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BACKGROUND@#Cardiovascular (CV) disease is the leading cause of morbidity and mortality in adults with type 2 diabetes (T2D). The aim of this study was to determine the CV risk in Chinese patients with T2D based on the 2019 European Society of Cardiology (ESC) and the European Association for the Study of Diabetes (EASD) guidelines on diabetes, pre-diabetes, and CV diseases.@*METHODS@#A total of 25,411 patients with T2D, who participated in the study of China Cardiometabolic Registries 3B study, were included in our analysis. We assessed the proportions of patients in each CV risk category according to 2019 ESC/EASD guidelines.@*RESULTS@#Based on the 2019 ESC/EASD guidelines, 16,663 (65.6%), 1895 (7.5%), and 152 (0.6%) of patients were included in "very high risk," "high risk," and "moderate risk" categories, respectively. The proportions of patients in each category varied based on age, sex, body mass index, and duration. While 58.7% (9786/16,663) of elderly patients were classified to "very high risk" group, 89.6% (3732/4165) of patients with obesity were divided into "very high risk" group. Almost all patients with a duration of diabetes >10 years had "very high risk" or "high risk." However, 6701 (26.4%) of Chinese T2D patients, who had shorter duration, and one or two risk factors, could not be included in any category (the "unclear risk" category).@*CONCLUSIONS@#In China, most patients with T2D have "very high" or "high" CV risk based on 2019 ESC/EASD guidelines. However, the risk of patients in "unclear risk" group needs to be further classified.
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Adult , Aged , Humans , Cardiovascular Diseases/epidemiology , Cross-Sectional Studies , Diabetes Mellitus, Type 2 , Heart Disease Risk Factors , Risk FactorsABSTRACT
Objective:To compare the efficacy and safety of Changsulin ? with Lantus ? in treating patients with type 2 diabetes mellitus (T2DM). Methods:This was a phase Ⅲ, multicenter, randomized, open-label, parallel-group, active-controlled clinical trial. A total of 578 participants with T2DM inadequately controlled on oral hypoglycemic agents were randomized 3∶1 to Changsulin ? or Lantus ? treatment for 24 weeks. The efficacy measures included changes in glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG), 2h postprandial plasma glucose (2hPG), 8-point self-monitoring of blood glucose (SMBG) profiles from baseline, and proportions of subjects achieving targets of HbA1c and FPG. The safety outcomes included rates of hypoglycemia, adverse events (AEs) and anti-insulin glargine antibody. Results:After 24 weeks of treatment, mean HbAlc decreased 1.16% and 1.25%, FPG decreased 3.05 mmol/L and 2.90 mmol/L, 2hPG decreased 2.49 mmol/L and 2.38 mmol/L in Changsulin ? and in Lantus ?, respectively. No significant differences could be viewed in above parameters between the two groups (all P>0.05). There were also no significant differences between Changsulin ? and Lantus ? in 8-point SMBG profiles from baseline and proportions of subjects achieving the targets of HbA1c and FPG (all P>0.05). The rates of total hypoglycemia (38.00% and 39.01% for Changsulin ? and Lantus ?, respectively) and nocturnal hypoglycemia (17.25% and 16.31% for Changsulin ? and Lantus ?, respectively) were similar between the two groups (all P>0.05). Most of the hypoglycemia events were asymptomatic, and no severe hypoglycemia were found in both groups. No differences were observed in rates of AEs (61.77% vs.52.48%) and anti-insulin glargine antibody (after 24 weeks of treatment, 6.91% vs.3.65%) between the two groups (all P>0.05). Conclusions:Changsulin ? shows similar efficacy and safety profiles compared with Lantus ? and Changsulin ? treatment was well tolerated in patients with T2DM.
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Objective To evaluate the clinical characteristics and etiologies of central diabetes insipidus (CDI).Methods The clinical data of 230 patients with CDI in the Department of Endocrinology of Chinese PLA General Hospital from 2008 June to 2014 December were collected and analyzed retrospectively.Results The three most common causes of CDI were idiopathic CDI,lymphocytic hypophysitis and intracranial germ cell tumors.Among all the CDI,the idiopathic CDI accounted for 37.48％.There were significant differences in age onset and gender distribution among the different causes of CDI.The patients with intracranial germ cell tumors [age of onset(19.2± 10.2) years] were younger than the other types of CDI.Germ cell tumors patients were more common in male,and lymphocytic hypophysitis patients were more common in female.The most frequent abnormality of anterior pituitary in patients with CDI was growth hormone deficiency,followed by hypogonadism,adrenal insufficiency and hypothyroidism.The dysfunction of thyroid axis and adrenal axis in patients with germ cell tumor was more common than those in patients with idiopathic and lymphocytic hypophysitis.Conclusions The most common causes of central diabetes insipidus were idiopathic CDI,lymphocytic hypophysitis and intracranial germ cell tumors.There were differences in age of onset,gender distribution and abnormal production of anterior pituitary hormones among all causes of CDI patients.
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Objective To evaluate the clinical characteristics of patients with growth-hormone adenoma (GHA) and summarize the diagnosis and treatment experience.Methods The clinical data of 338 GHA cases at the General Hospital of PLA from Jan. 1990 to Dec. 2016 were collected, of which 252 cases with more complete clinical data were retrospectively analyzed including their general situation, medical history, laboratory tests and auxiliary examinations, and treatment modalities and outcomes. Parts of the patients were followed up.Results The cases of hospitalized GHA patients have increased year by year since 1990, and the number of patients admitted in the last 3 years accounted for 56.2% of the total number of cases. The sex ratio for GHA patients was nearly 1:1. Age of visiting followed Gaussian distribution while the 41-50 age group occupied the largest part. The most typical sign is hand and foot enlargement (60.7%), followed by the hypertrophy of nasal ala. The most common symptoms are headache (42.5%), hypopsia, visual field defect and diplopia. More than half of GHA patients were complicated with prediabetes and diabetes (72.6%), sleep apnea (69.5%), goiter or thyroid nodularity (56.4%), cardiac insufficiency (57.0%) and colon polyp (54.1%); while the percentages of cases undergone the relevant examination in the total number of cases were as follows: 75g OGTT test (42.1%), polysomnography (23.4%), thyroid ultrasound (37.3%), echocardiogram (47.6%) and colonoscopy (14.7%); GHA was 23.37±1.42μg/L and IGF-1 was 804.28±273.93ng/ml on average; 85.0% of somatotroph tumors are macroadenoma. Surgery remains the mainstay of therapy to GHA, while medical therapy was selected by less patients. During the follow-up, only 38.0%of GHA patients can be contacted, among them the remission rate decreased to 40.5%. The positive rate of long-term remission evaluated by early postoperative GHA level was consistent with that confirmed by the long-term follow-up (χ2=3.368,P>0.05). Conclusions The number of hospitalized GHA patients have increased recent years. The common clinical signs and symptoms are somatic enlargement and nonspecific headache. Due to uncompleted screening, GHA associated complications are always misdiagnosed; It is essential to establish a sound model of follow-up to improve patients' quality of life. The early postoperative GHA levels may predict the prognosis of surgery.
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To study thyroid hormone receptor β(THRβ)gene mutation in a pituitary-resistance to thyroid hormone syndrome family. The peripheral blood samples of the patient, his sister, parents, and 4 maternal relatives were collected. Then serum was isolated for detecting thyroid hormone levels with chemiluminescence immunoassay, and DNA was extracted for PCR, and 10 exons of THRβ gene were sequenced. The patient and his mother had the hyperthyroid symptom for many years and his mother with atrial fibrillation. The G→A heterozygous transition mutation was confirmed by exon sequencing at nucleotide 949 within exon 9 of THRβ gene in the patient and his mother, which was a missense mutation causing a substitution of Alanine to Threonine(A317T). No mutation was found in THRβ gene in other family members. This is the first Chinese family reported with pituitary thyroid hormone resistance syndrome caused by a A317T mutation in the thyroid hormone receptor β gene.
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Diabetes prevalence increased year by year,among which population of gestational diabetes mellitus,children and adolecnts with diabetes,and older adults with diabetes were also increased.These special population are different in physiological charateriscs and treatment demands.Here we reviewed the management challenges and strategies for these special diabetes populations.
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[Summary] Acarbose is a kind of α-glucosidases that binds competitively to the complex oligosaccharide at the brush border of the small intestine,thus delaying the breakdown of sucrose and starch and the absorption of glucose and fructose. During the exacerbation of T2DM,Acarbose mono therapy gradually failed to control blood glucose,and should be combined with other oral hypoglycemic agents,such as Metformin,insulin secretagogues,dipeptidyl peptidase-4 (DPP-4)inhibitors,glucagon-like peptide (GLP-1),sodium-glucose cotransporter 2 (SGLT-2)inhibitors or insulin. Here we reviewed recent researches about the therapeutic effect of Acarbose in combination with other anti-diabetic agents.
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[Summary] There is a complementary or synergistic action of saxagliptin and metformin when used in combination. Combination therapy with saxagliptin and metformin can effectively reduce blood glucose and body weight with a low risk of hypoglycemia in patients with diabetes. Additionally,the cardiovascular safety of saxagliptin has been confirmed by the SAVOR study,whereas a cardiovascular protective effect of metformin has been demonstrated by the UKPDS study. As being taken orally once daily,saxagliptin and metformin extended-release fix-dose combination tablet can further improve patients′compliance and adherence. According to the guidelines,this tablet could be recommended as the initial treatment for newlydiagnosed type 2 diabetes with HbA1 c higher than 7. 5%,or in those with inadequately glycemic control under metformin monotherapy.
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Objective To summarize the current status and trend of hypoglycemic agents of diabetic inpatients in different departments of Chinese PLA General Hospital.Methods The clinical data of diabetic patients admitted to Chinese PLA General Hospital from January 2000 to May 2014 were collected(those hospitalized in the department of endocrinology were excluded).A total of 10 041 patients were selected by stratified random sampling.The type of hypoglycemic agents in different departments and the variation on anti-hyperglycemic drugs with time were retrospectively analyzed.Results Of all the patients in non-endocrinological wards, 50.2% were treated with insulin, 36.9% with metformin, 21.3% with α-glycosidase inhibitor, and 18.9% with sulfonylureas.Metformin, α-glucosidase inhibitors, pre-mixed 30R, and insulin glargine were more commonly used than other anti-hyperglycemic agents, accounting for 36.9%, 21.0%, 14.0%, 8.7%, respectively.Metformin, sulfonylureas, α-glucosidase inhibitor, and different types of insulin were more widely applied in internal medicine while insulin therapy was more frequently used in surgical department.During the past 15 years, the proportions of insulin, glinides, α-glucosidase inhibitor, and thiazolidinediones application were gradually increased, while the proportions of sulfonylureas and metformin treatment were on the decline trend.Conclusion Most of the inpatients were treated with oral antidiabetic drugs.Metformin, α-glucosidase inhibitor, pre-mixed 30R, and insulin glargine were the most frequently prescribed agents for the inpatients.
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To improve the differential diagnosis of sellar region mass,4 cases with sellar mass and misdiagnosed as lymphocytic hypophysitis (LYH) were reviewed retrospectively.The 4 patients (2 male and 2 female) aged 20-60 years old were all presented with symptoms of headache,polydipsia and polyuria.Biochemical studies confirmed the diagnoses of central diabetes insipidus and hypopituitarism.Head MRI scans showed LYH like image for all the cases,and,thus,high dose methylprednisolone pulse therapy (HDMPT) was applied to the patients.Their symptoms deteriorated and the sellar mass enlarged after a short period of partial improvement.Operations were performed in all the patients.Histology study showed craniopharyngioma with abscess,primary abscess,secondary hypophysitis caused by Wegener's granulomatosis,and germinoma with secondary hypophysitis,respectively.In conclusion,surgery or biopsy is necessary for those who presented with sellar region mass and was suspected to be with LYH,but with poor response or even worse after HDMPT.
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Objective: To evaluate the clinical value of Captopril test for diagnosing primary aldosteronism (PA) and to calculate the best cut-off point for PA diagnosis. Methods: We retrospectively analyzed 96 PA patients with conifrmed diagnosis by clinical situation, laboratory test and auxiliary examination in our hospital from 1994-06 to 2012-05, and meanwhile, studied 45 highly suspicious PA patients with final exclusion by confirmed diagnosis of primary hypertension (PH). All patients received the in-hospital Captopril test, the area under the curve of receiver operating characteristic (AUCROC) was applied to evaluate plasma aldosterone level and the ratio of aldosterone/renin after Captopril test and to obtain the best cut-off point with the corresponding sensitivity and speciifcity for PA diagnosis. Results: At 1h and 2h after Captopril test, AUCROC for plasma levels of aldosterone were 0.831 and 0.818, the ratios of aldosterone/rennin were 0.909 and 0.922 respectively. At 1h after Captopril test, the cut-off point of aldosterone level was 544.95 pmol/L and the diagnostic sensitivity was 70%, speciifcity was 90.7%; at 2h after Captopril test, the cut-off point of aldosterone level was 466.8 pmol/L and the diagnostic sensitivity was 69.8%, speciifcity was 70.5%. At 1h after Captopril test, the ratio of aldosterone/rennin was 34.6 [ng/dl: μg/(ml·h)] with the sensitivity at 78.3% and speciifcity at 88.4%. At 2h after Captopril test, the maximum AUCROC for the ratio of aldosterone/rennin was obtained, when cut-off point of aldosterone level was 42.2[ng/dl: μg/(ml·h)] , the diagnostic sensitivity was 76.7%, speciifcity was 95.3%. Conclusion: At 1h and 2h after Captopril test, plasma aldosterone level and the ratio of aldosterone/rennin had been valuable for PA diagnosis, the maximum diagnostic value could be obtained at 2h after Captopril test.
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Objective: To evaluate the diagnostic value of saline infusion test (SIT) in patients with primary aldosteronism (PHA). Methods: A total of 116 patients with PHA or essential hypertension (EH) treated in our hospital from 1994-06 to 2013-05 were retrospectively studied. The patients were divided into 2 groups: PHA group,n=72 and EH group, the patients with excluded PHA,n=44. post-SIT plasma levels of aldosterone and post-SIT ratio of aldosterone/renin activity were evaluated by ROC curve in order to analyze the diagnostic capability and the best diagnostic cut-off point. Results: The area under curve (AUC) by ROC for post-SIT aldosterone level was 0.759, the sensitivity and speciifcity were 74.6% and 63.6% respectively; AUC for post-SIT ratio of aldosterone/renin activity was 0.899, the sensitivity and speciifcity were 83.6% and 88.6% with the best diagnostic cut-off point at 111 [ng/dl:ng/(ml?h)]. Conclusion: Post-SIT plasma level of aldosterone and post-SIT ratio of aldosterone/renin activity had the diagnostic value of PHA; post-SIT ratio of aldosterone/renin activity had the higher diagnostic value of PHA.
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Objective To evaluate the effectiveness and safety on once-daily (OD) insulin detemir (IDet) in Chinese patients with type 2 diabetes mellitus (T2DM) who were treated with different types or combinations of oral anti-diabetic drugs (OADs).Methods The SOLVETM study was a 24-week observational study on the initiation of IDet OD in T2DM patients with uncontrolled hyperglycemia on diet,exercise,and one or more OADs.Subjects were grouped based on the numbers of OADs taken before (＞ 2-OAD,2-OAD,and 1-OAD groups).Efficacy and safety endpoints were evaluated and compared in different groups.Results This study includes 3 272 patients,among them 464 (14.2％) were treated with more than 2OADs,1511 (46.2％) with 2OADs,and 1 218 (37.2％) with 1OAD before the study.The mean glycosylated hemoglobin A1c (HbA1c) was 8.4％,8.3％,8.4％ at baseline,and 7.3％,7.2％,7.1％ at the end of 24-week in each 3 groups (all P ＜0.001 vs.baseline values).The HbA1c reductions were not statistically significant different among groups.Body weight tended to decrease in patients from all groups,however,only that in the 2-OAD group reached statistically significance.No major hypoglycaemia events were reported.However,the overall minor hypoglycaemia rate in the 2-OAD group was higher at the end of the study than that at baseline (P ＜ 0.05).No differences in the rate of nocturnal minor hypoglycaemia were observed in all groups after IDet treatment.Conclusion Initiation of IDet OD was effective and well-tolerated in Chinese patients with T2DM whose glycemia was poorly controlled on OADs irrespective of the number of OADs taken before.(registration number NCT00825643)
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Objective To investigate the influence of glycosylated hemoglobin A1c (HbA1c) standard value (2007 and 2010 Chinese Diabetes Prevention Guide) on glycemic control and treatment of type 2 diabetic patients in Chinese cities.Methods A cross-sectional study was carried out in type 2 diabetes mellitus from outpatients in selected hospitals all over China in 2009 and 2012.Patients treated with oral antidiabetic drugs (OADs),insulin or OAD combined with insulin were enrolled.A questionnaire including general characters,therapy,complications and blood glucose was completed by trained surveyors.Results A total of 30 853 patients were enrolled in 2009,and 48 232 patients in 2012.The distribution of HbA1c ＜6.5％,6.5％-＜7.0％,7.0％-＜8.0％,8.0％-＜9.0％,9.0％-＜ 10.0％ and ≥ 10.0％ was 20.35％,12.59％,35.50％,18.94％,6.46％ and 6.16％ in 2012; 14.81％,27.72％,14.55％,6.55％ and 8.36％ in 2009,respectively.The top three OAD were biguanides,sulfonylureas and thiazolidine.The most common treatment options for combined therapy are metformin combined with sulfonylurea in both 2009 and 2012.Conclusions There is an increase in the proportion of patients with good and general blood glucose control in 2012.With the generalization of Chinese Diabetes Prevention Guide,a steady tendency is presented in blood glucose control.
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<p><b>BACKGROUND</b>Given the pace with which standards of care have changed, timely assessment of their impact on routine clinical practice and patient outcomes is needed. In coordination with the Chinese Diabetes Society (CDS), we developed a quantitative survey to explore the implementation of standards of care for type 2 diabetes (T2D) in China.</p><p><b>METHODS</b>A national online survey of physicians involved in the management of T2D in China was conducted over a 4-week period in 2012. Completed responses were obtained from 1 028 physicians. Participants responded to 52 questions designed to capture information relating to their demographic and clinical practice profiles. The questionnaire was divided into three sections: basic information, diagnosis practices and screening methods on main complications, and treatment and control practices. The questionnaire was developed in conjunction with the CDS.</p><p><b>RESULTS</b>Overall, 83% of surveyed physicians were at least "aware" of the CDS guidelines on standards of care for T2D. Level of awareness was directly related to hospital grade, specialty, geographic location, professional rank and participation in CDS training. The 2-hour oral glucose tolerance test was reported as the most ever-used approach across all three hospital grades and physician specialties, with a usage rate of 97%. Respondents selected their choice of primary treatment for newly diagnosed T2D patients. Just over half (52%) indicated the use of oral anti-diabetic drugs (OAD) monotherapy, in line with CDS recommendations. However, OAD use varied considerably between different regions and city tiers. Despite hemoglobin A1c being defined as the gold standard for glucose control, it was not universally measured, with more physicians indicating routine use of glucose before fasting and glucose non-fasting.</p><p><b>CONCLUSION</b>The standards-of-care analysis has provided important insights into the current management of T2D among physicians in China across different geographical regions, hospital grades, specialties, professional statuses, and levels of CDS guideline awareness and training.</p>
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Adult , Female , Humans , Male , Middle Aged , China , Data Collection , Diabetes Mellitus, Type 2 , Glucose Tolerance Test , Standard of CareABSTRACT
Objective To analyze the relationship between obesity and arterial stiffness among population of different glucose tolerance status. Methods A cross-sectional study recruited the population aged 40 years or older from ShiJingShan district in Beijing. 9080 subjects were included by measured weight, waist circumference (WC), body mass index (BMI), waist/hip ratio (WHR) and WC/height ratio (WHtR) and hemodynamic indexes and the aortic stiffness (using brachial-ankle pulse wave velocity(baPWV). They were divided into 3 groups based on the results of OGTT and diabetes history: normal glucose tolerance group ( NGT group) ,impaired glucose regulation group ( IGR group) and diabetes mellitus group ( DM group) . The association between baPWV and different obese indexes was analyzed by multi-ple linear regression. Results According to the criterion of WC, WHR and WHtR, baPWV of central obesity group was significantly higher than the normal group(P0. 05), but it was of sta-tistically significant differences in NGT group and IGR group. Central obese indexes( WC、WHR、WHtR) showed a positive correlation to PWV in the studied groups(P0. 05). After adjusting for age, gender and cardiovascular risk factors, the multiple regression analysis found that for every 0. 1 point increase in WHR and WHtR, the PWV increased 40. 6 cm/s and 55. 3cm/s respectively. Conclusion There is a positive correlation between central obese indexes (WC、WHR、WHtR) and arterial stiffness, and the central obese indexes correlated with arterial stiffness better than BMI.
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Objective To study whether preoperative serum thyrotropin ( TSH) concentration can be used for risk prediction of papillary thyroid microcarcinoma ( PTMC ) . Methods The cohort of this retrospective study consisted of 1 707 patients who underwent surgery on thyroid nodules at Chinese PLA General Hospital from October 1999toFebruary2011. 37.32%(n=637)ofthesepatientssufferedfromdifferentiatedthyroidcancer(DTC),and 14. 18%(n=242) of patients with DTC suffered from PTMC. Results (1) The mean TSH level in patients with DTC was significantly higher than that in patients with benign thyroid nodules [(1. 99(1. 25-3. 19) vs 1. 48 (0. 85-2. 32) mU/L, P<0. 01]. DTC with diameter greater than 10 mm had higher serum TSH level compared with that in benign thyroid nodules[2. 04(1. 26-3. 36) vs 1. 45(0. 83-2. 30), P<0. 01]. Serum TSH level was not significantly raised in cases where-as the diameter of tumor was 10 mm or less. (2) With the increasing level of TSH, the prevalence of DTC and tumours with diameter greater than 10 mm rose significantly, but the increasing trend was not significant in PTMC. (3) Raised TSH level was an independent risk factor of DTC based on Binary logistic regression. Conclusions Serum TSH is an independent risk predictor of DTC, it is an independent risk predictor of the diameter of DTC greater than 10 mm, but it is not a good risk predictor in PTMC.
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[Summary] Treatment of type 2 diabetes which is characterized by the progressive β-cell dysfunction currently faces various challenges.A new generation of drug need to protect β-cell function in early stage of the disease.Liraglutide is a glucagon-like peptide 1 analogue and provides a new therapeutic option due to its unique clinical efficacy.Early and long-term usage of liraglutide improves glycemic control,reduces body weight and systolic blood pressure,as well as protects β-cell function for the patients with diabetes.
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Objective To assess the pituitary function in patients with pituitary adenoma after transsphenoidal ectomy of hypophysoma.Methods Data of 106 patients with pituitary adenoma who were admitted in endocrine department and underwent the operation in PLA General Hospital from January 1993 to January 2010 were collected.Assessments of pituitary function were made before and after surgery.Results Total 23.6％ and 16.0％ of 106 patients underwent pituitary function evaluation by 1 week and 3 months after surgery,respectively.23.5％ and 5.9％ of patients with hyopituitarism before surgery underwent pituitary function evaluation by 1 week and 3 months after surgery respectively,and the respective figures in those without hypopituitarism were 23.6％ and 20.8％.The incidences of new onset of hypopituitarism among 106 patients that underwent surgical procedure were 48.0％ within 1 week after surgery and 35.3％ by 3 months after surgery.Conclusion The rate of re-evaluation of pituitary function by 1 week and 3 months after pituitary surgery was low.Probably,many patients were missed the diagnosis of hypopituitarism after pituitary surgery.
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Objective To analyze the clinical characteristics and prognosis of patients with insulin autoimmune syndrome (IAS) and to get better understanding of IAS by literatures reviewing.Methods Nine cases of IAS who were diagnosed in the General Hospital of the People's Liberation Army from 2001 to 2011 were analyzed.Results All patients had hypoglycemic syndrome and episodes of hypoglycemia during both postprandial and fasting states.Most cases (8/9) were accompanied with autoimmune diseases,including 6 cases of Graves' disease treated with methimazole.The biochemical data showed extremely elevated serum insulin level (9/9) during hypoglycemic episode.For most patients,the tests of insulin autoantibodies were positive (7/9) while results of imaging examinations were negative(8/9).After removal of possible offending medications and with diet treatment,hypoglycemic episodes were ameliorated in 5 of 9 cases.For severe patients,acarbose (1/9) and prednisone (3/9)therapy were useful.During the period of follow-up,four cases experienced no episode of hypoglycemia and 3 cases with markedly reduced episodes.Conclusions IAS is characterized by hypoglycemic episodes,elevated blood insulin levels,and positive insulin autoantibodies.It is strongly related with autoimmune disease and is able to be induced by methimazole.Most patients undergo remission after diet treatment,drug withdrawal,and oral prednisone.