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DOI:10.16662/ki.1674-0742.2021.33.089艾司西酞普兰与喹硫平联合治疗首发抑郁症的效果分析杨晓江泉州市第三医院精神科,福建泉州362121[摘要]目的探讨艾司西酞普兰与喹硫平联合治疗首发抑郁症的效果。
方法方便选取2018年1月—2020年12月在该院就诊的116例首发抑郁症患者为研究对象,以随机数表法将其划分为两组。
对照组58例患者应用艾司西酞普兰治疗,研究组58例在此基础上联合喹硫平治疗。
比较两组患者的临床疗效、治疗前后的神经因子水平[髓鞘间隙蛋白(MBP)与神经营养因子(BDNF)],治疗前、治疗4周与8周时的认知功能[以重复性成套神经心理状态测验(RBANS)评价]以及不良反应情况。
结果研究组治疗的总有效率为94.83%较对照组79.31%高,差异有统计学意义(χ2=6.202,P<0.05)。
治疗后,研究组MBP(4.52±0.85)ng/mL较对照组(5.79±0.69)ng/mL低,BDNF(27.52±4.03)ng/mL较对照组(24.33±5.00)ng/mL高,差异有统计学意义(t=8.834、3.783,P<0.05)。
治疗4周与8周时,研究组RBANS评分(73.52±10.00)分、(78.62±10.40)分较对照组高(68.03±8.46)分、(71.32±9.05)分,差异有统计学意义(t=3.192,4.033,P<0.05)。
研究组不良反应发生率为10.34%,对照组不良反应发生率为8.62%,差异无统计学意义(χ2=0.100,P>0.05)。
结论首发抑郁症患者应用艾司西酞普兰与喹硫平联合治疗能够提高临床疗效,改善神经因子水平与认知功能,安全性佳,具有临床推广价值。
[关键词]艾司西酞普兰;喹硫平;首发抑郁症[中图分类号]R5[文献标识码]A[文章编号]1674-0742(2021)11(c)-0089-04. All Rights Reserved.Analysis of the Effect of Escitalopram and Quetiapine in the Treatment ofFirst-episode DepressionYANG XiaojiangDepartment of Psychiatry,Quanzhou Third Hospital,Quanzhou,Fujian Province,362121China[Abstract]Objective To explore the effect of escitalopram and quetiapine in the treatment of first-episode depression.Methods Conveniently selected the116first-episode depression patients who visited the hospital from January2018toDecember2020for research.They were divided into two groups using a random number table.58patients in the controlgroup were treated with escitalopram,and58patients in the study group were treated with quetiapine on this basis.Compared the clinical efficacy of the two groups of patients,the levels of neurological factors[myelin interstitial protein(MBP)and neurotrophic factor(BDNF)]before and after treatment,and the cognitive function[in a repetitive set ofneuropsychological status test(RBANS)evaluation]before and after treatment,4weeks and8weeks of treatment,andadverse reactions.Results The total effective rate of treatment in the study group was94.83%higher than79.31%in thecontrol group,the difference was statistically significant(χ2=6.202,P<0.05).After treatment,MBP(4.52±0.85)ng/mL in thestudy group was lower than that in the control group(5.79±0.69)ng/mL,and BDNF(27.52±4.03)ng/mL was higher thanthat in the control group(24.33±5.00)ng/mL,the difference was statistically significant(t=8.834,3.783,P<0.05).In thetreatment of4weeks and8weeks,the RBANS score of the study group was(73.52±10.00)points and(78.62±10.40)pointshigher than that of the control group(68.03±8.46)points and(71.32±9.05)points,the difference was statistically significant(t=3.192,4.033,P<0.05).The incidence of adverse reactions in the study group was10.34%,and the incidence of adversereactions in the control group was8.62%,the difference was not statistically significant(χ2=0.100,P>0.05).Conclusion Thecombined treatment of escitalopram and quetiapine in patients with first-episode depression can improve the clinicalefficacy,improve the level of neurological factors and cognitive function,with good safety and clinical promotion value.[Key words]Escitalopram;Quetiapine;First episode depression[作者简介]杨晓江(1978-),男,本科,主治医师,研究方向为精神病。
慢性胰腺炎患者消化不良的诊治进展胡良皞，金震东海军军医大学第一附属医院消化内科，上海 200433通信作者：金震东，****************（ORCID：0000-0003-1196-9047）摘要：消化不良是临床常见的一组症状，可以分为器质性和功能性两类。
慢性胰腺炎（CP）时常出现脂肪泻、腹胀、腹痛等消化不良症状，其中大部分患者伴有胰腺外分泌功能不全（PEI），属于器质性消化不良。
临床上，PEI和消化不良的诊断需综合评估患者的临床表现、营养状况和胰腺外分泌功能，并以此制订个性化的治疗方案。
但部分患者外分泌功能良好却有消化不良的症状，其诊断和治疗仍为临床难点。
本文针对CP患者消化不良的诊治研究进展进行综述。
关键词：胰腺炎，慢性；胰腺外分泌功能不全；消化不良；诊断；治疗学Advances in the diagnosis and treatment of dyspepsia in chronic pancreatitis patientsHU Lianghao，JIN Zhendong.（Department of Gastroenterology，The First Affiliated Hospital of Navy Medical University，Shanghai 200433， China）Corresponding author： JIN Zhendong，****************（ORCID： 0000-0003-1196-9047）Abstract：Dyspepsia is a common group of clinical symptoms and can be classified into organic and functional dyspepsia. Patients with chronic pancreatitis （CP） often have the symptoms of dyspepsia such as fatty diarrhea， abdominal distention，and abdominal pain， and most patients have pancreatic exocrine insufficiency （PEI）， which belongs to organic dyspepsia. In clinical practice，the diagnosis of PEI and dyspepsia requires a comprehensive assessment of clinical manifestations，nutritional status， and pancreatic exocrine function， and an individualized treatment regimen should be developed based on such factors. However， some patients with normal exocrine function may have the symptoms of dyspepsia， and the diagnosis and treatment of such patients are still difficulties in clinical practice. This article reviews the advances in the diagnosis and treatment of dyspepsia in CP patients.Key words：Pancreatitis， Chronic； Exocrine Pancreatic Insufficiency； Dyspepsia； Diagnosis； Therapeutics消化不良指的是胃和十二指肠的不适症状，主要包括上腹部胀气、上腹疼痛或烧灼感、餐后饱胀及早饱、嗳气、恶心等，若存在器质性、代谢性疾病等病因（如消化性溃疡、胃肠道肿瘤、胰腺疾病、甲状腺功能亢进、药物不良反应等）则为器质性消化不良，其余无法用疾病原因解释的则为功能性消化不良［1］。
江苏南师大附中2022—2023学年高三一模适应性考试英语本卷满分150分，考试时间120分钟第一部分听力（共两节，满分30分）做题时，先将答案标在试卷上。
录音内容结束后，你将有两分钟的时间将试卷上的答案转涂到答题卡上。
第一部分听力（共两节，满分30分）第一节（共5小题；每小题1.5分，满分7.5分）听下面5段对话。
每段对话后有一个小题，从题中所给的A、B、C三个选项中选出最佳选项。
听完每段对话后，你都有10秒钟的时间来回答有关小题和阅读下一小题。
每段对话仅读一遍。
1. What did the woman forget?A. Her gloves.B. Her scarf.C. Her coat.2. What does the boy suggest doing?A. Going to the circus.B. Playing with small animals.C. Taking a trip to a farm.3. How far is the last stop sign?A. Two blocks away.B. Three blocks away.C. Five blocks away.4. Why couldn’t the woman hear the man clearly?A. The man was eating.B. The man was in the shower.C. The woman has bad hearing.5. Where are the speakers?A. In a gas station.B. In a clinic.C. In an interview room.第二节（共15小题；每小题1.5分，满分22.5分）听下面5段对话或独白。
每段对话或独白后有几个小题，从题中所给的A、B、C三个选项中选出最佳选项，并标在试卷的相应位置。
听每段对话或独白前，你将有时间阅读各个小题，每小题5秒钟；听完后，各小题将给出5秒钟的作答时间。
中屮中医药杂志(原中国医药学报)2021年2;j第36卷第2期CJTCMP，February 2021, Vol.36, No.2•869 -•临证经验•周斌微观辨证治疗自身免疫性胃炎经验莫方正\郭哲宇-，周斌2r北京中医药大学，北京100029; 2中国中医科学院广安门医院，北京100053)摘要：文章概述了 &身免疫性胃炎的临床特点，总结r周斌教授应丨n中医中药辨证治疗丨'丨»免疫性胃炎的临 床经验周斌教授提出先天®赋不足，脏腑发育+a，致使脾肾两虚，足木病的主要病因，治疗时强调从发病之初即补益脾肾，并贯穿疾病治疗的始终；同时根据现代胃镜及病理、血淸学等手段进行微观辨丨I丨•:，结合患荇不同的症状表现，微观辨证与宏观辨证相结合，精准治疗，从而冇效的治疗n a免疫n胃炎关键词：f丨身免疫性胃炎；周斌；微观辨证；经验C l i n i c a l experience o f Z H O U Bin i n t r e a t i n g autoimmune g a s t r i t i s based onmicroscopic syndrome d i f f e r e n t i a t i o nM O F a n g-z h e n g1,G U O Z h e-y u:,Z H O U B i n-('Beijing University o f C h i n e s e M e d i c i n e, Beijing 100029, C h i n a: "G u a n g'a n m e n Hospital, C h i n a A c a d e m y o fC h i n e s e M e d i c a l Sciences, Beijing 100053, C h i n a )A b s t r a c t:T h e article s u m m a r i z e s the clinical characteristics o f a u t o i m m u n e gastritis a n d the clinical e x p e r i e n c e o fprofessor Z H O U B i n in a p p l y i n g T C M dialectical therapy to a u t o i m m u n e gastritis. Professor Z H O U B i n pointed out that lack ofcongenital e n d o w m e n t a n d p o o r d e v e l o p m e n t o f viscera result in deficiency o f both spleen a n d kidney, w h i c h are the m a i n causeso f this disease. D u r i n g treatment, i t is e m p h a s i z e d that the spleen a n d k i d n e y sh o u l d be n o u r i s h e d f r o m the b e g i n n i n g o f the diseasea n d r u n t h r o u g h the treatment. Besides, the treatment s h o u l d reference the gastroscopy, histology, s e r u m m a r k e r s a n d differents y m p t o m s o f patients. T h e c o m b i n a t i o n o f m i c r o s c o p i c s y n d r o m e difTerentiation a n d m a c r o s c o p i c s y n d r o m e differentiationprovides precise treatment, thus effectively treating a u t o i m m u n e gastritis.K e y W O r d S I A u t o i m m u n e gastritis; Z H O U Bin: M i c r o s c o p i c s y n d r o m e differentiation; E x p e r i e n c e《胃炎的分类和分级——新悉尼系统》n i将慢性 胃炎根据病变部位的不同分为A型胃炎及B型胃炎，A 型胃炎即自身免疫性胃炎（a u t o i m m u n e gastrilis,A I G);相对于B型胃炎以胃窦病变为主要表现，A l(;病变部位 主要在胃体及胃底，而胃窦基本不受影响在我国传统中医学文献中，A1G尚无对应的中医病名，但根据 其症状体征，周斌教授认为本病当归于“痞病”“虚 劳”等范畴。
・综述・ 胫骨远端关节外骨折的治疗研究进展杜武军1,2徐彬2刘宸赫2【摘要】 胫骨远端骨折是创伤骨科较为常见的骨折。
目前胫骨远端骨折的治疗仍是创伤骨科治疗的难点及热点，治疗方法很多，但没有哪一种固定的治疗方式可以覆盖所有类型的骨折，治疗的热点多是围绕最大限度地减少破坏血运及损伤软组织情况。
随着AO及BO理念的不断完善，微创治疗已成为当前治疗的趋势。
本文就近年来胫骨远端骨折应用较多的几种微创固定治疗方式作一综合阐述。
【关键词】 胫骨骨折；内固定器；骨折固定术，髓内Study development for the treatment of extra-articular distal tibial fracture Du Wujun1,2, Xu Bin2,Liu Chenhe2. 1Shanxi Medical University, Taiyuan 030001, China; 2Department of Orthopaedics, the FirstHospital of Shanxi Medical University, Taiyuan 030001, ChinaCorresponding author: Xu Bin, Email: xushu07017@【Abstract】Distal tibial fracture is a common fracture in trauma department of orthopedics. So far,its treatment is still a hot pot and difficulty. There are many treatments about distal tibial fracture, but noone fixed treatment modality covers all sorts of fractures. And the hot pot of treatment centres on thereduction of destorying the blood supply and hurting soft issue in most largest extent. With the increasinglydevelopment of the aspect of AO and BO, minimally invasive fixation has been temporary trend oftreatment. This article carried on a comprehensive explaination about some minimally invasive fixationsmore used in the treatment of distal tibia fracture in recent years.【Key words】 Tibial fractures; Internal fixators; Fracture fixation, intramedullary胫骨远端骨折在创伤骨科中较为常见。
Chapter 1Human Body as a WholeMedical TerminologyLearn the following combining forms, prefixes and suffixesand write the meaning of the medical term in the space provided.1. a hormone secreted from the adrenal gland2. inflammation of the adrenal gland3. pertaining to medicine4. pertaining to biology5. pertaining to chemistry6. pertaining to the blood vessel7. pertaining to cells8. pertaining to molecules9. pertaining to the medicine of the living thing10. the study of the living thing11. pertaining to the physics of the living thing12. the study of the heart13. the disease of the heart14. the record of the heart waves15. the study of the human inner secretion from glands16. pertaining to the production of hormone17. the study of inner gland secretion18. the red blood cell19. the white blood cell20. the lymph cell21. the study of cell22. the study of chemistry of cell23. the study of biology of cell25. the tumor of the embryo26. the study of the disease of the embryo27. the study of the human inner secretion from glands28. pertaining to the inside of the heart29. pertaining to the inside of the cell30. above the skin31. above the skin32. inflammation of the skin33. red blood cells34. instrument of measuring red blood cells35. to breathe out the waste gas36. to drive somebody or something out37. to spread outside38. sth that produces diseases39. the study of blood40. blood cells41. the study of tissues42. the study of tissue pathology43. therapy treatment, hence tissue treatment44. pertaining to the base45. pertaining to the toxin46. pertaining to symptoms47. the study of body’s auto protection from diseases48. protected from49. deficiency in the immune system of the body50. substance from the adrenal gland51. water from it52. the study of societies53. the study of urinary system55. lymph cells56. tumor of the lymphatic system57. the study of the lymphatic system58. the study of physical growth59. a doctor of internal medicine60. treatment by physiological methods61. the new growth ,tumor62. the study of mind63. abnormal condition of the mind64. the study of the relationship between psychology and biology65. a condition of over activity of the thyroid gland66. the condition of under activity of the thyroid gland67. the inflammation of the thyroid gland68.cutting apart the human body as a branch of medical sciences69. cut open the bone70.to cut the heart open71. pertaining to the blood vessel72. inflammation of the blood vessel73. pertaining to the lymphatic system and the blood vesselKey to the Exercises B.1.（embryo）embryology2.(process/condition) mechanism3.(heart) cardiovascular4.(color) chromatin5.(secretion) endocrinology6.(cell) cytology7.(sth. that produces or is produced) pathogen8.(lymph) lymphatic9.(the study of) psychology10.(pertaining to) regularLanguage Points:put together组成known as 叫做joints between bones关节to provide points of attachment for the muscles that move the body牵动骨骼肌引起各种运动hip joint髋关节flexible有韧性的cushioning缓冲replaced by bone 骨化one bone moves in relation to the other两骨彼此靠近产生运动contents物质nourishment营养物质function发挥功能waste products废物accumulate积聚poison the body危害生命distributes运送needed materials有用的物质unneeded ones废物is made up of包括protect…against foreign invaders防止外来侵袭（See! Power Point）identical对等的receives吸收traveled through流经forced out压送reenter流入directly直接地channels 管道filters过滤larynx喉管trachea气管two lungs左右肺very large number of 大量的air spaces肺泡release释放出extending 延伸到broken down分解absorbed into吸收进chewing咀嚼esophagus食管Key to the Section B Passage 1 Exercises B.1. (The skeletal system consists of bones, joints and soft bones.)2. (Heart is generated when muscles are contracted, which helps keep the bodytemperature constant.)3. (The circulation of blood carries useful materials to all body cells while removing wasteones.)4. (Oxygen is inhaled and carbon dioxide is exhaled in the process of respiration.)5. (The digestion of food involves both mechanical and chemical procedures.)6. (The urinary system keeps normal levels of water and of certain chemicals in the body.)7. (The pituitary is a major gland located under the brain in the middle of the head.)8. (The brain collects and processes information and then sends instructions to all parts ofthe body to be carried out.)9. (The main function of the male reproductive system is to generate, transport and keepactive male sex cells.)10. (The largest of the body’s organs, the skin protects the inner structure of the body with acomplete layer.)Key to the Section A Passage 1 Exercises E.1.cardiovascular diseases2. function of the pituitary3. the urinary tract4. molecules5. artery6. endocrinology7. dyspnea / difficulty in respiration 8. saliva9. histology 10. blood circulation11. hematology 12. physiology13. anatomy 14. the female reproductive15. nervous cells 16. immunology17. indigestion / poor in digestion 18. voluntary muscle19. embryology 20. psychologySection B, Passage 2 Cells and TissuesLanguage PointsOrganized组（构）成arranged in to构成in turn are grouped into又进一步组成serves its specific有特定的bear in mind记住result from源于billions亿万determind确立fit on合在一起by contrast相比之下machinary机构while normally在正常情况下function with great efficiency高效地发挥作用are subject to易于发生result in导致millionth百万分之一equal等于average一般 a speck barely visible基本上看不见的一个小点The science that deals with cells on the smalleststructural and functional level is called molecular biology.从最小的结构及功能水平研究细胞的科学叫分子生物学。
Exercise and Type2DiabetesThe American College of Sports Medicine and the American Diabetes Association:joint position statementS HERI R.C OLBERG,PHD,FACSM1R ONALD J.S IGAL,MD,MPH,FRCP(C)2 B O F ERNHALL,PHD,FACSM3J UDITH G.R EGENSTEINER,PHD4B RYAN J.B LISSMER,PHD5R ICHARD R.R UBIN,PHD6L ISA C HASAN-T ABER,SCD,FACSM7A NN L.A LBRIGHT,PHD,RD8B ARRY B RAUN,PHD,FACSM9Although physical activity(PA)is a key element in the prevention and management of type2 diabetes,many with this chronic disease do not become or remain regularly active.High-quality studies establishing the importance of exercise andfitness in diabetes were lacking until recently, but it is now well established that participation in regular PA improves blood glucose control and can prevent or delay type2diabetes,along with positively affecting lipids,blood pressure, cardiovascular events,mortality,and quality of life.Structured interventions combining PA and modest weight loss have been shown to lower type2diabetes risk by up to58%in high-risk populations.Most benefits of PA on diabetes management are realized through acute and chronic improvements in insulin action,accomplished with both aerobic and resistance training.The benefits of physical training are discussed,along with recommendations for varying activities, PA-associated blood glucose management,diabetes prevention,gestational diabetes mellitus, and safe and effective practices for PA with diabetes-related complications.Diabetes Care33:e147–e167,2010 INTRODUCTIOND iabetes has become a widespreadepidemic,primarily because of theincreasing prevalence and inci-dence of type2diabetes.According to the Centers for Disease Control and Preven-tion,in2007,almost24million Ameri-cans had diabetes,with one-quarter of those,or six million,undiagnosed(261). Currently,it is estimated that almost60 million U.S.residents also have prediabe-tes,a condition in which blood glucose(BG)levels are above normal,thus greatlyincreasing their risk for type2diabetes(261).Lifetime risk estimates suggest thatone in three Americans born in2000orlater will develop diabetes,but in high-risk ethnic populations,closer to50%may develop it(200).Type2diabetes is asignificant cause of premature mortalityand morbidity related to cardiovasculardisease(CVD),blindness,kidney andnerve disease,and amputation(261).Al-though regular physical activity(PA)mayprevent or delay diabetes and its compli-cations(10,46,89,112,176,208,259,294),most people with type2diabetes are notactive(193).In this article,the broader term“physical activity”(defined as“bodilymovement produced by the contractionof skeletal muscle that substantially in-creases energy expenditure”)is used in-terchangeably with“exercise,”which isdefined as“a subset of PA done with theintention of developing physicalfitness(i.e.,cardiovascular[CV],strength,andflexibility training).”The intent is to rec-ognize that many types of physical move-ment may have a positive effect onphysicalfitness,morbidity,and mortalityin individuals with type2diabetes.Diagnosis,classification,andetiology of diabetesCurrently,the American Diabetes Associ-ation(ADA)recommends the use of anyof the following four criteria for diagnos-ing diabetes:1)glycated hemoglobin(A1C)value of6.5%or higher,2)fastingplasma glucoseՆ126mg/dl(7.0mmol/l),3)2-h plasma glucoseՆ200mg/dl(11.1mmol/l)during an oral glucose tol-erance test using75g of glucose,and/or4)classic symptoms of hyperglycemia(e.g.,polyuria,polydipsia,and unex-plained weight loss)or hyperglycemic cri-sis with a random plasma glucose of200mg/dl(11.1mmol/l)or higher.In the ab-sence of unequivocal hyperglycemia,thefirst three criteria should be confirmed byrepeat testing(4).Prediabetes is diag-nosed with an A1C of5.7–6.4%,fastingplasma glucose of100–125mg/dl(5.6–6.9mmol/l;i.e.,impaired fasting glucose[IFG]),or2-h postload glucose of140–199mg/dl(7.8–11.0mmol/l;i.e.,im-paired glucose tolerance[IGT])(4).The major forms of diabetes can becategorized as type1or type2(4).In type1diabetes,which accounts for5–10%ofcases,the cause is an absolute deficiencyof insulin secretion resulting from auto-immune destruction of the insulin-producing cells in the pancreas.Type2●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●From the1Human Movement Sciences Department,Old Dominion University,Norfolk,Virginia;the2De-partments of Medicine,Cardiac Sciences,and Community Health Sciences,Faculties of Medicine and Kinesiology,University of Calgary,Calgary,Alberta,Canada;the3Department of Kinesiology and Com-munity Health,University of Illinois at Urbana-Champaign,Urbana,Illinois;the4Divisions of General Internal Medicine and Cardiology and Center for Women’s Health Research,University of Colorado School of Medicine,Aurora,Colorado;the5Department of Kinesiology and Cancer Prevention Research Center,University of Rhode Island,Kingston,Rhode Island;the6Departments of Medicine and Pediatrics, The Johns Hopkins University School of Medicine,Baltimore,Maryland;the7Division of Biostatistics and Epidemiology,University of Massachusetts,Amherst,Massachusetts;the8Division of Diabetes Transla-tion,Centers for Disease Control and Prevention,Atlanta,Georgia;and the9Department of Kinesiology, University of Massachusetts,Amherst,Massachusetts.Corresponding author:Sheri R.Colberg,scolberg@.This joint position statement is written by the American College of Sports Medicine and the American Diabetes Association and was approved by the Executive Committee of the American Diabetes Association in July2010.This statement is published concurrently in Medicine&Science in Sports&Exercise and Diabetes Care.Individual name recognition is stated in the ACKNOWLEDGMENTS at the end of the statement.Thefindings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.DOI:10.2337/dc10-9990©2010by the American Diabetes Association.Readers may use this article as long as the work is properly cited,the use is educational and not for profit,and the work is not altered.See http://creativecommons.org/licenses/by-nc-nd/3.0/for details.See accompanying article,p.2692.R e v i e w s/C o m m e n t a r i e s/A D A S t a t e m e n t sdiabetes(90–95%of cases)results from a combination of the inability of muscle cells to respond to insulin properly(insu-lin resistance)and inadequate compensa-tory insulin secretion.Less common forms include gestational diabetes melli-tus(GDM),which is associated with a 40–60%chance of developing type2di-abetes in the next5–10years(261).Dia-betes can also result from genetic defects in insulin action,pancreatic disease,sur-gery,infections,and drugs or chemicals (4,261).Genetic and environmental factors are strongly implicated in the develop-ment of type2diabetes.The exact genetic defects are complex and not clearly de-fined(4),but risk increases with age,obe-sity,and physical inactivity.Type2 diabetes occurs more frequently in popu-lations with hypertension or dyslipide-mia,women with previous GDM,and non-Caucasian people including Native Americans,African Americans,Hispanic/ Latinos,Asians,and Pacific Islanders. Treatment goals in type2diabetes The goal of treatment in type2diabetes is to achieve and maintain optimal BG, lipid,and blood pressure(BP)levels to prevent or delay chronic complications of diabetes(5).Many people with type2di-abetes can achieve BG control by follow-ing a nutritious meal plan and exercise program,losing excess weight,imple-menting necessary self-care behaviors, and taking oral medications,although others may need supplemental insulin (261).Diet and PA are central to the man-agement and prevention of type2diabe-tes because they help treat the associated glucose,lipid,BP control abnormalities, as well as aid in weight loss and mainte-nance.When medications are used to control type2diabetes,they should aug-ment lifestyle improvements,not replace them.ACUTE EFFECTS OFEXERCISEFuel metabolism during exercise Fuel mobilization,glucose production, and muscle glycogenolysis.The main-tenance of normal BG at rest and during exercise depends largely on the coordina-tion and integration of the sympathetic nervous and endocrine systems(250). Contracting muscles increase uptake of BG,although BG levels are usually main-tained by glucose production via liver gly-cogenolysis and gluconeogenesis and mobilization of alternate fuels,such asfree fatty acids(FFAs)(250,268).Several factors influence exercise fueluse,but the most important are the inten-sity and duration of PA(9,29,47,83,111,133,160,181,241).Any activity causes ashift from predominant reliance on FFA atrest to a blend of fat,glucose,and muscleglycogen,with a small contributionfrom amino acids(15,31).With in-creasing exercise intensity,there is agreater reliance on carbohydrate as longas sufficient amounts are available inmuscle or blood(21,23,47,133).Earlyin exercise,glycogen provides the bulkof the fuel for working muscles.As gly-cogen stores become depleted,musclesincrease their uptake and use of circu-lating BG,along with FFA released fromadipose tissue(15,132,271).Intramus-cular lipid stores are more readily usedduring longer-duration activities andrecovery(23,223,270).Glucose pro-duction also shifts from hepatic glyco-genolysis to enhanced gluconeogenesisas duration increases(250,268).Evidence statement.PA causes increasedglucose uptake into active muscles bal-anced by hepatic glucose production,with a greater reliance on carbohydrate tofuel muscular activity as intensity in-creases.The American College of SportsMedicine(ACSM)evidence category A(seeTables1and2for explanation).Insulin-independent and insulin-dependent muscle glucose uptake dur-ing exercise.There are two well-definedpathways that stimulate glucose uptakeby muscle(96).At rest and postprandi-ally,its uptake by muscle is insulin de-pendent and serves primarily to replenishmuscle glycogen stores.During exercise,contractions increase BG uptake to sup-plement intramuscular glycogenolysis(220,227).As the two pathways are dis-tinct,BG uptake into working muscle isnormal even when insulin-mediated up-take is impaired in type2diabetes(28,47,293).Muscular BG uptake re-mains elevated postexercise,with thecontraction-mediated pathway persist-ing for several hours(86,119)and insulin-mediated uptake for longer(9,33,141,226).Glucose transport into skeletal mus-cle is accomplished via GLUT proteins,with GLUT4being the main isoform inmuscle modulated by both insulin andcontractions(110,138).Insulin activatesGLUT4translocation through a complexsignaling cascade(256,293).Contrac-tions,however,trigger GLUT4transloca-tion at least in part through activation of5Ј-AMP–activated protein kinase(198,293).Insulin-stimulated GLUT4translocation is generally impaired in type2diabetes(96).Both aerobic and resis-tance exercises increase GLUT4abun-dance and BG uptake,even in the presenceof type2diabetes(39,51,204,270).Evidence statement.Insulin-stimulatedBG uptake into skeletal muscle predomi-nates at rest and is impaired in type2diabetes,while muscular contractionsstimulate BG transport via a separate ad-ditive mechanism not impaired by insulinresistance or type2diabetes.ACSM evi-dence category A.Postexercise glycemic control/BGlevelsAerobic exercise effects.During mod-erate-intensity exercise in nondiabeticpersons,the rise in peripheral glucose up-take is matched by an equal rise in hepaticglucose production,the result being thatBG does not change except during pro-longed,glycogen-depleting exercise.Inindividuals with type2diabetes perform-ing moderate exercise,BG utilization bymuscles usually rises more than hepaticglucose production,and BG levels tend todecline(191).Plasma insulin levels nor-mally fall,however,making the risk ofexercise-induced hypoglycemia in any-one not taking insulin or insulin secreta-gogues very minimal,even withprolonged PA(152).The effects of a sin-gle bout of aerobic exercise on insulin ac-tion vary with duration,intensity,andsubsequent diet;a single session in-creases insulin action and glucose toler-ance for more than24h but less than72h(26,33,85,141).The effects ofmoderate aerobic exercise are similarwhether the PA is performed in a singlesession or multiple bouts with the sametotal duration(14).During brief,intense aerobic exercise,plasma catecholamine levels rise mark-edly,driving a major increase in glucoseproduction(184).Hyperglycemia can re-sult from such activity and persist for upto1–2h,likely because plasma catechol-amine levels and glucose production donot return to normal immediately withcessation of the activity(184).Evidence statement.Although moderateaerobic exercise improves BG and insulin ac-tion acutely,the risk of exercise-induced hy-poglycemia is minimal without use ofexogenous insulin or insulin secretagogues.Transient hyperglycemia can follow intensePA.ACSM evidence category C.Exercise and type2diabetesResistance exercise effects.The acute effects of a single bout of resistance train-ing on BG levels and/or insulin action in individuals with type2diabetes have not been reported.In individuals with IFG (BG levels of100–125mg/dl),resistance exercise results in lower fasting BG levels 24h after exercise,with greater reduc-tions in response to both volume(multi-ple-vs.single-set sessions)and intensity of resistance exercise(vigorous compared with moderate)(18).Evidence statement.The acute effects of resistance exercise in type2diabetes have not been reported,but result in lower fast-ing BG levels for at least24h after exercise in individuals with IFG.ACSM evidence category C.Combined aerobic and resistance and other types of training.A combination of aerobic and resistance training may be more effective for BG management than either type of exercise alone(51,238).Any increase in muscle mass that may re-sult from resistance training could con-tribute to BG uptake without altering themuscle’s intrinsic capacity to respond toinsulin,whereas aerobic exercise en-hances its uptake via a greater insulin ac-tion,independent of changes in musclemass or aerobic capacity(51).However,all reported combination training had agreater total duration of exercise and ca-loric use than when each type of trainingwas undertaken alone(51,183,238).Mild-intensity exercises such as tai chiand yoga have also been investigated fortheir potential to improve BG manage-ment,with mixed results(98,117,159,257,269,286,291).Although tai chi maylead to short-term improvements in BGlevels,effects from long-term training(i.e.,16weeks)do not seem to last72hafter the last session(257).Some studieshave shown lower overall BG levels withextended participation in such activities(286,291),although others have not(159,257).One study suggested that yo-ga’s benefits on fasting BG,lipids,oxida-tive stress markers,and antioxidant statusare at least equivalent to more conven-tional forms of PA(98).However,a meta-analysis of yoga studies stated that thelimitations characterizing most studies,such as small sample size and varyingforms of yoga,preclude drawingfirmconclusions about benefits to diabetesmanagement(117).Evidence statement.A combination ofaerobic and resistance exercise trainingmay be more effective in improving BGcontrol than either alone;however,morestudies are needed to determine if totalcaloric expenditure,exercise duration,orexercise mode is responsible.ACSM evi-dence category der forms of exercise(e.g.,tai chi,yoga)have shown mixed re-sults.ACSM evidence category C.Table1—Evidence categories for ACSM and evidence-grading system for clinical practice recommendations for ADAI.ACSM evidence categoriesEvidencecategory Source of evidence DefinitionA Randomized,controlled trials(overwhelming data)Provides a consistent pattern offindings with substantial studiesB Randomized,controlled trials(limited data)Few randomized trials exist,which are small in size,and results are inconsistentC Nonrandomized trials,observational studies Outcomes are from uncontrolled,nonrandomized,and/or observational studiesD Panel consensus judgment Panel’s expert opinion when the evidence is insufficient to place it in categoriesA–CII.ADA evidence-grading system for clinical practice recommendationsLevel ofevidence DescriptionA Clear evidence from well-conducted,generalizable,randomized,controlled trials that are adequately powered,including thefollowing:•Evidence from a well-conducted multicenter trial•Evidence from a meta-analysis that incorporated quality ratings in the analysisCompelling nonexperimental evidence,i.e.,the“all-or-none”rule developed by the Centre for Evidence-Based Medicine at OxfordSupportive evidence from well-conducted,randomized,controlled trials that are adequately powered,including the following:•Evidence from a well-conducted trial at one or more institutions•Evidence from a meta-analysis that incorporated quality ratings in the analysisB Supportive evidence from well-conducted cohort studies,including the following:•Evidence from a well-conducted prospective cohort study or registry•Evidence from a well-conducted meta-analysis of cohort studiesSupportive evidence from a well-conducted case-control studyC Supportive evidence from poorly controlled or uncontrolled studies,including the following:•Evidence from randomized clinical trials with one or more major or three or more minor methodologicalflaws that couldinvalidate the results•Evidence from observational studies with high potential for bias(such as case series with comparison to historical controls)•Evidence from case series or case reportsConflicting evidence with the weight of evidence supporting the recommendationE Expert consensus or clinical experienceColberg and AssociatesTable2—Summary of ACSM evidence and ADA clinical practice recommendation statementsACSM evidence and ADA clinical practice recommendation statements ACSM evidence category (A,highest;D,lowest)/ ADA level of evidence (A,highest;E,lowest)Acute effects of exercise•PA causes increased glucose uptake into active muscles balanced by hepatic glucoseproduction,with a greater reliance on carbohydrate to fuel muscular activity as intensityincreases.A/*•Insulin-stimulated BG uptake into skeletal muscle predominates at rest and is impairedin type2diabetes,while muscular contractions stimulate BG transport via a separate,additive mechanism not impaired by insulin resistance or type2diabetes.A/*•Although moderate aerobic exercise improves BG and insulin action acutely,the risk ofexercise-induced hypoglycemia is minimal without use of exogenous insulin or insulinsecretagogues.Transient hyperglycemia can follow intense PA.C/*•The acute effects of resistance exercise in type2diabetes have not been reported,butresult in lower fasting BG levels for at least24h postexercise in individuals with IFG.C/*•A combination of aerobic and resistance exercise training may be more effective inimproving BG control than either alone;however,more studies are needed todetermine whether total caloric expenditure,exercise duration,or exercise mode isresponsible.B/*•Milder forms of exercise(e.g.,tai chi,yoga)have shown mixed results.C/*•PA can result in acute improvements in systemic insulin action lasting from2to72h.A/*Chronic effects of exercise training •Both aerobic and resistance training improve insulin action,BG control,and fatoxidation and storage in muscle.B/*•Resistance exercise enhances skeletal muscle mass.A/*•Blood lipid responses to training are mixed but may result in a small reduction in LDLcholesterol with no change in HDL cholesterol or bined weight lossand PA may be more effective than aerobic exercise training alone on lipids.C/*•Aerobic training may slightly reduce systolic BP,but reductions in diastolic BP are lesscommon,in individuals with type2diabetes.C/*•Observational studies suggest that greater PA andfitness are associated with a lowerrisk of all-cause and CV mortality.C/*•Recommended levels of PA may help produce weight loss.However,up to60min/daymay be required when relying on exercise alone for weight loss.C/*•Individuals with type2diabetes engaged in supervised training exhibit greatercompliance and BG control than those undertaking exercise training withoutsupervision.B/*•Increased PA and physicalfitness can reduce symptoms of depression and improvehealth-related QOL in those with type2diabetes.B/*PA and prevention of type2diabetes •At least2.5h/week of moderate to vigorous PA should be undertaken as part oflifestyle changes to prevent type2diabetes onset in high-risk adults.A/APA in prevention and control of GDM •Epidemiological studies suggest that higher levels of PA may reduce risk of developingGDM during pregnancy.C/*•RCTs suggest that moderate exercise may lower maternal BG levels in GDM.B/*Preexercise evaluation•Before undertaking exercise more intense than brisk walking,sedentary persons withtype2diabetes will likely benefit from an evaluation by a physician.ECG exercisestress testing for asymptomatic individuals at low risk of CAD is not recommended butmay be indicated for higher risk.C/CRecommended PA participation for persons with type2 diabetes •Persons with type2diabetes should undertake at least150min/week of moderate tovigorous aerobic exercise spread out during at least3days during the week,with nomore than2consecutive days between bouts of aerobic activity.B/B•In addition to aerobic training,persons with type2diabetes should undertakemoderate to vigorous resistance training at least2–3days/week.B/B •Supervised and combined aerobic and resistance training may confer additional healthbenefits,although milder forms of PA(such as yoga)have shown mixed results.Persons with type2diabetes are encouraged to increase their total daily unstructuredPA.Flexibility training may be included but should not be undertaken in place ofother recommended types of PA.B/C(continued)Exercise and type2diabetesInsulin resistanceAcute changes in muscular insulin re-sistance.Most benefits of PA on type2 diabetes management and prevention are realized through acute and chronic im-provements in insulin action(29,46, 116,118,282).The acute effects of a re-cent bout of exercise account for most of the improvements in insulin action,with most individuals experiencing a decrease in their BG levels during mild-and mod-erate-intensity exercise and for2–72h af-terward(24,83,204).BG reductions are related to the dura-tion and intensity of the exercise,preex-ercise control,and state of physical training(24,26,47,238).Although previ-ous PA of any intensity generally exerts its effects by enhancing uptake of BG for gly-cogen synthesis(40,83)and by stimulat-ing fat oxidation and storage in muscle (21,64,95),more prolonged or intense PAacutely enhances insulin action for longerperiods(9,29,75,111,160,238).Acute improvements in insulin sensi-tivity in women with type2diabetes havebeen found for equivalent energy expen-ditures whether engaging in low-intensityor high-intensity walking(29)but may beaffected by age and training status(24,75,100,101,228).For example,mod-erate-to heavy-intensity aerobic trainingundertaken three times a week for6months improved insulin action in bothyounger and older women but persistedonly in the younger group for72–120h.Acute changes in liver’s ability to pro-cess glucose.Increases in liver fat con-tent common in obesity and type2diabetesare strongly associated with reduced he-patic and peripheral insulin action.En-hanced whole-body insulin action afteraerobic training seems to be related to gainsin peripheral,not hepatic,insulin action(146,282).Such training not resulting inoverall weight loss may still reduce hepaticlipid content and alter fat partitioning anduse in the liver(128).Evidence statement.PA can result inacute improvements in systemic insulinaction lasting from2to72h.ACSM evi-dence category A.CHRONIC EFFECTS OFEXERCISE TRAININGMetabolic control:BG levels and insu-lin resistance.Aerobic exercise has beenthe mode traditionally prescribed for dia-betes prevention and management.Even1week of aerobic training can improvewhole-body insulin sensitivity in individ-uals with type2diabetes(282).Moderateand vigorous aerobic training improve in-Table2—ContinuedACSM evidence and ADA clinical practice recommendation statements ACSM evidence category (A,highest;D,lowest)/ ADA level of evidence (A,highest;E,lowest)Exercise with nonoptimal BG control •Individuals with type2diabetes may engage in PA,using caution when exercising withBG levels exceeding300mg/dl(16.7mmol/l)without ketosis,provided they arefeeling well and are adequately hydrated.C/E•Persons with type2diabetes not using insulin or insulin secretagogues are unlikely toexperience hypoglycemia related to ers of insulin and insulin secretagogues areadvised to supplement with carbohydrate as needed to prevent hypoglycemia duringand after exercise.C/CMedication effects on exercise responses •Medication dosage adjustments to prevent exercise-associated hypoglycemia may berequired by individuals using insulin or certain insulin secretagogues.Most othermedications prescribed for concomitant health problems do not affect exercise,withthe exception of-blockers,some diuretics,and statins.C/CExercise with long-term complications of diabetes •Known CVD is not an absolute contraindication to exercise.Individuals with anginaclassified as moderate or high risk should likely begin exercise in a supervised cardiacrehabilitation program.PA is advised for anyone with PAD.C/C•Individuals with peripheral neuropathy and without acute ulceration may participatein moderate weight-bearing prehensive foot care including dailyinspection of feet and use of proper footwear is recommended for prevention and earlydetection of sores or ulcers.Moderate walking likely does not increase risk of footulcers or reulceration with peripheral neuropathy.B/B•Individuals with CAN should be screened and receive physician approval and possiblyan exercise stress test before exercise initiation.Exercise intensity is best prescribedusing the HR reserve method with direct measurement of maximal HR.C/C•Individuals with uncontrolled proliferative retinopathy should avoid activities thatgreatly increase intraocular pressure and hemorrhage risk.D/E•Exercise training increases physical function and QOL in individuals with kidneydisease and may even be undertaken during dialysis sessions.The presence ofmicroalbuminuria per se does not necessitate exercise restrictions.C/CAdoption and maintenance of exercise by persons with diabetes •Efforts to promote PA should focus on developing self-efficacy and fostering socialsupport from family,friends,and health care providers.Encouraging mild or moderatePA may be most beneficial to adoption and maintenance of regular PA participation.Lifestyle interventions may have some efficacy in promoting PA behavior.B/B*No recommendation given.Colberg and Associates。
司维拉姆联合血液灌流治疗血液透析患者顽固性皮肤瘙痒症的临床研究曹珊，刘玉（萍乡市人民医院肾内科，江西萍乡337000）摘要：目的探究司维拉姆联合血液灌流治疗血液透析患者顽固性皮肤瘙痒症的临床价值。
方法选取2018年12月至2020年6月于本院行血液透析治疗＞3个月且合并顽固性皮肤瘙痒患者50例作为研究对象，按照随机数字表法分为两组，每组25例。
对照组给予血液灌流治疗，观察组在对照组基础上给予司维拉姆治疗。
比较两组临床疗效、血清因子、皮肤瘙痒评分及不良反应发生率。
结果治疗后，观察组瘙痒症状缓解率（96.00%）高于对照组（80.00%），但差异无统计学意义；观察组改良Duo氏瘙痒评分、血清磷（P）、甲状旁腺素（PTH）、肌酐（SCr）、尿素氮（BUN）均低于对照组，差异具有统计学意义（P＜0.05）；两组血清钙（Ca）、不良反应发生率比较差异无统计学意义。
结论司维拉姆联合血液灌流治疗血液透析患者的顽固性皮肤瘙痒效果显著，可明显改善患者的临床瘙痒症状。
关键词：司维拉姆；血液灌流；血液透析；顽固性皮肤瘙痒症Clinical study on sevelamer combined with hemoperfusion in treatment of hemodialysis patientswith intractable cutaneous pruritusCAO Shan,LIU Yu(Department of Nephrology,Pingxiang People's Hospital,Pingxiang,Jiangxi,337000,China) Abstract:Objective To investigate the clinical value of sevelamer combined with hemoperfusion in treatment of hemodialysis patients with in-tractable cutaneous pruritus.Methods50patients with intractable cutaneous pruritus who underwent hemodialysis treatment3months in our hospi-tal from December2018to June2020were selected as the research subjects,and they were divided into two groups according to the random number table method,with25cases in each group.The control group was given hemoperfusion treatment,and the observation group was given sevelamer treatment on the basis of the control group.The clinical efficacy,serum factors,skin pruritus score and the incidence of adverse reactions were com-pared between the two groups.Results After treatment,the remission rate of cutaneous pruritus in the observation group(96.00%)was higher than that of the control group(80.00%),but the difference was not statistically significant;the modified Duo's pruritus score,serum phosphorus(P),para-thyroid hormone(PTH),and serum creatinine(SCr)and blood urea nitrogen(BUN)in the observation group were lower than those of the control group,and the difference was statistically significant(P＜0.05);there was no significant difference in the incidence of serum calcium(Ca)and ad-verse reactions between the two groups.Conclusion Sevelamer combined with hemoperfusion in treatment of hemodialysis patients with intractable cutaneous pruritus has significant efficacy of improving clinical pruritus symptoms.Key words:Sevelamer;Hemoperfusion;Hemodialysis;Intractable cutaneous pruritus皮肤瘙痒症是终末期肾脏病常见并发症，22%～48%的维持性血液透析患者存在中重度皮肤瘙痒[1]。
unit 1hemoglobin 血红蛋白polycythemia 红血球增多症hypertrophy 肥大，过度增大atrophy 萎缩mutate 改变，使突变anomaly 异常，不规则congenital defect 先天性缺陷lesion 损害，机能障碍infectious agent 传染剂pathogenesis 发病原diagnosis 诊断prognosis 预后autopsy 尸体解剖heredity 遗传hemophilia 血友病syndrome 综合征alcoholism 酗酒anemia 贫血pregnancy 怀孕delivery 分娩，交付leukemia 白血病malnutrition 营养不良hyperactive thyroid 活跃甲状腺hyperthyroidism 甲状腺功能亢进mongolism 先天愚型urinalysis 尿分析physician 内科医生surgeon 外科医生remission 缓解relapse 复发complication 并发症pneumonia 肺炎sequela 后遗症paralysis 麻痹polio 小儿麻痹fallopian tubes 输卵管alleviate 减轻masterpiece 杰作defective 有缺陷的deficient 不足的concurrent 并发的respectively 分别地utilize 利用perceive 察觉terminal 末端，晚期的severity 严重fracture 破裂prostate 前列腺transmit 传输，遗传trigger 引发，触发protrude 突出，伸出counteract 抵消，中和prescribe 开处方，规定exacerbate 使加剧aggravate 恶化，加重resemble 类似subside 平息，沉淀onset 开始，着手confined to 只限于compensate 补偿，赔偿traumatize 使。
•指南与共识•利妥昔单抗静脉快速输注中国专家共识(2020年版）扫码阅读电子版中国老年保健协会淋巴瘤专业委员会中华医学会血液学分会通信作者:黄慧强，中山大学胖瘤防治中心胖瘤内科，广州 510060，Email:huanghq@【摘要】利妥昔单抗上市20多年以来，在临床实践中疗效和安全性良好。
美国食品药品管理局(FD A)于2012年批准了利妥昔单抗的静脉快速输注用于第2个及后续疗程。
目前，利妥昔单抗90 min静脉快速输注方案已在国外成熟应用，美国国立综合癌症网络（NCCN)指南中也推荐第1个疗程利妥昔单抗输注未出现输注反应的患者,后续疗程可进行利妥昔单抗90 min静脉快速输注。
我国也有研究数据证实了利妥昔单抗90 1^»静脉快速输注方案的安全性和耐受性。
因此，基于国内外循证医学证据，为了提高患者的就诊质量以及节约医疗成本，本专家共识推荐，对于首次输注未发生明显不良反应的患者，后续疗程可使用利妥昔单抗90 min静脉快速输注方案。
【关键词】淋巴瘤，非霍奇金；利妥昔单抗；静脉快速输注；输注相关反应DOI： 10.3760/l 15356-20201030-00259Chinese expert consensus on rapid infusion of rituximab (2020 version)Lymphoma Committee of Chinese Aging Well Association, Chinese Society of Hematology, Chinese MedicalAssociationCorresponding author: Huang Huiqiang, Department of Oncology, Sun Yat-sen University Cancer Center,Guangzhou 510060, China, Email:******************.cn【Abstract】Rituximab has received marketing authorization for more than 20 years and has goodefficacy and safety in clinical practice. The U. S. Food and Drug Administration (FDA) approved a rapidinfusion of rituximab for the second and subsequent cycles of treatment in 2012. Nowadays, the 90-minuterapid infusion of rituximab in foreign countries has been maturely applied. The National Comprehensive CancerNetwork (NCCN) guidelines also recommend a 90 - minute rapid infusion of rituximab for the second andsubsequent cycles of rituximab to patients who do not experience infusion - related reactions during the firstcycle of rituximab infusion. In China, there are emerging research data confirming the safety and tolerability ofthe 90-minute rapid infusion of rituximab. Therefore, based on evidences from evidence - based medicine athome and abroad, in order to improve the quality of patients' hospital visits and further save healthcare costs,this expert consensus recommends the use of 90-minute rapid infusion of rituximab for patients who have noobvious adverse reactions during the first cycle of infusion.【Keywords】Lymphoma, non-Hodgkin; Rituximab; Rapid infusion; Infusion related reactionsDOI ： 10.3760/l 15356-20201030-00259利妥昔单抗是一种靶向CD20的单克隆抗体，能 显著改善CD20阳性非霍奇金淋巴瘤（NHL)患者的预 后。
Treatment of Epsilon Moves in Subset ConstructionGertjan van Noord∗Rijksuniversiteit GroningenThe paper discusses the problem of determinisingfinite-state automata containing large numbers of -moves.Experiments withfinite-state approximations of natural language grammars often give rise to very large automata with a very large number of -moves. The paper identifies and compares a number of subset construction algorithms which treat -moves.Experiments have been performed which indicate that the algorithms differ con-siderably in practice,both with respect to the size of the resulting deterministic automaton, and with respect to practical efficiency.Furthermore,the experiments suggest that the av-erage number of -moves per state can be used to predict which algorithm is likely to be the fastest for a given input automaton.1Introduction1.1Finite-state Language ProcessingAn important problem in computational linguistics is posed by the fact that the grammars which are typically hypothesised by linguists are unattractive from the point of view of computation.For instance,the number of steps required to anal-yse a sentence of n words is n3for context-free grammars.For certain linguistically more attractive grammatical formalisms it can be shown that no upper-bound to the number of steps required tofind an analysis can be given.The human lan-guage user,however,seems to process in linear time;humans understand longer sentences with no noticeable delay.This implies that neither context-free gram-mars nor more powerful grammatical formalisms are likely models for human lan-guage processing.An important issue therefore is how the linearity of processing by humans can be accounted for.A potential solution to this problem concerns the possibility of approximating an underlying general and abstract grammar by techniques of a much simpler sort. The idea that a competence grammar might be approximated byfinite-state means goes back to early work by Chomsky(Chomsky,1963;Chomsky,1964).There are essentially three observations which motivate the view that the processing of nat-ural language isfinite-state:1.humans have afinite(small,limited,fixed)amount of memory availablefor language processing2.humans have problems with certain grammatical constructions,such ascenter-embedding,which are impossible to describe byfinite-state means(Miller and Chomsky,1963)3.humans process natural language very efficiently(in linear time)1.2Finite-state Approximation and -movesIn experimenting withfinite-state approximation techniques for context-free and more powerful grammatical formalisms(such as the techniques presented in Black (1989),Pereira and Wright(1991),Rood(1996),Pereira and Wright(1997),Evans (1997),Nederhof(1997),Nederhof(1998),Johnson(1998))we have found that the resulting automata often are extremely large.Moreover,the automata contain many -moves(jumps).Andfinally,if such automata are determinised then the re-sulting automata are often smaller.It turns out that a straightforward implementa-tion of the subset construction determinisation algorithm performs badly for such inputs.In this paper we consider a number of variants of the subset-construction algorithm which differ in their treatment of -moves.Although we have observed thatfinite-state approximation techniques typi-cally yield automata with large amounts of -moves,this is obviously not a ne-cessity.Instead of trying to improve upon determinisation techniques for such au-tomata it might be more fruitful,perhaps,to try to improve these approximation techniques in such a way that more compact automata are produced.1However, because research intofinite-state approximation is still of an exploratory and ex-perimental nature,it can be argued that more robust determinisation algorithms do still have a role to play:it can be expected that approximation techniques are much easier to define and implement if the resulting automaton is allowed to be non-deterministic and to contain -moves.Note furthermore that even if our primary motivation is infinite-state approx-imation,the problem of determinisingfinite-state automata with -moves may be relevant in other areas of language research as well.1.3Subset construction and -movesThe experiments were performed using the FSA Utilities.The FSA Utilities tool-box(van Noord,1997;van Noord,1999;Gerdemann and van Noord, 1999;van Noord and Gerdemann,1999)is a collection of tools to manipu-late regular expressions,finite-state automata andfinite-state transducers.Ma-nipulations include determinisation,minimisation,composition,complementa-tion,intersection,Kleene closure,etc.Various visualisation tools are available to browsefinite-state automata.The tool-box is implemented in SICStus Pro-log,and is available free of charge under Gnu General Public License via anonymous ftp at ftp://ftp.let.rug.nl/pub/vannoord/Fsa/,and via the web at http://www.let.rug.nl/˜vannoord/Fsa/.At the time of our initial experiments withfinite-state approximation,an old version of the tool-box was used,which ran into memory problems for some of these automata.For this reason,the sub-set construction algorithm has been re-implemented,paying special attention to the treatment of -moves.Three variants of the subset construction algorithm are identified which differ in the way -moves are treated:per graph The most obvious and straightforward approach is sequential in the fol-lowing sense.Firstly,an equivalent automaton without -moves is con-structed for the input.In order to do this,the transitive closure of the graphconsisting of all -moves is computed.Secondly,the resulting automatonis then treated by a subset construction algorithm for -free automata.Dif-ferent variants of per graph can be identified,depending on the implemen-tation of the -removal step.per state For each state which occurs in a subset produced during subset construc-tion,compute the states which are reachable using -moves.The results ofthis computation can be memorised,or computed for each state in a pre-processing step.This is the approach mentioned briefly in Johnson andWood(1997).2per subset For each subset Q of states which arises during subset construction, compute Q ⊇Q which extends Q with all states which are reachable fromany member of Q using -moves.Such an algorithm is described in Aho,Sethi,and Ullman(1986).The motivation for this paper is the experience that thefirst approach turns out to be impractical for automata with very large numbers of -moves.An integration of the subset construction algorithm with the computation of -reachable states performs much better in practice for such automata.Section2presents a short statement of the problem(how to determinise a givenfinite-state automaton),and a subset construction algorithm which solves this problem in the absence of -moves.Section3defines a number of subset con-struction algorithms which differ with respect to the treatment of -moves.Most aspects of the algorithms are not new and have been described elsewhere,and/or were incorporated in previous implementations;a comparison of the different al-gorithms had not been performed previously.We provide a comparison with re-spect to the size of the resulting deterministic automaton(in section3)and prac-tical efficiency(in section4).Section4provides experimental results both for ran-domly generated automata and for automata generated by approximation algo-rithms.Our implementations of the various algorithms are also compared with AT&T’s FSM utilities(Mohri,Pereira,and Riley,1998),to establish that the experi-mental differences wefind between the algorithms are truly caused by differences in the algorithm(as opposed to accidental implementation details).2Subset Construction2.1Problem statementLet afinite-state machine M be specified by a tuple(Q,Σ,δ,S,F)where Q is a finite set of states,Σis afinite alphabet,δis a function from Q×(Σ∪{ })→2Q. Furthermore,S⊆Q is a set of start states and F⊆Q is a set offinal states.3 Let -move be the relation{(q i,q j)|q j∈δ(q i, )}. -reachable is the reflexive and transitive closure of -move.Let -CLOSURE:2Q→2Q be a function which is defined as:-CLOSURE(Q )={q|q ∈Q ,(q ,q)∈ -reachable} Furthermore,we write -CLOSURE−1(Q )for the set{q|q ∈Q ,(q,q )∈ -reachable}.For any givenfinite-state automaton M=(Q,Σ,δ,S,F)there is an equivalent deterministic automaton M =(2Q,Σ,δ ,{Q0},F ).F is the set of all states in2Q containing afinal state of M,i.e.,the set of subsets{Q i∈2Q|q∈Q i,q∈F}.M has a single start state Q0which is the epsilon closure of the start states of M,i.e., Q0= -CLOSURE(S).Finally,δ ({q1,q2,...,q i},a)= -CLOSURE(δ(q1,a)∪δ(q2,a)∪...∪δ(q i,a))funct construction((Q,Σ,δ,S,F))indexclosure(S)add(Start)whilemark(T)foreachU:=epsilonod(States,Σ,Trans,{Start},Finals)endadd(U)Reachable-state-set Maintenanceifadd U unmarked to Statesif Finals:=Finals∪{U}fiendinstructions(P)Instruction Computationreturnfunct closure(U)variant1:No -movesreturnFigure1Subset-construction algorithm.An algorithm which computes M for a given M will only need to take into account states in2Q which are reachable from the start state Q0.This is the reason that for many input automata the algorithm does not need to treat all subsets of states(but note that there are automata for which all subsets are relevant,and hence exponential behaviour cannot be avoided in general).Consider the subset construction algorithm infigure1.The algorithm main-tains a set of subsets States.Each subset can be either marked or unmarked(to in-dicate whether the subset has been treated by the algorithm);the set of unmarked subsets is sometimes referred to as the agenda.The algorithm takes such an un-marked subset T and computes all transitions leaving T.This computation is per-formed by the function instructions and is called instruction computation by Johnson and Wood(1997).The function indexThe procedure add is responsible for‘reachable-state-set maintenance’,by en-suring that target subsets are added to the set of subsets if these subsets were not encountered before.Moreover,if such a new subset contains afinal state,then this subset is added to the set offinal states.3Variants for -MovesThe algorithm presented in the previous section does not treat -moves.In this section,possible extensions of the algorithm are identified to treat -moves.3.1Per graphIn the per graph variant two steps can be identified.In thefirst step,efree,an equiv-alent -free automaton is constructed.In the second step this -free automaton is determinised using the subset construction algorithm.The advantage of this ap-proach is that the subset construction algorithm can remain simple because the input automaton is -free.An algorithm for efree is described for instance in Hopcroft and Ullman (1979)[page26-27].The main ingredient of efree is the construction of the func-tion -CLOSURE,which can be computed by using a standard transitive closure algorithm for directed graphs:this algorithm is applied to the directed graph con-sisting of all -moves of M.Such an algorithm can be found in several textbooks (see,for instance,Cormen,Leiserson,and Rivest(1990)).For a givenfinite-state automaton M=(Q,Σ,δ,S,F)efree computes M = (Q,Σ,δ ,S ,F ),where S = -CLOSURE(S),F = -CLOSURE−1(F),and δ (p,a)={q|q ∈δ(p ,a),p ∈ -CLOSURE−1(p),q∈ -CLOSURE(q )}.Instead of using -CLOSURE on both the source and target side of a transition,efree can be optimised in two different ways by using -CLOSURE only on one side:•efree t:M =(Q,Σ,δ ,S ,F),where S = -CLOSURE(S),andδ (p,a)={q|q ∈δ(p,a),q∈ -CLOSURE(q )}.•efree s:M =(Q,Σ,δ ,S,F ),where F = -CLOSURE−1(F),andδ (p,a)={q|q∈δ(p ,a),p ∈ -CLOSURE−1(p)}.Although both variants appear very similar,there are some differences.Firstly, efree t might introduce states which are not co-accessible:states from which no path exists to afinal state;in contrast,efree s might introduce states which are not acces-sible:states from which no path exists from the start state.A straightforward mod-ification of both algorithms is possible to ensure that these states are not present in the output.Thus efree t,c ensures that all states in the resulting automaton are co-accessible;efree s,a ensures that all states in the resulting automaton are accessi-ble.As a consequence,the size of the determinised machine is in general smaller if efree t,c is employed,because states which were not co-accessible(in the input) are removed(this is therefore an additional benefit of efree t,c;the fact that efree s,a removes accessible states has no effect on the size of the determinised machine because the subset construction algorithm already ensures accessibility anyway).Secondly,it turns out that applying efree t in combination with the subset-construction algorithm generally produces smaller automata than efree s(even if we ignore the benefit of ensuring co-accessibility).An example is presented infig-ure2.The differences can be quite significant.This is illustrated infigure3.Below we will write per graph X to indicate the non-integrated algorithm based on efree X.(1)a(2)aaaFigure 2Illustration of the difference in size between two variants of efree .(1)is the inputautomaton.The result of efree t is given in (2);(3)is the result of efree s .(4)and (5)are the result of applying the subset construction to the result of efree t and efree s ,respectively.0200040006000800010000120001400016000180002000000.20.40.60.81 1.2 1.4 1.61.82N u m b e r o f S t a t e sDeterministic Jump Density (mean)efree-source efree-targetFigure 3Difference in sizes of deterministic automata constructed with either efree s or efree t ,for randomly generated input automata consisting of 100states,15symbols,and various numbers of transitions and jumps (cf.section 4).Note that all states in the input are co-accessible;the difference in size is due solely to the effect illustrated in figure 2.functt∈T dowhilemark(t)foreachif add q unmarked to DfiodDendclosure function.The approach in which the transitive closure is computed for one state at a time is defined by the following definition of the epsilonepsilonmemo(u∈Umemo(closure({u})))endepsilon4This is an improvement over the algorithm given in a preliminary version of this paper(van Noord,1998).returnThe motivation for the per state variant is the insight that in this case the closure algorithm is called at most|Q|times.In contrast,in the per subset approach the transitive closure algorithm may need to be called2|Q|times.On the other hand, in the per state approach some overhead must be accepted for computing the union of the results for each state.Moreover,in practice the number of subsets is often much smaller than2|Q|.In some cases,the number of reachable subsets is smaller than the number of states encountered in those subsets.3.3ImplementationIn order to implement the algorithms efficiently in Prolog,it is important to use ef-ficient data-structures.In particular,we use an implementation of(non-updatable) arrays based on the N+K trees of O’Keefe(1990,pp.142-145)with N=95and K=32. On top of this datastructure,a hash array is implemented using the SICStus library predicate term5All the automata used in the experiments are freely available fromhttp://www.let.rug.nl/˜vannoord/Fsa/.6Leslie uses the terms absolute density and deterministic density.1101001000100001000001e+06110C P U -t i m e (m s e c ) / N u m b e r o f S t a t e s (i n p u t +o u t p u t )Deterministic Densityfsa fsm statesFigure 5Deterministic transition density versus CPU-time in msec.The input automata have 25states,15symbols,and no -moves.fsa represents the CPU-time required by our FSA6implementation;fsm represents the CPU-time required by AT&T’s FSM library;states represents the sum of the number of states of the input and output automata.tion time,and the maximum number of states,at an approximatedeterministic density of2.Most of the area under the curve occurswithin0.5and2.5deterministic density—this is the area in whichsubset construction is expensive.Conjecture.For a given NFA,we can compute the expected num-bers of states and transitions in the corresponding DFA,producedby subset construction,from the deterministic density of the NFA.In addition,this functional relationship gives rise to a Poisson-likecurve with its peak approximately at a deterministic density of2.A number of automata were generated randomly,according to the number of states,symbols,and transition density.For thefirst experiment,automata were generated consisting of15symbols,25states,and various densities(and no -moves).The results are summarised infigure5.CPU-time was measured on a HP 9000/785machine running HP-UX10.20.Note that our timings do not include the start-up of the Prolog engine,nor the time required for garbage collection.In order to establish that the differences we obtain later are genuinely due to differences in the underlying algorithm,and not due to‘accidental’implemen-tation details,we have compared our implementation with the determiniser of AT&T’s FSM utilities(Mohri,Pereira,and Riley,1998).For automata without -moves we establish that FSM normally is faster:for automata with very small tran-sition densities FSM is up to four times as fast,for automata with larger densities the results are similar.A new concept called absolute jump density is introduced to specify the num-ber of -moves.It is defined as the number of -moves divided by the square of the number of states(i.e.,the probability that an -move exists for a given pair of states).Furthermore,deterministic jump density is the number of -moves divided by the number of states(i.e.,the average number of -moves which leave a given state).In order to measure the differences between the three implementations,a number of automata has been generated consisting of15states and15symbols, using various transition densities between0.01and0.3(for larger densities the automata tend to collapse to an automaton forΣ∗).For each of these transition densities,deterministic jump densities were chosen in the range0to2.5(again,for larger values the automata tend to collapse).Infigures6to9the outcomes of these experiments are summarised by listing the average amount of CPU-time required per deterministic jump density(for each of the algorithms),using automata with 15,20,25and100states respectively.Thus,every dot represents the average for de-terminising a number of different input automata with various absolute transition densities and the same deterministic jump density.The striking aspect of these experiments is that the integrated per subset and per state variants are much more efficient for larger deterministic jump density.The per graph t is typically the fastest algorithm of the non-integrated versions.However, in these experiments all states in the input are co-accessible by construction;and moreover,all states in the input arefinal states.Therefore,the advantages of the per graph t,c algorithm could not be observed here.The turning point is around a deterministic jump density of around0.8:for smaller densities the per graph t is typically slightly faster;for larger densities the per state algorithm is much faster.For densities beyond1.5,the per subset algorithm tends to perform better than the per state algorithm.Interestingly,this generalisa-tion is supported by the experiments on automata which were generated by ap-proximation techniques(although the results for randomly generated automata are more consistent than the results for‘real’examples).1010010001000000.511.52 2.5M e a n C P U -t i m e (m s e c )#Jumps/#Statesper_graph(t)per_graph(s)per_graph(s,a)per_graph(t,c)per_subset per_statefsmFigure 6Average amount of CPU-time versus jump density for each of the algorithms,and FSM.Input automata have 15states.Absolute transition densities:0.01-0.3.1010010001000000.511.52 2.5M e a n C P U -t i m e (m s e c )#Jumps/#Statesper_graph(t)per_graph(s)per_graph(s,a)per_graph(t,c)per_subset per_statefsmFigure 7Average amount of CPU-time versus jump density for each of the algorithms,and FSM.Input automata have 20states.Absolute transition densities:0.01-0.3.1010010001000010000000.511.52 2.5M e a n C P U -t i m e (m s e c )#Jumps/#Statesper_graph(t)per_graph(s)per_graph(s,a)per_graph(t,c)per_subset per_statefsmFigure 8Average amount of CPU-time versus deterministic jump density for each of the algorithms,and FSM.Input automata have 25states.Absolute transition densities:0.01-0.3.10010001000010000000.511.52 2.5M e a n C P U -t i m e (m s e c )#Jumps/#Statesper_graph(t)per_graph(s)per_graph(s,a)per_graph(t,c)per_subset per_statefsmFigure 9Average amount of CPU-time versus deterministic jump density for each of the algorithms,and FSM.Input automata have 100states.Absolute transition densities:0.001-0.0035.Comparison with the FSM library We also provide the results for AT&T’s FSM li-brary again.FSM is designed to treat weighted automata for very general weight sets.The initial implementation of the library consisted of an on-the-fly computa-tion of the epsilon-closures combined with determinisation.This was abandoned for two reasons:it could not be generalised to the case of general weight sets,and it was not outputting the intermediate epsilon-removed machine(which might be of interest in itself).In the current version -moves must be removed before deter-minisation is possible.This mechanism thus is comparable to our per graph variant. Apparently,FSM employs an algorithm equivalent to our per graph s,a.The result-ing determinised machines are generally larger than the machines produced by our integrated variants and the variants which incorporate -moves on the target side of transitions.The timings below are obtained for the pipefsmrmepsilon|fsmdeterminizeThis is somewhat unfair since this includes the time to write and read the interme-diate machine.Even so,it is interesting to note that the FSM library is a constant factor faster than our per graph s,a;for larger numbers of jumps the per state and per subset variants consistently beat the FSM library.Experiment:Automata generated by approximation algorithms The automata used in the previous experiments were randomly generated.However,it may well be that in practice the automata that are to be treated by the algorithm have typical proper-ties which were not reflected in this test data.For this reason results are presented for a number of automata that were generated using approximation techniques for context-free grammars.In particular,automata have been used which were cre-ated by Nederhof,using the technique described in Nederhof(1997).In addition,a small number of automata have been used which were created using the technique of Pereira and Wright(1997)(as implemented by Nederhof).We have restricted our attention to automata with at least1000states in the input.The automata typically contain lots of jumps.Moreover,the number of states of the resulting automaton is often smaller than the number of states in the input au-tomaton.Results are given in the tables1and2.One of the most striking examples is the ygrim automaton consisting of3382states and9124jumps.For this example, the per graph implementations ran out of memory(after a long time),whereas the implementation of the per subset algorithm produced the determinised automaton (containing only9states)within a single CPU-second.The FSM implementation took much longer for this example(whereas for many of the other examples it is faster than our implementations).Note that this example has the highest number of jumps per number of states ratio.This confirms the observation that the per sub-set algorithm performs better on inputs with a high deterministic jump density.5ConclusionWe have discussed a number of variants of the subset-construction algorithm for determinisingfinite automata containing -moves.The experiments support the following conclusions:•The integrated variants per subset and per state work much better forautomata containing a large number of -moves.The per subset varianttends to improve upon the per state algorithm if the number of -movesincreases even further.•We have identified four different variants of the per graph algorithm.Inour experiments,the per graph t is the algorithm of choice for automataInput Output#states#jumps#statesper graph tper subsetper stateg14403137131 ovis4.n2210164107 g131006337329 rene22597846844 ovis9.p279124781386 ygrim542299 ygrim.p63704702702 java192833319711855 java164393531863078 zovis37889551744182 zovis28040065615309 Table1The automata generated by approximation algorithms.The table lists the number of states, transitions and jumps of the input automaton,and the number of states of the determinised machine using respectively the efree s,efree t,and the efree t,c variants.CPU-time(sec)graph t graph s subset FSM0.40.30.40.1ovis4.n 1.1 1.00.60.90.6 1.20.2rene20.30.20.236.616.925.221.9ygrim--21.0--562.14512.4 java1967.445.019.030.035.011.3 3.0zovis3557.5407.4302.5909.2-454.4392.1 Table2Results for automata generated by approximation algorithms.The dashes in the table indicate that the corresponding algorithm ran out of memory(after a long period of time) for that particular example.containing few moves,because it is faster than the other algorithms,andbecause it produces smaller automata than the per graph s and per graph s,avariants.•The per graph t,c variant is an interesting alternative in that it produces thesmallest results.This variant should be used if the input automaton isexpected to contain many non-co-accessible states.•Automata produced byfinite-state approximation techniques tend tocontain many -moves.We found that for these automata the differencesin speed between the various algorithms can be enormous.The per subsetand per state algorithms are good candidates for this application.We have attempted to characterize the expected efficiency of the various al-gorithms in terms of the number of jumps and the number of states in the input automaton.It is quite conceivable that other simple properties of the input automa-ton can be used even more effectively for this purpose.One reviewer suggests to use the number of strongly -connected components(the strongly connected com-ponents of the graph of all -moves)for this purpose.We leave this and other pos-sibilities to a future occasion.AcknowledgmentsI am grateful to Mark-Jan Nederhof for support,and for providing me with lots of (often dreadful)automata generated by hisfinite-state approximation tools.The comments of the anonymous FSMNLP and CL reviewers were extremely useful.ReferencesAho,Alfred V.,Ravi Sethi,and Jeffrey D. pilers.Principles, Techniques and Tools.Addison Wesley. 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