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第一章测试1【判断题】(5分) Peopledoresearchinordertohaveabetterunderstandingofourworld.A.对B.错2【判断题】(5分)Wedon’tneedtobecreativeinresearchasanyresearchisbasedonevidences.A.错B.对3【判断题】(5分)Goodresearchquestionsareimportantinresearch.A.错B.对4【判断题】(5分) Literaturereviewisneededinsomeresearchpapers.A.对B.错5【判断题】(5分) Agoodresearchpaperneedscarefulrevisingandproofreading.A.错B.对6【判断题】(5分) Unintentionalplagiarismcanbeexcusedasitisnotcommitteddeliberately.A.对B.错7【判断题】(5分) Academicfalsificationisonecommontypeofacademicdishonesty.A.对B.错8【多选题】(5分) Whatroledoesaliteraturereviewplayinaresearchpaper?A.Itenhancesthecredibilityofyourpaper.B.Itprovestheexistenceofaresearchgap.C.Itsynthesizestheexistingstudiesinyourarea.D.Itprovidesevidencesforyourargument.9【单选题】(5分) WhichofthefollowingisNOTanessentialstepinaresearchpaperwriting?A.ChoosingatopicB.ConsultinginstructorsC.LocatingsourcesD.OutliningthePaper10【多选题】(5分) Whichofthefollowingmayleadtoacademicdishonesty?A.AcademicplagiarismB.AcademicpromotionC.AcademicinterestD.Academicfabrication第二章测试1【多选题】(5分)Inchoosingaresearchtopic,whichofthefollowingdoweneedtoconsider?A.PublicationpossibilitiesB.AcademicimportanceC.OurresearchinterestD.Ourmanageability2【判断题】(5分)Tocheckthevalidityofaresearchtopic,weneedtobecriticalenough.A.对B.错3【判断题】(5分) Itisanactofplagiarismifonesimplyparaphrasesabookforaresearchpaper.A.对B.错4【判断题】(5分) StudentsshouldbebraveenoughtotrychallengingissuesfortheirBAtheses.A.对B.错5【判断题】(5分) Carefulreadingofliterarytextisimportantinliterarystudies.A.对B.错6【判断题】(5分) Literarytheoriestakepriorityoverliterarytextsinliteraryanalysis.A.错B.对7【判断题】(5分) ICstudycanbechallengingbutinterestingandpracticalinlife.A.错B.对8【判断题】(5分) Expertssharesimilarunderstandingsoverthestandardsoftranslation.A.错B.对9【判断题】(5分) Translationstrategiesandtranslationtechniquesaredifferentconceptsintranslation.A.对B.错10【判断题】(5分) Sociolinguisticsisoneofthebranchesofappliedlinguistics.A.对B.错第三章测试1【判断题】(5分) Aworkingbibliographyincludesthesourceswehavesofarcollectedforaresearchproject.A.对B.错2【判断题】(5分) Knowingwhatsourcesyouneedisofvitalimportanceinevaluatingyoursources.A.错B.对3【判断题】(5分) Sourcesfromleadingscholarscanbeveryusefultoyourresearch.A.错B.对4【判断题】(5分)Inreadingsources,weneedtobecriticalandformourpersonalresponses.A.对B.错5【判断题】(5分) Theplanforanempiricalresearchshouldcoveritspurpose,method,subjects,andprocedure.A.错B.对6【判断题】(5分) Itiswisefortheobservernottotakepartintheactivityobservedatalltime.A.错B.对7【多选题】(5分)InBooleanLogic,ifonewantstosearchonlyforsourcesrelevantwithcomputervirus,thesearchformul ashouldbe_______.A.computernotvirusB.computernearvirusC.computerorvirusD.computerandvirus8【多选题】(5分) Theannotationofasourceinanannotatedbibliographymayhaveyour____:A.reflectionofthesourceB.adaptationofthesourceC.summaryofthesourceD.assessmentofthesource9【单选题】(5分)Inaquestionnaireentitled“ASurveyontheThirdYearEnglishMajors’EnglishVocabularyinXXUniv ersity”,the“thethirdyearEnglishmajors”shouldbe：A.ThetimeofthesurveyB.ThesubjectofthesurveyC.ThecontentofthesurveyD.Themodeofthesurvey10【单选题】(5分)Inanexperimententitled“AStudyontheEffectsofWriting-after-ReadingActivityonEnglishMajors EnglishVocabulary”,students’languageproficiencyshouldbe:A.IrrelevantvariableB.dependentvariableC.Independentvariable第四章测试1【判断题】(5分)Aresearchproposalshouldbepersuasiveinnature.A.错B.对2【判断题】(5分) Wecanaskforsuggestionsfromtheexpertsforourresearchinourproposal.A.错B.对3【判断题】(5分) Weneedtoputforwardourresearchquestionsinourresearchproposals.A.错B.对4【判断题】(5分) Aresearchproposaldemonstratesthesignificanceofourproposedresearch.A.错B.对5【判断题】(5分) Theliteraturereviewsectioninaproposalprovestheexistenceofaresearchgap.A.对B.错6【判断题】(5分)The“ApplicationoftheResearch”tellshowyourresearchwillbenefitinpractice.A.对B.错7【判断题】(5分)A“PreliminaryBibliography”isalistofthesourcesyouhavecitedinyourproposal.A.错B.对8【判断题】(5分) Thesignificanceofyourresearchemphasizespossibleresearchcontributions.A.对B.错9【判断题】(5分)Simpleasitis,aBAthesisproposalincludesalltheelementsinagrantresearchproposal.A.错B.对10【多选题】(5分)WhichofthefollowingisNOTincludedinthree-moveschemeoftheproposalsummary?A.researchneedB.potentialcontributionsC.possiblelimitationsD.researchmethod第五章测试1【判断题】(5分) Theuseofsignalphrasesincitationcanenhancethefluencyofwriting.A.对B.错2【判断题】(5分) Theintegrationofthesourcesmustfitourwritinginstructureandgrammar.A.错B.对3【判断题】(5分) Researchlimitationisacompulsoryelementinallresearchpapers.A.错B.对4【判断题】(5分) CARSModelisapatternforintroductionwritinginresearchpapers.A.对B.错5【判断题】(5分)Inrevising,weneedtofocusontheerrorslikegrammarandspelling.A.错B.对6【判断题】(5分) Aliteraturereviewmainlypresentsasummaryofeachsourceinchronologicalorder.A.错B.对7【单选题】(5分) Characteristicsofacademicwritingincludesallthefollowingexcept________.A.thefirst-personviewB.aformaltoneC.aclearfocusD.precisewordchoice8【单选题】(5分) Itisessentialtoalwaysacknowledgethesourceofborrowedideasinyourpaper.Todootherwiseisconsi dered_________.A.IgnoranceB.CarelessnessC.Plagiarism9【单选题】(5分)Whichofthefollowingarefeaturesofagoodtitle?A.ClearB.AlloftheaboveC.Attractive.D.Direct10【单选题】(5分)Abstractscanbedividedintotwotypes accordingto their_________.A.functionsB.length第六章测试1【判断题】(5分)MLAin-textcitationrequiresthattheauthorinformationshouldbeputeitherinthetextofthepaperorint heparentheticalcitation.A.错B.对2【判断题】(5分)InMLAdocumentation,parentheticalcitationinthetextofthepapermustalwaysincludetheauthor’sn ameandthework’stitle.A.错B.对3【判断题】(5分)MLAworkscitedlistisorganizedalphabeticallybytheauthor’slastnames(orbytitleforaworkwithnoa uthor).A.错B.对4【判断题】(5分)Whenawork’sauthorisunknown,theworkislistedunder“Anonymous”inthelistofMLAworkscited.A.错B.对5【单选题】(5分)Lee(2007)stated,“Theabilitytothinkcriticallyisneededinthisrevolutionaryageoftechnologicalcha nge”(p.82).Thein-textcitationusedhereis__________.A.integratedB.non-integrated6【多选题】(5分)WhatarethefunctionsofAPAdocumentation?A.Tociteothers’ideasandinformationusedwithinyourpaperB.TodemonstratethetypeofresearchconductedC.ToindicatethesourcesintheReferenceslist7【单选题】(5分)Writethelistofworkscited,usingtheAPAformat.Aparaphraseofanideafrompage121ofWritingSpace:TheComputer;Hypertext,andtheHistoryofWr iting,byJayDavidBolter.This1991bookwaspublishedbyLawrenceErlbaumAssociatesofHillsdale, NewJersey.Whichofthefollowingiscorrectfortheauthor’sname?A.Bolter,J.DB.J.D.BolterC.Jay,D.BolterD.Bolter,JayDavid【单选题】(5分)Writethelistofworkscited,usingtheAPAformat.Aquotationfrompage78ofanarticlebyBartKoskoandSatornIsakafromtheJuly1993issueofScientifi cAmerican,amonthlypublication.Thearticleisentitled"FuzzyLogic"andappearsonpages76to81in volume239,ofthejournal. Whichofthefollowingisthecorrectformatforthevolumeandpagernumber?A.ScientificAmerican,239,78B.ScientificAmerican,239,76-81C.ScientificAmerican,239:76-81D.ScientificAmerican,239,76-81.9【多选题】(5分)Bohren,M.A.,G.J.Hofmeyr,C.Sakala,R.K.Fukuzawa,andA.Cuthbert.(2017).Continuoussupportf orwomenduringchildbirth.CochraneDatabaseofSystematicReviews,2017(7).https:///10.1 002/14651858.CD003766.pub6Errorsmadeinthisentryinclude_________.A.authors’namesB.issuenumberC.theword“and”D.doinumber10【单选题】(5分)Perrey,S.(2017).Doweperformbetterwhenweincreaseredbloodcells?TheLancetHaematology,17, 2352-3026.https:///10.1016/S2352-3026(17)30123-0.RetrievedAugust23,2018.Whatinfo rmationisNOTneededinthisentry?A.ThedateofretrievalB.ThepagerangeC.Thedoinumber。
英语二级笔译实务模拟试卷参考答案Section 1：英译汉（50 分）Passage 1我以杜鹃为例说明普通人的无知，并不是因为我对这种鸟儿能发表什么权威见解。
这样做的原因，只是那年春天我曾在某个教区居住，当时全非洲的杜鹃似乎都蜂拥而至，我由此发现自己以及我碰见的所有人对这种鸟儿都知之甚少。
但是，你我的无知并不仅限于杜鹃这一方面，而是涉及宇宙万物，从太阳、月亮一直到各种花卉的名称。
有一天，我听见一位聪明伶俐的太太提出了这样一个问题：新月是不是总在一周中的同一天露面？她接着又说：不知道倒好，正因为人不知道在什么时候、在天空的哪一处能看见它，新月出现才能给人带来惊喜。
然而我想，哪怕有人对月亮的盈亏时间了然于心，他看见新月出现时还是会又惊又喜，春回大地，花开花落，莫不如是。
即使我们对一年四季草木节令了如指掌，知道报春花开花在三月或四月而不在十月，但我们看见一株早开花的报春花，还是照样地高兴。
另外，我们知道苹果树先开花，后结果，可是五月一旦到来，果园里一片欢闹的花海，我们不是仍然惊为奇观吗？此外，倘在每年春天，把许多花卉之名重温一遍，也别有一番乐趣，就像把一本差不多忘得干干净净的书再重新读一遍。
蒙田说过，他记性很差，所以他随时都能拿起一本旧书，像从未读过的新书一样地看。
我自己的记忆力也漏洞百出、不听使唤。
我甚至能拿起《哈姆雷特》和《匹克威克外传》，当作是初登文坛的新作家刚刚印出来的作品来读，因为自从上回读过以后，这两部书在我脑子里的印象已经模模糊糊了。
这样的记忆力在某些时候自然叫人伤脑筋，而且假如人一心追求准确，就更是如此。
不过，在这种时候，人生的目的就必然不止是娱乐，还会有其他更高的目标了。
如果只讲享受的话，记性坏比记性好究竟差到哪里去，还真是不太好说呢。
记性坏的人可以一辈子不断地读普卢塔克的《希腊罗马名人传》和《天方夜谭》，而永远感到新鲜。
人的记忆力再差，也很可能留下一星半点的印象，恰如一只只绵羊从篱笆洞里接连通过，总不免在那刺条上留下几缕羊毛。
江苏省南京市2025届高三英语下学期第三次模拟试题（含解析）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，并标在试卷的相应位置。
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. 【此处可播放相关音频，请去附件查看】When does the conversation probably take place?A. In the morning.B. In the afternoon.C. In the evening.【答案】B【解析】【原文】M: I’m so hungry, Mom. Is dinner going to be ready soon?W: We just had lunch an hour ago! And you had two full plates of breakfast when you woke up.2. 【此处可播放相关音频，请去附件查看】What is the full price of the man’s jacket？A. $15.B. $30.C. $50.【答案】B【解析】【原文】W: So, what did you buy?M: A jacket. It was a real bargain. I got it for half price, so I saved 15 dollars.W: That’s very cheap. I bought a similar o ne for 50 dollars last year.3. 【此处可播放相关音频，请去附件查看】Who is the woman?A. A passenger.B. A health worker.C. A customs officer.【答案】C【解析】【原文】M: Is the customs examination here?W: That’s right. Your passport and health certificate, please.M: Here you are.4. 【此处可播放相关音频，请去附件查看】What does the woman know about?A. Major rivers.B. Famous mountains.C. Capital cities.【答案】C【解析】【原文】M: Do you know the major rivers and famous mountains in Europe?W: Hm. Ask me about capital cities instead.5. 【此处可播放相关音频，请去附件查看】Why does the man meet the woman？A. To apply for a job.B. To sell her something.C. To reserve a seat.【答案】A【解析】【原文】W: Take a seat, Mr. Black. Could you tell me which position interests you most?M: The sales manager position.W: OK. But do you have any relevant experience?其次节（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。
一例以严重肝功能受损为主要临床表现的成人EB病毒相关性T细胞淋巴增殖性疾病患者52岁女性,主因”乏力纳差2月,加重伴皮肤巩膜黄染10+天”于2013-11-04就诊于我院消化内科.追溯病史，该患者5年前体检时发现脾脏增大，血常规红细胞、粒细胞、血小板正常，后反复查示三系偏低，3年前无明显诱因出现发热、不伴畏寒、寒战，体温可至38-39℃，发热无明确周期性，但多于18时左右开始，不做处理可出汗后自行降至正常，入院前2月,患者因“脾脏明显长大、血常规三系明显减低“在院外行脾脏切除手术。
手术前患者一般情况可，术前骨髓涂片：穿刺部位增生减低，原早粒偶见，红系比例增高骨髓象，肝功正常，腹部CT提示患者肝脏稍增大，术后血常规三系基本恢复正常，术后病检结果示：脾脏体积20X13X9cm，脾门血管淤血扩张，脾组织纤维组织增生，病变符合脾功能亢进。
但患者仍反复发热，性质同术前，并逐渐出现乏力纳差，入院前10+天前出现皮肤巩膜明显黄染、乏力纳差加重，入我院就诊。
既往诉有乙型肝炎病史6年，无明确药物及饮酒史。
查体：精神萎靡，消瘦，全身皮肤及巩膜重度黄染，全身浅表淋巴结未扪及，肝脏肋下5cm扪及，质中，触之疼痛。
辅助检查：甲肝及戊肝标志物阴性，乙肝表面抗体及核心抗体阳性，高精度HBV-DNA阴性，血清EB病毒DNA8.32E+03copies/mL，EB病毒IgA抗体阳性，肝功能指标示总胆红素330.1umol/L,直接胆红素281umol/L,间接胆红素49umol/L，ALT72IU/L，AST103IU/L，碱性磷酸酶705IU/L，谷氨酰胺酶174IU/L,凝血功能示PT>120秒，APTT>180秒，血常规示血红蛋白95g/L，血小板76X10^9/L，白细胞12.61X10^9/L，外周血未查见异常细胞，免疫全套基本正常。
胸部CT提示肺部感染，腹部CT提示肝脏明显长大，实质密度减低，肝内外胆管未见异常，行骨髓涂片提示增生活跃，粒系70.5%，红系16.0%，未查见异常细胞，骨髓活检示骨髓造血细胞增生活跃，三系均有，见灶性碎屑样坏死，免疫组化查见CD20(-)、CD3ε(+)、CD30(-)、CD56(-)淋巴细胞散在或簇状分布，EBER1/2-ISH(+,P)，怀疑EB病毒相关T淋巴细胞增生性疾病浸润，骨髓流式查见细胞体积偏大的淋巴细胞，细胞表型CD2(+)、CD3(+)、CD7(+)、CD8(+)、CD11c(+)、CD38(+),TCRγδ+,CD4(-)CD16(-)CD56(-)CD57(-).考虑T细胞淋巴增殖性疾病，因患者胆红素极高，故未行肝组织病理活检。
雅思阅读第122套P2-Meas...雅思阅读第122套P2-Measures to combat infectious disease in tsarist RussiaREADING PASSAGE 2You should spend about 20 minutes on Questions 14-26, which are based on Reading Passage 2 on the following pages. Measures to combat infectious disease in tsarist RussiaA In the second half of the seventeenth century, Russian authorities began implementing controls at the borders of their empire to prevent the importation of plague, a highly infectious and dangerous disease. Information on disease outbreak occurring abroad was regularly reported to the tsar’s court through various means, including commercial channels (travelling merchants), military personnel deployed abroad, undercover agents, the network of Imperial Foreign Office embassies and representations abroad, and the customs offices. For instance, the heads of customs offices were instructed to question foreigners entering Russia about possible epidemics of dangerous diseases in their respective countries.B If news of an outbreak came from abroad, relations with the affected country were suspended. For instance, foreign vessels were not allowed to dock in Russian ports if there was credible information about the existence of epidemics in countries from whence they had departed. In addition, all foreigners entering Russia from those countries had to undergo quarantine. In 1665, after receiving news about a plague epidemic in England, Tsar Alexei wrote a letter to King Charles II in which he announced the cessation of Russian trade relationswith England and other foreign states. These protective measures appeared to have been effective, as the country did not record any cases of plague during that year and in the next three decades. It was not until 1692 that another plague outbreak was recorded in the Russian province of Astrakhan. This epidemic continued for five months and killed 10,383 people, or about 65 percent of the city’s population. By the end of the seventeent h century, preventative measures had been widely introduced in Russia, including the isolation of persons ill with plague, the imposition of quarantines, and the distribution of explanatory public health notices about plague outbreaks.C During the eighteenth century, although none of the occurrences was of the same scale as in the past, plague appeared in Russia several times. For instance, from 1703 to 1705, a plague outbreak that had ravaged Istanbul spread to the Podolsk and Kiev provinces in Russia, and then to Poland and Hungary. After defeating the Swedes in the battle of Poltava in 1709, Tsar Peter I (Peter the Great) dispatched part of his army to Poland, where plague had been raging for two years. Despite preventive measures, the disease spread among the Russian troops. In 1710, the plague reached Riga (then part of Sweden, now the capital of Latvia), where it was active until 1711 and claimed 60,000 lives. During this period, the Russians besieged Riga and, after the Swedes had surrendered the city in 1710, the Russian army lost 9.800 soldiers to the plague. Russian military chronicles of the time note that more soldiers died of the disease after the capture of Riga than from enemy fire during the siege of that city.D Tsar Peter I imposed strict measures to prevent the spread of plague during these conflicts. Soldiers suspected of beinginfected were isolated and taken to areas far from military camps. In addition, camps were designed to separate divisions, detachments, and smaller units of soldiers. When plague reached Narva (located in present-day Estonia) and threatened to spread to St. Petersburg, the newly built capital of Russia, Tsar Peter I ordered the army to cordon off the entire boundary along the Luga River, including temporarily halting all activity on the river.In order to prevent the movement of people and goods from Narva to St Petersburg and Novgorod, roadblocks and checkpoints were set up on all roads. The tsar’s orders were rigorously enforced, and those who disobeyed were hung.E However, although the Russian authorities applied such methods to contain the spread of the disease and limit the number of victims, all of the measures had a provisional character: they were intended to respond to a specific outbreak, and were not designed as a coherent set of measures to be implemented systematically at the first sign of plague. The advent of such a standard response system came a few years later.F The first attempts to organise procedures and carry out proactive steps to control plague date to the aftermath of the 1727- 1728 epidemic in Astrakhan. In response to this, the Russian imperial authorities issued several decrees aimed at controlling the future spread of plague. Among these decrees, the 'Instructions for Governors and Heads of Townships’ required that all governors immediately inform the Senate - a government body created by Tsar Peter I in 1711 to advise the monarch - if plague cases were detected in their respective provinces.Furthermore, the decree required that governors ensure the physical examination of all persons suspected of carrying thedisease and their subsequent isolation. In addition, it was ordered that sites where plague victims were found had to be encircled by checkpoints and isolated for the duration of the outbreak. These checkpoints were to remain operational for at least six weeks.The houses of infected persons were to be burned along with all of the personal property they contained, including farm animals and cattle. The governors were instructed to inform the neighbouring provinces and cities about every plague case occurring on their territories. Finally, letters brought by couriers were heated above a fire before being copied.G The implementation by the authorities of these combined measures demonstrates their intuitive understanding of the importance of the timely isolation of infected people to limit the spread of plague.SECTION 2: QUESTIONS 14-26Questions 14-19Reading Passage 2 has SEVEN sections, A-G.Choose the correct heading for sections A-F from the list of headings below.Write the correct number, i-viii.14 _____________ Section A15 _____________ Section B16 _____________ Section C17 _____________ Section D18 _____________ Section E19 _____________ Section FQuestions 20-21Choose TWO letters, A—E.Write the correct letters.Which TWO measures did Russia take in the seventeenth century to avoid plague outbreaks?A Cooperation with foreign leaders.B Spying.C Military campaigns.D Restrictions on access to its ports.E Expulsion of foreigners.Questions 22-23Choose TWO letters, A-E.Write the correct letters.Which TWO statements are made about Russia in the early eighteenth century?A Plague outbreaks were consistently smaller than before.B Military casualties at Riga exceeded the number of plague victims.C The design of military camps allowed plague to spread quickly.D The tsar’s plan to protect St Petersburg from plague was not strictly implemented.E Anti-plague measures were generally reactive rather than strategic.Questions 24-26Complete the sentences below.Choose ONE WORD ONLY from the passage for each answer.An outbreak of plague in 24 _________________ prompted the publication of a coherent preventative strategy.Provincial governors were ordered to burn the 25_________________ and possessions of plague victims.Correspondence was held over a 26 _________________ prior to copying it.。
上半年《英语知识与教学能力》（高中）试题(附答案).第 1 题 (单项选择题)(每题 2.00 分) > 未分类 >Which of the following is the feature shared by the Englishphonemes/m/and/p/?{A}. Voiced.{B}. Voiceless.{C}. Bilabial.{D}. Dental.正确答案：C,第 2 题 (单项选择题)(每题 2.00 分) > 未分类 >Which of the following is true of English sound system?{A}. Aspiration is a distinctive feature.{B}. Voicing is a distinctive phonetic feature.{C}. Nasalization of vowels gives rise to another vowel.{D}. Length of vowels differentiates one vowel from the other. 正确答案：B,第 3 题 (单项选择题)(每题 2.00 分) > 未分类 >Though the government encourages foreign investment,__________ investors arereluctant to commit fimds in the current climate situation in the country.{A}. potential{B}. affluent{C}. optimistic{D}. solid正确答案：A,第 4 题 (单项选择题)(每题 2.00 分) > 未分类 >The man __________ the dark glasses fled away from the spot veryrapidly.{A}. in{B}. at{C}. of{D}. by正确答案：A,第 5 题 (单项选择题)(每题 2.00 分) > 未分类 >The morpheme \"-ceive\" in the word \"conceive\" isa__________.{A}. stem{B}. root{C}. allomorph{D}. suffix正确答案：B,第 6 题 (单项选择题)(每题 2.00 分) > 未分类 >There is no need__________ to teach children how to behave. {A}. however{B}. whatsoever{C}. forever{D}. whenever正确答案：B,第 7 题 (单项选择题)(每题 2.00 分) > 未分类 >__________advance seems to be following advance on almost a monthly basis.{A}. So rapid is the rate of progress that{B}. Rapid as the rate of progress is that{C}. So rapid is the rate of progress as{D}. Rapid as the rate of progress as正确答案：A,第 8 题 (单项选择题)(每题 2.00 分) > 未分类 >Tom, see that your sister gets safely back, __________?{A}. can you{B}. won't we{C}. won' t you{D}. should we正确答案：C,第 9 题 (单项选择题)(每题 2.00 分) > 未分类 >What rhetoric device is used in the sentence \"This is a successfulfailure\"?{A}. Simile{B}. Metonymy{C}. Metaphor{D}. Oxymoron正确答案：D,第 10 题 (单项选择题)(每题 2.00 分) > 未分类 >The expression\"As far as I know ...\" suggests that peopleusually observe the Maxim of __________ in their daily conversations.{A}. Quantity{B}. Quality{C}. Relevance{D}. Manner正确答案：B,第 11 题 (单项选择题)(每题 2.00 分) > 未分类 >When the teacher attempts to elicit more information from the students bysaying \"And...?\",\"Good. Anything else?\", etc, he/she isplaying the role of a __________.{A}. prompter{B}. participant{C}. manager{D}. consultant正确答案：A,第 12 题 (单项选择题)(每题 2.00 分) > 未分类 >For more advanced learners, group work may be more appropriate thanpair work for tasks that are__________.{A}. linguistically simple{B}. structurally controlled{C}. cognitively challenging{D}. thematically non-demanding正确答案：C,第 13 题 (单项选择题)(每题 2.00 分) > 未分类 >When you focus on \"utterance function\" and \"expectedresponse\" by using examples like\"Here you are\",\"Thanks\", you are probably teaching language at the __________.{A}. lexical level{B}. sentence level{C}. grammatical level{D}. discourse level正确答案：D,第 14 题 (单项选择题)(每题 2.00 分) > 未分类 >Which of the following tasks fails to encourage active language use?{A}. Reciting a text.{B}. Bargaining in a shop.{C}. Writing an application letter.{D}. Reading to get a message.正确答案：A,第 15 题 (单项选择题)(每题 2.00 分) > 未分类 >A teacher may encourage students to__________ when they come acrossnew words in fast reading.{A}. take notes{B}. ask for help{C}. guess meaning from context{D}. look up the words in a dictionary正确答案：C,第 16 题 (单项选择题)(每题 2.00 分) > 未分类 >Which of the following statements about task design is incorrect?{A}. Activities must have clear and attainable objectives.{B}. Activities should be confined to the classroom context.{C}. Activities must be relevant to students' life experiences.{D}. Activities should help develop students' language ability. 正确答案：B,第 17 题 (单项选择题)(每题 2.00 分) > 未分类 >If someone says \"I know the word\", he should not only understandits meaning but also be able to pronounce, spell, and __________ it.{A}. explain{B}. recognize{C}. memorize{D}. use正确答案：D,第 18 题 (单项选择题)(每题 2.00 分) > 未分类 >Teachers could encourage students to use__________ to gather and organizetheir ideas for writing.{A}. eliciting{B}. mind mapping{C}. explaining{D}. brainstorming正确答案：B,第 19 题 (单项选择题)(每题 2.00 分) > 未分类 >When students are asked to go to the local museum, libraries, etc. tofind out information about endangered animals and work out a plan for anexhibition, they are doing a(n) __________.{A}. survey{B}. experiment{C}. project{D}. presentation正确答案：C,第 20 题 (单项选择题)(每题 2.00 分) > 未分类 >Which of the following tasks fails to develop students′ skill ofrecognizing discourse patterns?{A}. Analyzing the structure of difficult sentences.{B}. Checking the logic of the author's arguments.{C}. Getting the scrambled sentences into a paragraph.{D}. Marking out common openers to stories and jokes.正确答案：A,第 21 题 (单项选择题)(每题 2.00 分) > 未分类 >请阅读Passage l，完成小题。
㊃论著㊃基金项目:蚌埠医学院自然科学项目重点项目主观认识下降转化为轻度认知功能障碍的临床预测模型的构建与评估(2021b yz d 190)通信作者:冯敏,E m a i l :f e n gm 1970@163.c o m 脑小血管病磁共振总负担对认知功能的影响朱方方,魏学志,冯 敏(蚌埠医学院第二附属医院神经内科,安徽蚌埠233000) 摘 要:目的 探索脑小血管病患者脑磁共振总负担与认知功能的相关性㊂方法 选择2021年9月至2022年10月入住我院神经内科并经脑磁共振成像(m a g n e t i c r e s o n a n c e i m a g i n g ,M R I )确诊的227例脑小血管病患者,收集相应的临床资料㊁脑影像资料㊁血液学指标,使用蒙特利尔认知评估量表(M o C A )评估认知状态,探索磁共振影像学标志物与认知功能障碍的相关性㊂结果 ①经多因素分析,年龄㊁高血压病㊁同型半胱氨酸㊁尿酸㊁腔隙性梗死评分和脑小血管病总负荷均与M o C A 分数存在相关性,差异有统计学意义(P <0.05)㊂②其他变量保持不变的情况下,脑小血管病总负荷每增加1分,M o C A 分数下降2.27分;腔隙评分每增加1分,M o C A 分数下降0.74分;同无高血压病的患者相比,合并高血压病者M o C A 分数下降0.94分;尿酸和同型半胱氨酸水平每升高1个单位,M o C A 分数分别下降0.01分和0.07分;年龄每长1岁,M o C A 分数下降0.07分㊂总体来看,所有的预测变量解释了M o C A 分数下降55.1%的变化㊂结论 脑小血管病患者的认知功能受多种因素影响,脑M R I 表现在一定程度上代表了脑小血管病脑内的病理状态,提示脑M R I 总负担对认知功能下降有预警意义㊂关键词:脑小血管病;M R I 总负担;认知;M o C A 量表中图分类号:R 743 文献标志码:A 文章编号:1004-583X (2023)11-0984-07d o i :10.3969/j.i s s n .1004-583X.2023.11.004E f f e c t o f t o t a lm a g n e t i c r e s o n a n c e i m a g i n g b u r d e no n t h e c o gn i t i v e f u n c t i o n i n p a t i e n t sw i t h c e r e b r a l s m a l l v e s s e l d i s e a s e sZ h uF a n g f a n g ,W e iX u e z h i ,F e n g Mi n D e p a r t m e n t o f N e u r o l o g y ,t h eS e c o n dA f f i l i a t e d H o s p i t a l o f B e n g b u M e d i c a lC o l l e g e ,B e n gb u 233000,C h i n a C o r r e s p o n d i n g a u t h o r :F e n g M i n ,E m a i l :f e n gm 1970@163.c o m A B S T R A C T :O b je c t i v e T oe x p l o r et h ec o r r e l a t i o nb e t w e e nt o t a lc e r e b r a lm a g n e t i cr e s o n a n c ei m a g i n g (M R I )b u r d e na n d c o gn i t i v e f u n c t i o n i n p a t i e n t sw i t h c e r e b r a l s m a l l v e s s e l d i s e a s e s (C S V D s ).M e t h o d s At o t a l o f 227C S V D p a t i e n t sd i a g n o s e db y t h eb r a i nM R I a n dh o s p i t a l i z e d i n t h eD e p a r t m e n t o fN e u r o l o g y f r o mS e pt e m b e r 2021t oO c t o b e r 2022w e r e r e c r u i t e d .T h e i rc l i n i c a l d a t a ,b r a i n i m a g i n g d a t a ,a n dh e m a t o l o g i c a l i n d i c a t o r sw e r ec o l l e c t e d .C o gn i t i v e f u n c t i o n w a se v a l u a t e d u s i n g t h e M o n t r e a lC o gn i t i v e A s s e s s m e n t (M o C A )s c a l e .T h ec o r r e l a t i o n b e t w e e n M R I m a r k e r sa n dc o g n i t i v ed y s f u n c t i o nw a se x p l o r e d .R e s u l t s T h em u l t i v a r i a t ea n a l y s i ss h o w e dt h a t a g e ,h y p e r t e n s i o n ,h o m o c y s t e i n e (H C Y ),u r i c a c i d (U A ),l a c u n a r s t r o k es c o r e (L a c )a n dt o t a l b u r d e no fC S V D sw e r ea l l s i g n i f i c a n t l yc o r r e l a t e dw i t h t h eM o C As c o r e (P <0.05).W h e no t h e r v a r i a b l e s r e m a i n e du n c h a n g ed ,t he M o C As c o r ed e c r e a s e d b y 2.27p o i n t sf o r e a c h p o i n t i n c r e a s e i n t h e t o t a l b u r d e n o f C S V D.T h eM o C As c o r e d e c r e a s e db y 0.74p o i n t s f o r e a c h p o i n t i n c r e a s e i n t h eL a c s c o r e .T h eM o C As c o r e d e c r e a s e db y 0.94p o i n t s f o r p a t i e n t sw i t hah i s t o r y o f h y pe r t e n s i o n c o m p a r e dw i t h t h o s e l a c k i n g t h eh i s t o r y of h y p e r t e n s i o n .T h e M o C As c o r ed e c r e a s e db y 0.01p o i n t sa n d0.07p o i n t s f o r e a c hu n i t i n c r e a s e i n U Aa n d H C Yl e v e l s ,r e s p e c t i v e l y .T h e M o C As c o r ed e c r e a s e db y 0.07p o i n t s f o ro n e y e a r o l d e r .O v e r a l l ,a l l p r e d i c t o r se x p l a i n e dt h e55.1%d e c r e a s e i n M o C As c o r e s .C o n c l u s i o n T h ec o gn i t i v e f u n c t i o no f C S V D p a t i e n t s i sa f f e c t e db y m a n y f a c t o r s ,a n dt h eb r a i n M R Iv i s u a l i z e st h ei n t r a c r a n i a l p a t h o l o gi c a ls t a t e .I t i s s u g g e s t e d t h a t t h e t o t a l b u r d e no f b r a i n M R I h a s a ne a r l y w a r n i n g s i g n i f i c a n c e f o r c o gn i t i v e d e c l i n e .K E Y W O R D S :c e r e b r a l s m a l l v e s s e l d i s e a s e ;t o t a lM R I b u r d e n ;c o gn i t i v e f u n c t i o n ;M o C As c a l e 脑小血管病(c e r e b r a ls m a l lv e s s e ld i s e a s e,C S V D )是一组累及脑内小动脉㊁小静脉等微血管所引起的以血管周围含铁血红素沉积为主要特征的一种脑实质亚临床损害[1-2],是老年人认知功能下降的重要原因[3-4]㊂C S V D 在影像学上有多种表现,如腔隙性梗死(l a c u n e ,L a c )㊁脑白质高信号(w h i t em a t t e rh y p e r i n t e n s i t y,WMH )㊁脑微出血(c e r e b r a l m i c r o b l e e d s ,C M B s )㊁扩大的血管周围间隙(l a r ge d p e r i v a s c u l a r s p a c e s ,E P V S )和脑萎缩等[5]㊂脑磁共振成像(m a g n e t i cR e s o n a n c e I m a g i n g ,M R I )影像学表现能反映出C S V D 患者脑内病理状态的严重程度,临床上发现C S V D 患者脑内的这些神经病理学改变并不单独存在,常常表现为多种病理损伤[6],目㊃489㊃‘临床荟萃“ 2023年11月20日第38卷第11期 C l i n i c a l F o c u s ,N o v e m b e r 20,2023,V o l 38,N o .11前对C S V D患者影像学标志物的研究多集中于一种标志物,不能全面反映脑内病理损伤对认知功能的影响,故学者们开始尝试探讨能代表活体全脑病理改变的指标即磁共振总负担对认知功能下降的影响,目前已见类似文献发表,但由于影像学参数㊁研究人群及入组标准的差异,未形成一致性结论㊂故本研究通过M R I总负担探讨C S V D患者脑内病理状态对认知功能的影响,为早期发现C S V D相关认知功能障碍提供线索㊂1资料与方法1.1病例选择在2021年9月至2022年10月期间我院神经内科共有256例经脑M R I诊断为C S V D 的患者,最终纳入227例患者㊂纳入标准:C S V D的诊断标准依据‘中国脑小血管病诊治专家共识2021“[7]严格筛选㊂排除标准:合并重度脏器功能不全者;因代谢㊁营养或毒性因素(如甲状腺功能减退㊁维生素B缺乏或酗酒)导致的认知功能障碍者;合并创伤性脑损伤㊁中枢神经系统感染和肿瘤者;严重精神疾病㊁谵妄㊁听力损失㊁视觉障碍者;脱髓鞘疾病㊁放疗或化疗引起的WMH㊂1.2方法1.2.1临床数据收集与认知功能评估通过病历系统收集人口学资料㊁脑影像学资料和临床资料㊂包括性别㊁年龄㊁受教育年限㊁吸烟史(平均每天1支烟,有1年吸烟史)㊁饮酒史(平均每天饮酒50m l,每周1次)㊁既往病史㊁相关血液学指标 甘油三脂(t r i g l y c e r i d e s,T G)㊁总胆固醇(c h o l e s t e r o l,C HO L)㊁高密度脂蛋白(h i g h-d e n s i t y l i p o p r o t e i n,H D L)㊁低密度脂蛋白(l o w-d e n s i t y l i p o p r o t e i n,L D L)㊁尿酸(u r i c a c i d,U A)㊁同型半胱氨酸(h o m o c y s t e i n e,H C Y)㊁空腹血糖(F a s t i n g b l o o ds u g a r,F B G) ㊂所有患者在就诊后1周内均完成了脑M R I扫描㊂根据电子病历记录收集认知结局,本研究的认知评估均由受过训练的神经内科医生使用中文版蒙特利尔认知评估量表(M o C A)评估㊂以M o C A分数<26分认定为认知功能障碍,教育年限<12年的额外加1分[6,8]㊂1.2.2 M R IC S V D总负荷评估所有患者均行头颅M R I检查(G E公司1.5T M R),将M R I设定层厚6mm,间距1.2mm,包括轴向弥散加权成像扫描:脉冲重复时间(r e p e t i t i o nt i m e,T R)5000m s,回波时间(e c h o t i m e,T E)81.5m s,扫描野(f i e l do f v i e w, F O V)240mmˑ240mm;轴位T1液体衰减反转恢复序列:T R1945m s,T E21.4m s,F O V240m mˑ192m m;轴位T2液体衰减反转恢复序列:T R8000 m s;T E145.7m s;F O V240mmˑ240mm;轴向磁敏感加权成像扫描:T R50.1m s,T E40m s,F O V 230mmˑ189mm㊂所有轴位扫描平面均平行于前联合-后联合线㊂C S V D的影像学表现由两名神经内科医生使用盲法独立评估,不一致的时候,请影像科医生协助㊂其中,脑白质疏松采用F a z e k a s[9-10]量表评估,脑室旁WMH评分:0分,无病变;1分,发生帽状或铅笔样薄层病变;2分,WMH病变存在光滑晕圈;3分,无规则的脑室旁WMH拓展到深处白质㊂深部WMH评分:0分,无病变;1分,发生点状病变;2分,病变发生少许融合;3分,病变发生大面积融合㊂C S V D总负担的评定采用4种影像学评分的总和来计算[11-12],评分方法如下:①WMH评分,脑室旁WMH(F a z e k a s3分)或深部WMH(F a z e k a s 2分及以上)评1分;②E P V S数目ȡ11个,评1分;③L a c数目ȡ1个,评1分;④C M B s数目ȡ1个,评1分;C S V D总分最高为4分㊂1.2.3统计学方法使用R软件(4.1.1)统计分析及绘图㊂计量资料进行正态性检验,满足正态分布采用均数ʃ标准差(x-ʃs)表示,行t检验,不满足正态分布采用中位数(四分位数)[M(P25,P75)]描述,行秩和检验㊂定性资料用[例(%)]描述,行卡方检验㊂将单因素分析中有统计学意义的变量纳入多因素分析,以M o C A分数为因变量,以多因素分析有统计学意义的变量为自变量,进入多因素线性回归分析,建立线性回归模型,并验证模型,P<0.05为差异有统计学意义㊂2结果2.1两组临床资料及影像学指标比较最终纳入227例C S V D患者其中男性156例,女性71例,年龄在49~83岁,平均年龄为(66.7ʃ6.99)岁,教育年限为(9.37ʃ3.18)年,吸烟者105例(46.3%),饮酒者90例(39.6%),高血压病105例(46.3%),冠心病89例(39.2%),糖尿病88例(38.8%),卒中史98例(43.2%)㊂以M o C A分数<26分定义为认知障碍,分为认知障碍组和认知正常组,两组年龄㊁吸烟㊁高血压病㊁C H O L㊁H C Y㊁U A㊁L a c评分㊁C M B s评分㊁WMH评分和C S V D总负荷差异有统计学意义㊂见表1㊂2.2多因素分析以M o C A分数是否小于26分为因变量,以单因素分析差异有统计学意义的变量作为预测变量,进入多因素线性回归模型,建立模型m o d e l1,定性资料中,无吸烟赋值为0,有吸烟赋值为1;无高血压病赋值为0,有高血压病赋值为1㊂结果显示年龄㊁高血压病㊁H C Y㊁U A㊁L a c评分和C S V D总负荷与M o C A分数存在相关性(P<0.05)㊂见表2和图1㊂㊃589㊃‘临床荟萃“2023年11月20日第38卷第11期 C l i n i c a l F o c u s,N o v e m b e r20,2023,V o l38,N o.11表1两组临床资料及影像学指标比较T a b.1 C o m p a r i s o no f c l i n i c a l d a t a a n d i m a g i n g i n d i c a t o r s b e t w e e n t h e t w o g r o u p s项目认知障碍组(n=100)认知正常组(n=127)χ2/t/F值P值性别[例(%)]男女69(69.0)31(31.0)87(68.5)40(31.5)0.0111.000年龄(x-ʃs)69.00ʃ6.7364.80ʃ6.660.619<0.01教育年限(x-ʃs)9.39ʃ3.359.35ʃ3.050.0140.919吸烟[例(%)]无有45(45.0)55(55.0)77(60.6)50(39.4)0.3170.023饮酒[例(%)]无有62(62.0)38(38.0)75(59.1)52(40.9)0.0600.683高血压病[例(%)]无有43(43.0)57(57.0)79(62.2)48(37.8)0.3920.005冠心病[例(%)]无有57(57.0)43(43.0)81(63.8)46(36.2)0.1390.339糖尿病[例(%)]无有63(63.0)37(37.0)76(59.8)51(40.2)0.0650.681卒中史[例(%)]无有53(53.0)47(47.0)76(59.8)51(40.2)0.1380.345T G(mm o l/L)2.17ʃ0.712.04ʃ0.670.1980.140C H O L(mm o l/L)4.85ʃ1.074.57ʃ1.120.2580.055H D L(mm o l/L)1.93ʃ0.511.89ʃ0.520.0810.544L D L(mm o l/L)2.49ʃ1.122.44ʃ1.020.0510.702H C Y(mm o l/L)17.20ʃ6.1614.00ʃ5.840.533<0.01U A(mm o l/L)396.00ʃ65.50378.00ʃ69.200.2620.050F B G(mm o l/L)6.01ʃ1.125.89ʃ0.970.1100.407L a c评分(分)0.70ʃ0.460.50ʃ0.500.4230.002C M B s评分[M(P25,P75)]0.00(0.00,1.00)0.00(0.00,0.00)0.4090.002 WMH评分(x-ʃs)0.69ʃ0.460.35ʃ0.480.710<0.01E P V S评分(x-ʃs)0.28ʃ0.450.27ʃ0.440.0270.838C S V D总负荷[M(P25,P75)]2.00(1.00,2.00)1.00(1.00,1.50)1.101<0.01表2 M o d e l1的多因素回归结果T a b.2 M u l t i v a r i a t e r e g r e s s i o n r e s u l t s f o rm o d e l1变量β值t值P值95%C I下限上限年龄[49,83]-0.07-3.495<0.01-0.11-0.03吸烟0(n=122)1(n=105)0.010.0500.961-0.520.55高血压病0(n=122)1(n=105)-0.96-3.545<0.01-1.49-0.43 H C Y[4,46]-0.06-2.8570.005-0.11-0.02 U A[226,656]-0.00-2.5000.013-0.01-0.00 C H O L[2.5,7.6]-0.17-1.4320.154-0.410.07 L a c评分[0,1]-0.83-2.3600.019-1.52-0.14 C M B s评分[0,1]0.380.8260.410-0.531.29 WMH评分[0,1]-0.48-1.2300.220-1.250.29 C S V D评分[1,4]-2.20-6.658<0.01-2.85-1.55㊃689㊃‘临床荟萃“2023年11月20日第38卷第11期 C l i n i c a l F o c u s,N o v e m b e r20,2023,V o l38,N o.11图1 m o d e l 1的森林图F i g.1 F o r e s t d i a g r a mo fm o d e l 12.3 多元线性回归 将m o d e l 1模型中差异有统计学意义的变量为自变量,以M o C A 分数为因变量,拟合多元线性回归模型m o d e l 2,无高血压病赋值为0,有高血压病赋值为1㊂结果:R 2=0.551,P <0.05㊂其他变量保持不变的情况下,C S V D 总负担每增加1分,M o C A 分数下降2.27分;腔隙性脑梗死评分每增加1分,M o C A 分数下降0.74分;同无高血压病病史的患者比,合并高血压病病史者M o C A 分数下降0.94分;U A 和H C Y 水平每升高一个单位,M o C A 分别下降0.01分和0.07分;年龄每增长1岁,认知评分下降0.07分㊂见表3,图2~3㊂2.4 验证回归模型 结果显示m o d e l 2模型拟合良好㊂见图4㊂表3 M o d e l 2的多因素回归结果T a b .3 M u l t i v a r i a t e r e gr e s s i o n r e s u l t s f o rm o d e l 2变量β值t 值P 值95%C I下限上限年龄[49,83]-0.07-3.57<0.01-0.110.03高血压病0(n =122)1(n =105)-0.94-3.47<0.01-1.48-0.41H C Y[4,46]-0.07-3.100.002-0.11-0.03U A [226,656]-0.01-2.530.012-0.01-0.00L a c 评分[0,1]-0.74-2.650.009-1.28-0.19C S V D 总负荷[1,4]-2.27-11.43<0.01-2.66-1.88图2 M o d e l 2的森林图F i g.2 F o r e s t d i a g r a mo fm o d e l 2㊃789㊃‘临床荟萃“ 2023年11月20日第38卷第11期 C l i n i c a l F o c u s ,N o v e m b e r 20,2023,V o l 38,N o .11图3 M o d e l 2的线性回归模型 注:蓝色代表回归曲线,红色代表预测区间,灰色代表可信区间F i g.3 L i n e a r r e g r e s s i o nm o d e l f o rm o d e l 2 B l u e r e p r e s e n t s t h e r e g r e s s i o n c u r v e ,r e d r e p r e s e n t s t h e p r e d i c t i o n i n t e r v a l ,a n d g r a y r e p r e s e n t s t h e c o n f i d e n c e i n t e r v al图4 M o C A 分数对m o d e l 2模型的回归诊断图F i g.4 R e g r e s s i o nd i a g n o s i s d i a g r a mo fM o C As c o r e o nm o d e l 23 讨 论既往有关C S V D 认知障碍的研究主要集中在单一M R I 标志物对认知功能的影响,如C M B s 或脑白质疏松与认知功能下降的相关性研究等[8,13]㊂单一影像学指标不能有效反映C S V D 全脑损伤的程度,故学者们提出了C S V D 总负担这一概念,用L a c㊁C M B s ㊁WMH 和E P V S 这4个指标的总分数来表示C S V D 患者脑内病理损害的严重程度,评分越高表示脑损伤的程度越重㊂本研究从脑M R I 总负担的角度探索在多因素环境下C S V D 总负荷对C S V D 患者认知功能的影响㊂本研究中共有100名C S V D 患者发生认知功能障碍,认知障碍的发生率为44.1%㊂本研究得出,两组年龄㊁吸烟㊁高血压病㊁C HO L ㊁U A ㊁H C Y ㊁L a c 评分㊁C M B s 评分㊁WMH 评分㊁C S V D 总负荷差异有统计学意义(P <0.05),与认知正常组相比,认知障碍组年龄更大,有吸烟史及高血压病的比例更高,C HO L ㊁U A 及H C Y 水平更高,C S VD 的磁共振总负担更重㊂多元线性回归模型显示年龄㊁高血压病㊁H C Y ㊁U A ㊁L a c 评分㊁C S V D 总负荷能比较好的预测C S V D 患者的认知功能障碍下降的程度㊂其他变量保持不变的情况下,C S V D 总负担每增加1分,M o C A 分数下降2.27分;而C S V D 中的腔隙每增加1个,M o C A 分数下降0.74分;同无高血压病的患者㊃889㊃‘临床荟萃“ 2023年11月20日第38卷第11期 C l i n i c a l F o c u s ,N o v e m b e r 20,2023,V o l 38,N o .11比,合并高血压病者M o C A分数下降0.94分;同理, U A和H C Y水平每升高一个单位,M o C A分别下降0.01分和0.07分;年龄每长一岁,认知评分下降0.07分㊂总体来看,所有的预测变量解释了M o C A分数下降55.1分的方差㊂国内外多项研究在探索C S V D认知障碍的危险因素时得出年龄[14]㊁高血压病[15-16]㊁H C Y[1,17-19]㊁U A[20]是C S V D患者认知功能下降的独立危险因素,其中的一项研究进一步阐明了血清H C Y水平与C S V D的发生呈剂量依赖关系[18]㊂本研究结果表明年龄㊁高血压病㊁H C Y㊁U A与C S V D患者认知下降存在明确的相关性,并且年龄越大㊁高血压病患者的比例㊁H C Y水平越高,认知障碍下降的越严重㊂而血U A对认知功能的影响一直存在争议:低水平的血U A与认知功能的快速下降有关,高水平的血U A 可能对神经有保护作用㊂一项研究认为U A是人体血浆中含量最丰富的天然抗氧化剂,它的抗氧化特性可能会防止自由基损伤,从而降低与氧化应激相关的认知障碍和痴呆症的风险[21],而另一项研究表达了血U A升高可促进氧化应激,增加体内炎症因子的释放,加速患者血管性痴呆的发展[22]㊂虽然低水平血U A与阿尔茨海默病相关的认知障碍存在关联,但是否具有因果关系还有待确定[23]㊂然而在一项针对中国社区老年人的研究中,作者认为较高的血U A水平在正常范围内与认知功能呈正相关,但在高尿酸血症的参与者中这种相关性并不明显[24]㊂另外也有研究显示,血U A水平的增加提高了认知障碍的风险[25]㊂李倩等[26]在研究中得出血U A水平升高为H型高血压合并M C I的保护因素,H型高血压患者的血U A水平与M o C A分数呈正相关(r= 0.279,P=0.008)㊂还有研究显示U A和认知功能障碍的联系在性别上也有所不同,男性血尿酸水平与认知障碍发生率呈U型关系,拐点为297m m o l/L,然而,在女性中,血尿酸水平与认知障碍之间没有关联[27]㊂综上,未来仍需进一步探索血U A在认知障碍疾病当中的作用㊂本研究结果显示C S V D总负荷与M o C A分数呈负相关关系,在调整了年龄㊁高血压病㊁尿酸㊁H C Y㊁腔隙后,这种相关性仍然存在;在调整了年龄㊁高血压病㊁尿酸㊁H C Y㊁C S V D总负荷后,4种磁共振影像标志物中,只有腔隙性梗死分与M o C A评分存在显著性负相关关系㊂单因素分析时脑M R I标志物腔隙性梗死㊁C M B s㊁脑白质疏松㊁C S V D总负担在认知障碍组和认知正常组差异有统计学意义㊂本研究中C M B s与脑白质疏松可能存在共线关系,导致在单因素分析时存在显著差异,从而将C M B s和脑白质疏松纳入多因素分析中,而在进一步的多因素线性回归分析时,通过控制混杂因素,又使C M B s及脑白质疏松与M o C A分数的假性关联消失了,故最终只有腔隙性梗死与M o C A分数呈负相关关系,这可能与本研究对象选择偏倚有关㊂本研究结果显示腔隙性梗死和C S V D总负荷均会影响认知功能,且均是负向影响;相对于腔隙性梗死对M o C A分数的影响, C V S D总负荷对M o C A分数的效应值β更显著,可以解释为C S V D总负荷对认知功能的损伤更严重㊂本研究的C S V D患者中,C S V D总负担与认知能力显著相关,这与既往研究结论一致[9,28]㊂本研究为横断面研究,存在一定局限性,未来需要进行纵向研究,进一步确定C S V D总负荷与认知功能下降之间是否存在因果关系㊂综上,脑M R I影像学总负担是活体状态下反映全脑损伤的一种安全无创的评估脑病理状态的简单方法,可以协助临床医生预测C S V D患者认知下降的程度,因此当患者存在多种C S V D标志物时,应树立为患者定期认知评估的意识,做好防治,降低认知障碍的发生率㊂参考文献:[1]王维维,申致远,李凡,等.血浆低密度脂蛋白胆固醇和同型半胱氨酸与脑小血管病患者认知功能的相关性研究[J].中国脑血管病杂志,2021,18(12):836-842.[2]张泽阳,王倩,陈卓友.脑小血管病影像学特征及其总体负荷与血管性认知障碍关系的研究进展[J].中国脑血管病杂志,2022,19(9):642-647.[3]王雅楠,姚琳,毛文静,等.脑小血管病患者氧化应激标志物㊁磁共振总负担与血管性认知障碍的相关性[J].中华行为医学与脑科学杂志,2020,29(10):898-903.[4]S t a a l s J,B o o t hT,M o r r i s Z,e t a l.T o t a lM R I l o a do f c e r e b r a ls m a l l v e s s e ld i s e a s ea n dc o g n i t i v ea b i l i t y i no l d e r p e o p l e[J].N e u r o b i o lA g i n 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; jgc@ | Journal of Geriatric CardiologyJournal of Geriatric Cardiology (2019) 16: 671-675 ©2019 JGC All rights reserved; Research Article∙Open Access ∙Simple hematological predictors of AF recurrence in patients undergoing atrial fibrillation ablationGeorge Bazoukis 1,#, Konstantinos P Letsas 1, Konstantinos Vlachos 1, Athanasios Saplaouras 1, Dimitrios Asvestas 1, Konstantinos Tyrovolas 1, Aikaterini Rokiza 1, Eirini Pagkalidou 2, Gary Tse 3,4, Stavros Stavrakis 5, Antonios Sideris 1, Michael Efremidis 11Department of Cardiology, Electrophysiology Laboratory, Evangelismos General Hospital of Athens, Athens, Greece 2Department of Hygiene and Epidemiology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece 3Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China; 4Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, China 5Department of Medicine, Cardiovascular Section, Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USAAbstractBackgound Red cell distribution width (RDW) and neutrophil-to-lymphocyte ratio (NLR) are simple hematologic indices that have been used to predict adverse outcomes in different clinical settings. The aim of our study is to determine whether RDW and NLR can predict atrial fibrillation (AF) recurrence in patients undergoing AF ablation. Methods Consecutive patients, without known hematological disor-ders, who underwent AF catheter ablation between January 2014 and April 2017 were enrolled into this study. Blood samples were taken one day before and five hours after the ablation procedure. Results A total of 346 patients (224 males (65%), mean age: 59 ± 11 years old) were included. After a mean follow up of 26.2 ± 12.1 months, 80 (23.1%) patients experienced late AF recurrence (defined as any recurrence after the blanking period of three months), while 97 (28%) patients experienced early AF recurrence during the blanking period. Univariate analysis showed that early arrhythmia recurrence, type of AF and NLR after the procedure were significantly associated with late AF recur-rence, while early arrhythmia recurrence and NLR remained significant in multivariate analysis. RDW was not associated with late AF re-currence. None of the parameters above predicted early arrhythmia recurrence. Conclusions Simple and inexpensive hematological indices such as NLR should be evaluated for their ability to predict AF recurrence in patients undergoing catheter ablation in larger prospective studies. J Geriatr Cardiol 2019; 16: 671-675. doi:10.11909/j.issn.1671-5411.2019.09.008 Keywords: Atrial fibrillation; Neutrophils; Radiofrequency ablation1 IntroductionHematological indices such as red cell distribution width (RDW) and neutrophil-to-lymphocyte ratio (NLR) have been associated with incident atrial fibrillation (AF).[1–6] RDW reflects variability in the size of circulating erythro-cytes and is a marker of anisocytosis,[7] while NLR is a sys-temic inflammatory marker with prognostic significance for cardiovascular diseases.[8] Specifically, a high neutrophil count reflects subclinical inflammation, and a reduced lym-phocyte count reflects physiologic stress and poor general health. As a result, the NLR provides information on both#Correspondence to: George Bazoukis, MD, MSc, Department of Cardi-ology, General Hospital of Athens “Evangelismos”, Ipsilantou 47, Athens, Greece. E-mail: gbazoykis@med.uoa.gr Received: November 18, 2018 Revised: December 31, 2018 Accepted: January 30, 2019Published online: September 28, 2019the inflammatory status and the stress response.[9] In light of the well-characterized association between inflammation and AF,[10] a number of studies have evaluated the role of corticosteroids in preventing AF recurrence after AF cathe-ter ablation.[11–14] Specifically, the STEROID-AF study showed that oral corticosteroids have significant effect in lowering certain cytokines, but this was not translated to better outcomes following AF ablation.[11] Another random-ized controlled trial reported that low dose corticosteroids administered for a short period, shortly after AF ablation may have a beneficial role in prevention of immediate and mid-term follow-up AF recurrences.[12] In addition, peripro-cedural short-term moderate intensity steroid therapy re-duced early arrhythmia recurrence but it was not effective in preventing late AF recurrence following AF ablation.[13] These findings highlight the possible association between inflammation and AF recurrence in patients undergo cathe-ter ablation. Furthermore, there is an increased interest infinding simple predictors for identifying patients who are at higher risk of AF recurrence and who might benefit from adjunctive antiarrhythmic medications post-ablation. There-fore, we investigated the values of RDW, NLR and other simple hematological indices for predicting AF recurrence in patients undergoing AF ablation in our center.2Methods2.1Patients and ablation procedureThis retrospective cohort study included consecutive pa-tients undergoing AF catheter ablation between January 2014 and April 2017 in our center. The exclusion criteria were those with known hematological disorders. Catheter ablation was performed under intravenous sedation with midazolam and remifentanyl by two experienced operators (Efremidis M and Letsas KP). The ablation procedure has been described in full details elsewhere.[15] In brief, after the three-dimensional geometry of the left atrium was obtained using CARTO (Biosense Webster, Inc.), wide circumferen-tial lesions for isolation of large atrial areas around both ipsilateral pulmonary veins (PVs) were applied using a 3.5 mm-tip ablation catheter (Thermo Cool Navi-Star and Smart Touch, Biosense Webster, Inc.). The endpoint of the ablation was the absence or dissociation of potentials in the isolated area as documented by the circular mapping cathe-ter (Lasso, BiosenseWebster, Inc.) placed within each of the PVs. In addition, exit block was confirmed by pacing around the circular mapping catheter from within each PV. Entrance and exit block of the PVs were evaluated 30 min after the initial isolation. The patients were anticoagulated using acenocoumarol with a target international normalized ratio of 2.0–3.0 or direct oral anticoagulants at least four weeks before and three months after the procedure. We rou-tinely received blood samples from all patients who under-went AF catheter ablation one day before and about five hours after the ablation procedure. We measured a complete blood count, creatinine and troponin levels.All patients in our institution underwent routine fol-low-up post-ablation, as per our institution’s protocol. Spe-cifically, patients were evaluated every week at the dedi-cated arrhythmia outpatient clinic of our institution for the first month after the procedure. Patients had follow-up visits with a 24-h Holter electrocardiogram at 1, 3, 6, 9, 12 months and for every 6 months thereafter or whenever they developed symptoms consistent with recurrent AF. Antiar-rhythmic drugs, except amiodarone, were discontinued five days before the ablation procedure and were re-initiated on the next day only in patients with non-paroxysmal AF for three months after the procedure. Amiodarone was discon-tinued for four weeks before the procedure to allow enough time for wash out while non-paroxysmal AF patients were reloaded after the procedure.[16] The study was approved by the Hospital’s Ethics Committee.2.2Statistical analysisContinuous variables are presented as mean ± SD, while categorical ones are presented as absolute and relative fre-quencies (percentages). Continuous variables were tested for normal distribution using the Kolmogorov-Smirnov test. Continuous variables with and without normal distribution were compared using Student’s t-test or the Mann-Whitney U test, respectively. Pearson’s chi-square or Fisher’s exact test were used to test for any associations between two categorical variables. We examined univariate models and multivariate models with forward selection of variables per likelihood ratio criteria by using binary logistic regression analysis. Variables with a univariate P-value < 0.2 were included in the multivariable model (Hosmer-Lemeshow). Receiving operating characteristics curve (ROC) was per-formed to assess the best cutoff value of significant contin-ues variables to predict AF recurrence. Analyses were per-formed with SPSS (version 17.0, SPSS Inc., Chicago, IL, USA) and all reported P-values are two-tailed. Dou-ble-sided P-values less than 0.05 were considered as indica-tive of statistical significance.3ResultsA total of 346 patients (224 males (65%), mean age: 59 ±11 years), who were followed for a mean period of 26.2±12.1 months, were included. The indication for AF ablation was symptomatic AF (paroxysmal AF: 216 (62%), persis-tent AF: 121 (35%), long standing persistent AF: 9 (3%)) refractory to antiarrhythmic drugs. During follow-up, 80 (23%) patients experienced late AF recurrence (defined as any recurrence after the blanking period of three months), while 97 (28%) patients experienced early AF recurrence during the blanking period. Of the different hematological indices studied, only NLR after ablation was significantly associated with late AF recurrence during after ablation (P = 0.035). By contrast, RDW before or after ablation procedure was not significantly associated with late arrhythmia recur-rence. Other factors significantly associated with late recur-rence of AF were early arrhythmia recurrence (P = 0.023), type of AF (P = 0.0009) and procedure time (0.041) (Table 1). Multivariate analysis was performed, including variables with P < 0.2 on univariate analysis. This revealed early ar-rhythmia recurrence (OR = 1.94, 95% CI: 1.11–3.41, P = 0.02) and NLR post-ablation (OR = 1.1, 95% CI: 1.01–1.20,Journal of Geriatric Cardiology| jgc@; ; jgc@ | Journal of Geriatric CardiologyTable 1. Baseline characteristics, procedural characteristics and hematological indices between patients with and without late atrial fibrillation recurrence.Late atrial fibrillation recurrenceYes (n = 80, 23.1%) No (n = 266, 76.9%) P - value Follow-up, months 28.3 ± 11.9 25.5 ± 12.1 0.05Hematological indices before ablationNLR 2.04 ± 0.74 2.12 ± 1.36 0.43WBC, cells/μL 7179 ± 1930 7454 ± 2110 0.30Platelets, ⨯ 109/L 234 ± 55 234 ± 63 0.57RBC, ⨯ 106/μL 4.93 ± 0.50 4.93 ± 0.55 0.99RDW-SD, fL 42.8 ± 3.20 42.4 ± 4.40 0.28RDW-CV 13.7% ± 1.00% 13.8% ± 1.68%0.85RDW-SD/PDW 3.12 ± 0.49 3.10 ± 0.53 0.53Troponin, ng/L 7.55 ± 6.40 10.1 ± 33.4 0.89Creatinine, mg/dL 0.85 ± 0.19 0.85 ± 0.25 0.44Hematological indices after ablationNLR 6.27 ± 3.64 5.25 ± 2.83 0.04WBC cells/μL 9821 ± 3077 9493 ± 2689 0.41Platelets, ⨯ 109/L 195 ± 47 201 ± 54 0.67RBC, ⨯ 106/μL 4.42 ± 0.45 4.52 ± 0.53 0.21RDW-SD fL 42.1 ± 3.22 41.8 ± 4.80 0.63RDW-CV 13.5% ± 0.95% 13.7% ± 1.67%1.00RDW-SD/PDW 3.17 ± 0.54 3.16 ± 0.55 0.57Troponin, mg/dL 808.5 ± 447960.7 ± 6350.09Baseline characteristics Male sex 53 (66.3%) 171 (64.3%) 0.75Age, yrs 59.6 ± 10.3 58.6 ± 11.2 0.57Paroxysmal AF 40 (50%) 176 (66.2%) 0.01Hypertension 46 (57.5%) 129 (48.5%) 0.19Diabetes 6 (7.5%) 27 (10.2%) 0.47Dyslipidemia 31 (38.8%) 101 (38%) 0.94Coronary artery disease 6 (7.5%)11 (4.1%)0.23Antiarrhythmic drugs β-blockers58 (72.5%) 183 (68.8%) 0.74Class Ic (flecainide, propafenone) 46 (57.5%) 139 (52.3%) 0.53Sotalol 20 (25%) 63 (23.7%) 0.90Amiodarone 19 (23.8%)58 (21.8%)0.80Procedure characteristics Fluoroscopy time, min 15.7 ± 8.3 16.5 ± 8.2 0.42Procedure time, min 186.9 ± 56.7 174.4 ± 53 0.04Radio-frequency time, min 30.15 ± 1.4729.96 ± 2.450.08Complications Stroke4 (5%)3 (1.1%)0.03Tamponade 0 1 (0.4%) 0.59Early arrhythmia recurrence 31 (38.8%) 66 (24.8%) 0.02Data are presented as mean ± SD or n (%). AF: atrial fibrillation; NLR: neu-trophil to lymphocyte ratio; PDW: platelet distribution width; RBC: red blood cells; RDW-CV: red cell distribution width-coefficient variation; RDW-SD: red cell distribution width-standard deviation; WBC: white blood cells.P = 0.03) were significantly associated with late AF recur-rence. No significant association between hematological in-dices and early arrhythmia recurrence was found (Table 2).Table 2. Baseline characteristics, procedural characteristics and hematological indices between patients with and without early atrial fibrillation recurrence.Early atrial fibrillation recurrenceYes (n = 97, 28%) No (n = 249, 72%)P - valueFollow-up, months 25.6 ± 12.5 26.4 ± 11.9 0.51Hematological indices before ablationNLR 1.94 ± 0.79 2.16 ± 1.37 0.31WBC, cells/μL 7396 ± 2118 7376 ± 1954 0.97Platelets, × 109/L 237 ± 74 233 ± 56 0.90RBC, ×106/μL 4.93 ± 0.54 4.93 ± 0.54 0.89RDW-SD, fL 42.8 ± 4.3 42.3 ± 4.1 0.67RDW-CV 13.9% ± 1.8% 13.7% ± 1.4% 0.23RDW-SD/PDW 3.1 ± 0.53 3.1 ± 0.52 0.91Troponin, ng/L 6.98 ± 5.59 10.5 ± 34.7 0.84Creatinine, mg/dL 0.85 ± 0.25 0.84 ± 0.2 0.99Hematological indices after ablationNLR 5.62 ± 3.27 5.43 ± 2.99 0.88WBC cells/μL 9545 ± 26669579 ± 28320.89Platelets, × 109/L202 ± 62.3198 ± 48.60.96RBC, × 106/μL 4.47 ± 0.51 4.5 ± 0.52 0.58RDW-SD, fL 42.4 ± 4.4 41.7 ± 4.52 0.36RDW-CV 13.8% ± 1.8% 13.6% ± 1.4% 0.22RDW-SD/PDW 3.15 ± 0.56 3.17 ± 0.54 0.77Troponin, mg/dL 968 ± 626 909 ± 589 0.57Baseline characteristics Male sex 62 (63.9%) 162 (65.1%) 0.84Age, yrs 59.6 ± 10.3 58.6 ± 11.2 0.92Paroxysmal AF 54 (55.7%) 162 (65.1%) 0.11Hypertension 50 (51.5%) 125 (50.8%) 0.90Diabetes 11 (11.3%) 22 (8.9%) 0.49Dyslipidemia 33 (34%) 99 (40.1%) 0.3Coronary artery disease 4 (4.1%) 13 (5.3%) 0.66Antiarrhythmic drugs Class Ic 55 (58.5%) 130 (54.9%) 0.55β-blockers 75 (78.1%) 166 (69.5%) 0.11Sotalol 28 (29.2%) 55 (23%) 0.24Amiodarone 26 (27.1%) 51 (21.3%) 0.26Procedure characteristics Fluoroscopy time, min 15.7 ± 8.3 16.5 ± 8.2 0.67Procedure time, min 230.5 ± 403174.4 ± 530.004ComplicationsStroke 2 (2.1%) 5 (2%) 0.99Tamponade 0 1 (0.4%) 0.53Data are presented as mean ± SD or n (%). AF: atrial fibrillation; NLR: neutrophil to lymphocyte ratio; PDW: platelet distribution width; RBC: red blood cells; RDW-CV: red cell distribution width-coefficient variation; RDW- SD: red cell distribution width-standard deviation; WBC: white blood cells.In ROC analysis, a NLR after ablation > 3.9 had a 70% sensitivity and 38% specificity for predicting late AF recur-rence (AUC = 0.58, 95% CI: 0.51 0.65, P = 0.035). We subsequently performed subgroup analysis regarding the type of AF (paroxysmal AF: 216 patients, non-paroxysmal AF: 130 patients). In paroxysmal AF patients, we did not find any statistically significant differences in either base-line characteristics or hematological indices (before or after ablation procedure) between patients with or without late AF recurrence. On the other hand, in non-paroxysmal AF patients, univariate analysis showed that lower platelet dis-tribution width (PDW) levels after ablation (P = 0.03) and higher RDW-SD/PDW (P = 0.01) and troponin levels (P = 0.04) after the ablation procedure were significantly associ-ated with late AF recurrence. However, the statistical sig-nificance was lost for these hematological indices in multi-variate analysis.4DiscussionThe main findings of our study are that NLR after abla-tion procedure and early arrhythmia recurrence were sig-nificantly associated with late AF recurrence in patients undergoing AF catheter ablation while we did not find a significant association between RDW and late AF recur-rence.Several studies have investigated the possible associa-tions between simple electrocardiographic [17] and hemato-logical markers, such as RDW and NLR, and AF ablation outcomes.[9,18–21] Elevated RDW and pre-ablation NLR have been found to be predictors of AF recurrence following cryoballoon-based AF ablation,[9,18] while pre-ablation white blood cell count was also found to significantly associated with AF recurrence after catheter ablation.[19] Consistent with our results, Guo and colleagues found that post-ablation NLR was associated with higher AF recurrence rates after the ablation procedure.[22] Similarly, a meta-analysis showed that high NLR, whether baseline or post-surgery/procedure, is associated with an increased risk of AF recurrence/occu-rrence after CABG, catheter ablation or cardioversion.[2] Additionally, post-ablation NLR has been found to be an independent predictor for early arrhythmia recurrence,[20] which is an important finding because early arrhythmia re-currence is significantly associated with late arrhythmia recurrence as revealed from the present study. However, our study did not show significant association between pre- or post-ablation NLR and early arrhythmia recurrence.Regarding the pathophysiology of the revealed associa-tion between NLR with late arrhythmia recurrence, the NLR provides information on both the inflammatory status and the stress response while the accumulating neutrophils con-tribute to atrial remodeling through the release of pro-in-flammatory mediators.[23] The findings of previous studies indicating that pre-ablation NLR levels were significantly associated with adverse ablation outcomes support the no-tion that pre-ablation inflammatory environment may have a role in AF recurrence and thus could be a pharmacological target to improve post-procedure outcomes. For example, previous studies investigated the role of corticosteroids in preventing AF recurrence after AF catheter ablation.[11–13] Future prospective studies are needed on this area and they will need to take into account other contributing factors towards AF recurrence, such as the ablation technique used,[24] heart failure status,[25] and electrophysiological sub-strates present at baseline and revealed during ablation by adenosine testing.[26]4.1ConclusionsIn conclusion, NLR after ablation procedure was found to be significantly associated with late AF recurrence in patients undergoing AF catheter ablation. Whether post- ablation NLR levels can be used as a risk stratification tool to identify patients at higher risk of AF recurrence remains to be determined. This has the potential to change common practice as this subgroup may benefit from adjunct antiar-rhythmic medications after the procedures.4.2LimitationsOur study is a retrospective small sized single-center ob-servational study. Importantly, the follow-up monitoring for the detection of arrhythmia recurrence was performed via 24-h or 48-h Holter recordings and 12-lead electrocardio-grams. More thorough methods of monitoring, such as loop recorders, 7-day Holter monitoring, can be used in the fu-ture to improve AF detection rates. AcknowledgmentsThis research received no specific grant from any fund-ing agency in the public, commercial or not-for-profit sec-tors. The authors have no conflicts of interest to declare. References1 Adamsson Eryd S, Borne Y, Melander O, et al. Red blood celldistribution width is associated with incidence of atrial fibril-lation. J Intern Med 2014; 275: 84–92.2 Shao Q, Chen K, Rha SW, et al. 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