevalence of GDM is rising globally in recent years，which has become a major public health issue endangering women's health. GDM patients have been found with a higher risk of developing type 2 diabetes，but which may be prevented or delayed effectively by low-cost interventions，so it is critical to carry out postpartum blood glucose screening. Many guidelines for postpartum glucose screening have been issued successively，with partial differences in contents，but a similarity of achieving low patient adherence to screening，which may be attributed to many factors，such as low awareness of postpartum glucose screening，and low rate of being informed about screening by physicians among patients，as well as insufficient communication between involved departments. Various attempts have been made to improve the postpartum glucose screening rate in this group，but the results are as yet unsatisfactory. To offer views on improving postpartum glucose follow-up management of GDM patients，we reviewed the guidelines on postpartum glucose screening among GDM patients，and their adherence to postpartum glucose screening，as well as methods improving the screening prevalence.

Effects of Gestational Diabetes on Glycolipid Levels and Macrosomia Incidence in Late Pregnancy　

YANG Jie，HOU Shanshan，ZHAO Lizheng，WANG Yutong

2021, 24(24): 3095-3100. DOI: 10.12114/j.issn.1007-9572.2021.00.583

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Background　Great attention has been paid to lifestyle intervention such as diet and exercise in pregnant women with gestational diabetes mellitus（GDM） clinically. Recent studies have found that glycemic control in pregnant women with GDM is satisfactory，but the incidence of macrosomia has not decreased significantly. Objective　To investigate the effects of GDM on glycolipid levels and macrosomia incidence in the third trimester of pregnancy. Methods　Through the hospital information system of Tongzhou Maternal & Child Health Hospital of Beijing，we retrospectively selected 16 134 women with full-term delivery in the hospital from 2014 to 2018，and divided them into GDM group〔including those with a delivered baby with macrosomia（GM subgroup） and with a delivered baby with normal birth weight（GN subgroup）〕and non-GDM group 〔including those with a delivered baby with macrosomia（NM subgroup） and with a delivered baby with normal birth weight（NN subgroup）〕by GDM prevalence. We compared total cholesterol （TC），triglyceride （TG），high-density lipoprotein cholesterol （HDL-C），low-high lipoprotein cholesterol （LDL-C），and fasting blood glucose（FBG） at the third trimester between GDM and non-GDM groups，GM and GN subgroups，NM and NN subgroups，NM and GM subgroups，and NN and GN subgroups，respectively. Multivariate Logistic regression analysis was used to explore the associated factors of macrosomia. Results　There were 3 834 cases in GDM group（411 in GM subgroup，and 3 423 in GN subgroup），and 12 300 in non-GDM group（898 in NM subgroup，and 11 402 in NN subgroup）. GDM group showed higher mean TG and FBG levels and lower mean TC，HDL-C and LDL-C levels than non-GDM group （P<0.05）. GN subgroup had lower mean TG and FBG levels and higher mean HDL-C level than GM subgroup （P<0.05）. NM subgroup had higher mean TC，HDL-C and LDL-C levels and lower mean TG and FBG levels than GM subgroup （P<0.05）. NN subgroup had higher mean TC，HDL-C and LDL-C levels and lower mean TG and FBG levels than GN subgroup （P<0.05）. NN subgroup had higher mean HDL-C level and lower mean TG and FBG levels than NM subgroup （P<0.05）. Multivariate Logistic regression analysis found that GDM〔OR=1.338，95%CI（1.158，1.547）〕，and pre-pregnancy BMI 〔emaciated：OR=0.476，95%CI（0.361，0.626）；overweight：OR=1.770，95%CI（1.537，2.039）；obesity：OR=2.854，95%CI（2.282，3.568）〕，weight gain during pregnancy 〔OR=1.100，95%CI（1.087，1.113）〕，gestational age at delivery 〔OR=1.728，95%CI（1.622，1.841）〕，TC in late pregnancy 〔OR=0.705，95%CI（0.514，0.966）〕，TG in late pregnancy 〔OR=1.282，95%CI（1.153，1.425）〕，LDL-C in late pregnancy 〔OR=1.487，95%CI（1.094，2.021）〕，and FBG in late pregnancy 〔OR=1.692，95%CI（1.482，1.933）〕 were associated with the delivery of a baby with macrosomia （P<0.05）. Conclusion　Elevated TG and FBG and decreased TC，HDL-C and LDL-C were found in pregnant women with GDM. GDM，blood lipid and blood glucose in late pregnancy may be associated factors of delivering a baby with macrosomia. To reduce macrosomia incidence，it is suggested to strengthen the monitoring of blood lipid and blood glucese（especially TG and FBG levels） as well as weight management in pregnancy.

Effectiveness and Safety of Immunosuppressive Agents Derived from Chinese Medicine with ACEI/ARB in Early- and Middle-stage Diabetic Nephropathy：a Meta-analysis　

WU Yu，ZHANG Zheng，FANG Jinying，WANG Yuedan，LI Wenge

2021, 24(24): 3101-3109. DOI: 10.12114/j.issn.1007-9572.2021.00.408

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Background　For early-and middle-stage diabetic nephropathy（DN），the efficacies of angiotensin-converting enzyme inhibitor（ACEI）and angiotensin Ⅱ receptor antagonist（ARB）are limited although they are used as first-line drugs. As inflammatory response play a key role in the development of DN，immunosuppressive agents derived from Chinese medicine may be used as adjuvant therapies for DN. Objective　To perform a meta-analysis of the effectiveness and safety of immunosuppressive agents derived from Chinese medicine with ACEI/ARB in the treatment of early-and middle-stage DN. Methods　Randomized controlled trials（RCTs）about effectiveness and safety in early-and middle-stage DN patients treated with immunosuppressive agents derived from Chinese medicine with ACEI/ARB（experimental group）compared with those treated with ACEI/ARB（control group）published in Chinese were screened from databases of CNKI，Wanfang Data，VIP and CBM，and those published in English from databases of Medline，EMBase，the Cochrane Library，Web of Science，from inception to May 5，2020. RevMan 5.3 software was used to complete the meta-analysis. Outcome indicators were the decrease in serum creatinine，24-hour urinary protein quantification and leukocyte count，improvement in serum albumin，and change in glutamic pyruvic transaminase after treatment，incidence of adverse reactions and overall response rate. Results　A total of 23 studies were included，involving 1 878 patients. The analysis revealed that compared to the control group，the experimental obtained greater decreases in serum creatinine level〔MD=-6.06，95%CI（-10.89，-1.22）〕，24-hour urinary protein quantification〔MD=-0.70，95%CI（-0.87，-0.53）〕，and white blood cell count〔MD=-0.42，95%CI（-0.76，-0.08）〕as well as improvement of serum albumin level〔MD=2.83，95%CI（1.66，4.01）〕. The experimental group had higher incidence of adverse reactions〔OR=1.87，95%CI（1.26，2.77）〕and overall response rate〔OR=3.05，95%CI（1.87，4.97）〕（P<0.05）. But there was no significant difference in the change of glutamic pyruvic transaminase level between the two groups〔MD=0.51，95%CI（-0.65，1.66），P=0.39〕. Conclusion　In patients with early-and middle-stage DN，the combination use of immunosuppressive agents derived from Chinese medicine and ACEI/ARB may effectively improve the renal function，serum albumin level and overall response rate，but it may result in higher risk of adverse reactions such as decreased white blood cell count，so it should be used cautiously in clinic practice.

A Systematic Review of the Incidence and Influencing Factors of Delayed Onset of LactogenesisⅡ　

HU Shanshan，LIU Jun，JIANG Panhua，SUN Zhaona，ZHU Qingxian，FU Jinyan

2021, 24(24): 3110-3115. DOI: 10.12114/j.issn.1007-9572.2021.00.460

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Background　Delayed onset of lactogenesis Ⅱ（DOLⅡ） has been proven to increase the rate of early breastfeeding cessation and shorten the duration of breastfeeding as well as raise the risk of excessive weight loss and formula milk supplementation among newborns. Therefore，understanding the incidence and influencing factors of DOLⅡ，and formulating effective interventions have a positive impact on breastfeeding. Objective　To systematically evaluate the incidence and influencing factors of DOLⅡ，to provide a scientific basis for conducting relevant research and delivering targeted interventions. Methods　Web of Science，PubMed，EMBase，Cochrane Library，VIP，CNKI，Wanfang Data and CBM were searched to collect literature about the incidence and influencing factors of DOLⅡ. Data extraction and methodological quality evaluation were performed by two researchers separately. Meta-analysis of quantitative data was conducted using Stata 12.0 software. Results　A total of 26 studies were included，and 25 of which had a report of DOLⅡincidence of 26%〔95%CI（21%，30%）〕. Meta-analysis showed that primiparity，cesarean section，gestational diabetes mellitus，insulin injection，pre-pregnancy BMI-based overweight or obesity，anxiety，depression，and delayed breastfeeding initiation time were risk factors of DOLⅡ （P<0.05），while maternal age and neonatal birth weight>3 600 g were not significantly associated with DOLⅡ （P>0.05）. Conclusion　The incidence of DOLⅡ is relatively high，which is associated with primiparity，cesarean section，gestational diabetes mellitus，insulin injection，pre-pregnancy BMI-based overweight or obesity，anxiety，depression，and delayed breastfeeding initiation time. There are still different opinions on the role of some risk factors in the development of DOLⅡ，and the causal relationship of them with DOLⅡ needs to be further verified.

Efficacy and Mechanism of Action of Danggui Niantong Decoction against Acute Gouty Arthritis in a Mouse Model：an Experimental Study　

CHEN Shaohua，WANG Chinyun，WU Changgui，ZHAO Xiao，XU Hao，SHI Qi，LIANG Qianqian

2021, 24(24): 3116-3121. DOI: 10.12114/j.issn.1007-9572.2021.00.455

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Background　Traditional Chinese Medicine（TCM）compound preparations can lower the uric acid and relieve symptoms of acute gouty arthritis（AGA），a disease caused by multiple factors，through exerting multi-target effects of multiple ingredients，but the specific mechanism of action is not completely clear. Objective　To investigate the efficacy and mechanism of action of Danggui Niantong Decoction（DND）against AGA. Methods　This experiment was conducted from 17 August to 7 October 2020. After 1 week of adaptive feeding，30 numbered male SPF C57BL/6 mice aged 10-12 weeks were equally randomized into control，solvent and DND groups，receiving phosphate buffer，3% suspension of monosodium urate，and 3% suspension of monosodium urate injected at the area around deep tarsometatarsal joints of both hind paws，respectively，for modeling. After modeling，control and solvent groups received intragastric administration of 0.9% sodium chloride injection for 1 week，while DND group received intragastric administration of DND solution for 1 week. Comparison was conducted in the three groups，involving body weight before and after treatment，increased percentage of hind paws thickness 6 hours after modeling and 1 to 7 days after treatment，relative mRNA expression quantities of IL-1β，TNF-α and iNOS in the injected hind paw tissues and serum uric acid concentration 7 days after treatment. Results　No significant inter-or intra-group difference in body weight was found in the three groups before or after treatment（P>0.05）. There was significant interaction in the increased percentage of hind paws thickness between intervention time and method（P<0.001）. The main effects of intervention time and method were both significant in the increased percentage of hind paws thickness（P<0.001）. Increased percentage of hind paws thickness in solvent group or DND group was thicker than that in control group 6 hours after modeling and 1 to 7 days after treatment，so was in DND group compared to solvent group except for the time point of the 6th day after treatment（P<0.05）. The control group had lower relative mRNA expression quantities of IL-1β，TNF-α and iNOS in the injected hind paw tissues than other two groups 7 days after treatment（P<0.01）. DND group had lower relative mRNA expression quantities of IL-1β，TNF-α and iNOS in the injected hind paw tissues compared to solvent group 7 days after treatment（P<0.01）. Serum uric acid concentration in DND group was lower than that of other two groups 7 days after treatment（P<0.01）. Conclusion　As an effective and safe prescription for multiple core issues of AGA，DND can effectively relief the degree of inflammatory swelling of the paw of AGA mice，down-regulate the mRNA expression of inflammatory factors such as IL-1β，TNF-α and iNOS，and reduce the serum uric acid concentration.

Mechanism of Protective Effect of Gubitong Recipe against Cartilage Matrix Degradation in a Model of Osteoarthritis：Exploring Based on Wnt/β-catenin Pathway　

YAN Zeran，CHEN Guangyao，CHEN Jiaqi，XU Yuan，LUO Jing，TAO Qingwen

2021, 24(24): 3122-3128. DOI: 10.12114/j.issn.1007-9572.2021.00.406

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Background　Gubitong Recipe（GR）has a good clinical effect on osteoarthritis（OA）. It also shows a good protective effect against cartilage damage in the OA rat model，but the specific mechanism of action is not yet clear. Objective　To explore the mechanism of protective effect of GR against cartilage matrix degradation in an OA model based on Wnt/β-catenin pathway. Methods　This experiment was carried out from June to September 2020. The viability of SW1353 chondrosarcoma cells was test by MTS method. The OA model of SW1353 chondrosarcoma cells was prepared using IL-1β，and the cells were divided into groups A（blank control，no interventions），B（positive control，intervened with 10 μg/L IL-1β），C（intervened with 10 μg/L IL-1β and 625 mg/L solution of GR），D（intervened with 10 μg/L IL-1β and 1 250 mg/L solution of GR），and E（intervened with 10 μg/L IL-1β and 2 500 mg/L solution of GR）. Relative mRNA expression quantites of MMP-1，MMP-3，and MMP-13 were tested by real-time quantitative polymerase chain reaction，relative protein expression quantites of MMP-1，MMP-3，MMP-13 and β-catenin by Western-blotting，supernatant solution contents of MMP-1，MMP-3，and MMP-13 by ELISA. Results　The concentration of 3 000 mg/L solution of GR partially inhibited the viability of SW1353 chondrosarcoma cells（P<0.05）. Group A had lower relative mRNA expression quantities of MMP-1，MMP-3 and MMP-13 than other four groups（P<0.05）. Group C had lower relative mRNA expression quantities of MMP-1，and MMP-3 than group B（P<0.05）. Group D had lower relative mRNA expression quantities of MMP-1，MMP-3，and MMP-13 than groups B and C（P<0.05），so did group E（P<0.05）. Group E had lower relative mRNA expression quantities of MMP-1，MMP-3 and MMP-13 than group D（P<0.05）. Group A had lower relative protein expression quantities of MMP-1，MMP-3 and MMP-13 than other four groups（P<0.05）. Group B had higher relative protein expression quantities of MMP-1 and MMP-3 than group C，and had higher relative protein expression quantities of MMP-1，MMP-3 and MMP-13 than groups D and E（P<0.05）. Group C had higher relative protein expression quantities of MMP-1 and MMP-13 than group D（P<0.05），and also had higher relative protein expression quantities of MMP-1，MMP-3 and MMP-13 than group E（P<0.05）. The relative protein expression quantities of MMP-1，MMP-3 and MMP-13 in group E were lower than those in group D（P<0.05）. The contents of MMP-1，MMP-3 and MMP-13 in supernatant solution in group A were lower than those of other four groups（P<0.05）. Group B had higher contents of MMP-1，MMP-3 and MMP-13 in supernatant solution than groups C，D，and E（P<0.05）. Group C had higher contents of MMP-1，MMP-3 and MMP-13 in supernatant solution than groups D and E（P<0.05）. The contents of MMP-1，MMP-3 and MMP-13 in supernatant solution in group E were lower than those in group D（P<0.05）. Two more groups，F〔SW1353 chondrosarcoma cells intervened with 10 μg/L IL-1β and 5 μmol/L solution of WAY-262611（an activating agent of Wnt/β-catenin pathway）〕and G（SW1353 chondrosarcoma cells intervened with 10 μg/L IL-1β and 10 μmol/L solution of dexamethasone）were created for further analysis. The relative protein expression quantities of MMP-13 and β-catenin in group A were lower than those of other six groups（P<0.05）. Group F had higher relative protein expression quantities of MMP-13 and β-catenin than groups B，C，D，E and G（P<0.05）. Group D had lower relative protein expression quantity of MMP-13 than groups B and C（P<0.05），so did groups E and G（P<0.05）. Group E had lower relative protein expression quantity of β-catenin than groups B and C（P<0.05），so did group G（P<0.05）. The relative protein expression quantity of MMP-13 in group G was lower than that of group D（P<0.05）. Group D showed higher relative protein expression quantity of β-catenin than groups E and G（P<0.05）. The relative protein expression quantities of MMP-13 and β-catenin in group G were lower than those in group E（P<0.05）. Conclusion　GR may play a partial role in protecting cartilage matrix from degradation，and the protective effect may be increased with the dose of the recipe. The major mechanism may be related to its effect of inhibiting the over-expression of MMPs and abnormal activation of Wnt/β-catenin pathway.

Fulminant Type 1 Diabetes Mellitus Complicated with Acute Myocarditis：a Case Report and Analysis　

YU Fang，WANG Aihua，JIN Jianlan，XU Chenglin，GONG Min

2021, 24(24): 3129-3133. DOI: 10.12114/j.issn.1007-9572.2021.00.526

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We reported the diagnosis and treatment of a patient with fulminant type 1 diabetes mellitus （FT1DM） with acute myocarditis，and discussed the possible pathogenesis. The FT1DM is a subtype featured by rapid-onset，critical condition，quick progression from hyperglycemia to diabetic ketoacidosis and nearly complete destruction of pancreatic beta cells even just after the onset while the patient is autoantibody negative. The patient that we encountered had a history of upper respiratory tract infection before the onset of FT1DM，and suffered from acute myocarditis one week after the onset of FT1DM，suggesting that FT1DM may be caused by the destruction of islet beta cells due to virus infection，which may be a clue for exploring the pathogenesis of type 1 diabetes. Clinicians should improve their understanding of FT1DM in order to identify it in the early stage and provide an active treatment.

Acute Renal Failure with Hypercalcemia Caused by Dihydrotachysterol in Hypoparathyroidism：a Case Analysis　

ZHOU Jiayan，JIANG Xiaohong，WANG Long

2021, 24(24): 3134-3136. DOI: 10.12114/j.issn.1007-9572.2021.00.517

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Hypercalcemia induced by dihydrotachysterol（DHT） poisoning is very rare，which is diagnosed based exclusively on medical history and medication history in general. We reported a case of acute renal failure and hypercalcemia caused by DHT poisoning with fatigue and anorexia as the first symptoms. This patient previously received surgery for benign thyroid nodules and suffered from postoperative hypoparathyroidism. Later she changed the medication regimen to DHT（ 0.5 mg/d） combined with calcium carbonate-vitamin D3（3 tablets/d） by herself. During the whole medication treatment，the serum calcium（SCa） level was not monitored. The patient was admitted to our hospital due to fatigue and anorexia without obvious inducers，who was diagnosed with acute renal failure according to serum creatinine （Scr）（458 μmol/L） and SCa（5.1 mmol/L） levels. After excluding other causes for hypercalcemia，DHT poisoning was considered. After terminating the treatment of DHT and calcium carbonate-vitamin D3，and receiving treatment with fluid replacement，diuresis，and calcitonin，the patient's Scr and SCa levels gradually returned to the reference range. So there are suggestions for clinicians and patients that during the treatment of DHT，especially treating for complex conditions（for example，comorbidities），or using DHT with other drugs，it is still necessary to regularly monitor the SCa，even if it has been controlled within the reference range before，thereby preventing the occurrence of hypercalcemia.

Adrenal Crisis Provoked by Levothyroxine in Autoimmune Polyglandular Syndrome TypeⅡ：a Case Report and Literature Review　

YUAN Haixia1，GAO Xuan2，ZHANG Jing2，HE Chunyan2，ZHOU Feng2*

2021, 24(24): 3137-3140. DOI: 10.12114/j.issn.1007-9572.2021.00.484

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Adrenal crisis is a life-threatening state of adrenal insufficiency that requires immediate treatment. Adrenal insufficiency is usually dividen into primary，secondary and tertiary. Addison's disease is the commonest cause of primary adrenal insufficiency，and is an important component of autoimmune polyglandular syndrome（APS）. APS is a rare endocrine disease with presence of autoimmune damage of more than one endocrine glands，which includes APS typeⅠ and APS type Ⅱ. This article reported a APS type Ⅱ patient with levothyroxine-induced adrenal crisis，with detailed analysis of the causes，hoping to offer more information for clinical practice.

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