SCEUS may be useful in evaluating radiotherapy efficacy for HCC.Radiotherapy is one of the available curative therapies for hepatocellular carcinoma (HCC). We investigate the use of contrast-enhanced ultrasound using Sonazoid (SCEUS) in evaluating the efficacy of radiotherapy for HCC. We enrolled 59 patients with 59 HCCs in this retrospective study. Tumor size and tumor vascularity were evaluated using SCEUS before and 1, 3, 7, 10, and 13 months after radiotherapy. The median follow-up period was 44.5 months (range: 16–82 months). Of the HCCs, 95% (56/59) had no local recurrence, while 5% (3/59) did. At 13 months after radiotherapy, in cases with no local recurrence, SCEUS showed a reduction in tumor vascularity in all cases, while tumor size reduction  was observed in 82.1% (46/56). In all three cases of local recurrence, vascularity and tumor size reduction were not observed during the follow-up period and residual HCCs were demonstrated pathologically. Compared with cases with local recurrence, tumor size reduction and reduction in tumor vascularity ( The global incidence of primary liver cancer is 841,080 people, accounting for 4.7% of all cancers . HepatocIn general, contrast-enhanced computed tomography (CECT) and contrast-enhanced magnetic resonance imaging (CEMRI) are recommended for follow-up after RT to evaluate treatment response and for long-term follow-up in short intervals  ,19,20,21®, Daiichi Sankyo, Tokyo, Japan) has been widely used in clinical practice in Japan, South Korea, Taiwan, and Norway.The European Federation of Societies for Ultrasound in Medicine and Biology guidelines highlight the role of CEUS as a cost-effective technique with a good safety profile, not only for the characterization and detection of focal liver lesions, but also for monitoring tumor response after curative, loco-regional, or systemic treatment for HCC ,24,25. CIn the present study, we investigate the use of CEUS with Sonazoid (SCEUS) for evaluating RT efficacy for HCCs with a follow-up period of at least 13 months.Between April 2013 and July 2018, 63 consecutive patients with 63 HCCs belonging to our institution were treated by RT at the Radiation Therapy Center at Ofuna Chuo Hospital, Kamakura, Japan. All SCEUS procedures were performed at our institution. Four HCCs were excluded, for the following reasons: Deep location in the liver and could not be assessed by grayscale ultrasound (US) or SCEUS (n = 3), or location near the diaphragm and could not be assessed by grayscale US and SCEUS (n = 1). Finally, 59 patients with 59 HCCs were enrolled in this retrospective study. This study was conducted in accordance with the Declaration of Helsinki. Institutional review board approval and informed consent from all patients were obtained for this retrospective study (number B180900067).The inclusion criteria were as follows: (1) Unresectable HCC due to infeasibility, difficulty, or patient refusal; (2) unsuitable for RFA, due to adjacency to the portal vein, hepatic vein, diaphragm, or heart, or patients who had a hemorrhagic tendency; (3) single HCC in patients at stage 0,A in Barcelona Clinic Liver Cancer (BCLC) staging; (4) patients with HCC detectable in grayscale US before RT; (5) patients who can sufficiently hold their breath when performing SCEUS; (6) Child–Pugh A chronic hepatitis, cirrhosis, or Child–Pugh B (Child–Pugh score 7) cirrhosis; and (7) ability to follow-up for more than 13 months after RT. The exclusion criteria were uncontrolled ascites or extrahepatic lesions.We assessed the detection of HCC lesions using the LOGIQ E9 ultrasound system  with native tissue harmonic grayscale imaging using a convex probe with a frequency of 1–6 MHz and a micro-convex probe with a frequency of 2–5 MHz .As previously reported ,29, a 0.CECT was performed using a 16 multi-detector CT scanner  with a tube voltage of 120 kV, a tube current setting at the automatic milliampere exposure setting, a reconstruction section and interval thickness of 5 mm, a pitch of 15, and a gantry speed of 0.5 s per rotation. A nonionic contrast agent, iopamidol , was injected. Then, a power injector  was used to inject 100 mL of iopamidol at 3 mL/s through a catheter placed in the antecubital vein. The scanning time in the arterial phase was confirmed using an automatic bolus-tracking program . The trigger point for starting AP scanning was set to an attenuation of 230 HU from the baseline attenuation of the abdominal aorta. Portal phase scanning was performed 70 s after contrast injection, and equilibrium phase images were acquired 180 s after injection.MR imaging was performed using a 1.5 T whole-body imager . A power injector  was used to inject 0.1 mL/kg of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid  at 1 mL/s through a catheter placed in the antecubital vein, followed by flushing with 20 mL of sterile saline solution at 2 mL/s. Arterial phase, portal phase, and late phase scanning were performed at 25–30, 70–85, and 180 s, respectively, after initiation of the contrast injection, while hepatobiliary phase scanning was performed 20 min after initiation of the contrast injection.As previously described , three kAll 59 cases were evaluated at 1, 4, 7, 10, and 13 months after RT treatment. Follow-up with imaging assessments every three months was continued as long as the patient was alive and could visit the hospital. The examination interval between CECT/CEMRI and SCEUS was about one week. Using the US procedure, the following were evaluated: (1) The change in tumor size using grayscale US or re-injection of Sonazoid in the PVP SCEUS, (2) tumor vascularity in AP or re-injection during PVP SCEUS, (3) hypervascularity of surrounding liver parenchyma during AP SCEUS, and (4) both irradiated HCC and surrounding liver parenchyma becoming a hypoechoic area (perfusion defect) in PVP SCEUS. A tumor size reduction was defined as a reduction of more than 30%, compared to the maximum diameter of the HCC lesion measured before RT treatment with grayscale US. An increase in tumor size was defined as an increase of more than 20% and more than 5 mm in diameter, compared to the maximum diameter of the HCC lesion measured before treatment with grayscale US. If a HCC lesion was unclear on grayscale US, but the HCC lesion and the surrounding liver parenchyma showed a hypoechoic area (perfusion defect) during PVP SCEUS, additional Sonazoid re-injection was performed during PVP, in order to evaluate the vascularity of the target HCC lesion and surrounding liver parenchyma. If the target HCC showed hypovascularity, compared with the surrounding liver parenchyma, and appeared as a perfusion defect during AP of re-injection, the target lesion was detected and measured. Local recurrence was suspected if the target HCC showed hypervascularity during AP SCEUS and a perfusion defect during PVP. Additional injections of Sonazoid during PVP were used to determine whether or not arterial blood flow entered the perfusion defect (defect re-injection method). If the fast wash-in of arterial flow was observed in the perfusion defect, this was considered a confirmatory sign of local recurrence . All SCEOf the 59 patients, 54 were available for contrast agents and were evaluated by CECT or CEMRI, performed 1, 4, 7, 10, and at least 13 months after RT. The presence or absence of local recurrence was assessed according to the evaluation of vascularity of the target HCC lesion and its size. Local recurrence was suspected if the target HCC showed hypervascularity during the AP and wash-out during the subsequent phases without tumor size reduction. For the remaining five patients, who had renal dysfunction or contrast allergy, non-enhanced CT and non-enhanced MRI were performed. In those cases, changes in tumor size were evaluated in non-enhanced CT or MRI; in non-enhanced MRI, the presence or absence of high signal intensity in the diffusion-weighted image (DWI) was observed.Follow-up with imaging assessments every three months was continued as long as the patient was alive and could visit the hospital. To evaluate the effects of RT, the CECT/CEMRI findings obtained before and after the RT were evaluated by two hepatologists (M.C. and H.F.), neither of whom was involved in the RT treatment, and both of whom were blind to the clinical information and other radiological findings of the patients. Each of the hepatologists had 20 years of clinical experience in evaluating MRI.Blood tests for AFP level were performed and followed up in the same way as for the imaging studies. AFP level was considered abnormal at >10 ng/mL.If neither reduction in tumor vascularity nor tumor size were observed by imaging modalities, as mentioned above, local recurrence was suspected. Tumor biopsy was performed under US guidance and the pathological results were used as the gold standard for the presence of local recurrence. In these cases, additional treatment was performed.If reductions in either tumor vascularity or tumor size were observed by the imaging modalities, no local recurrence was suspected. If these findings (as mentioned above) were observed on the basis of the imaging examinations at 16 months or more of follow-up, the patient was considered to have no local recurrence. Therefore, the gold standard for determining no local recurrence was imaging modalities alone.The follow-up period for the diagnosis of presence or absence of local recurrence ended on 31 August 2020.p < 0.05 was considered to be statistically significant. All statistical analyses were performed using the IBM SPSS statistics version 26.0 software .We compared and examined the SCEUS findings between cases with and without local recurrence. To determine whether AFP was effective in follow-up after RT, Fisher’s exact test was performed for cases with and without local recurrence in which the AFP was originally high. The SCEUS findings observed in the cases were examined using a Fisher’s exact test, in order to determine whether significant differences existed between cases with and without local recurrence. Statistical analysis was performed to calculate the sensitivity, specificity, and accuracy of the findings of the tumor size or vascularity for the diagnosis of local recurrence after RT. All cases received SCEUS procedures during follow-up periods after RT. At the beginning of the study, four patients could not undergo CECT or CEMRI due to renal dysfunction  after RT, 94.9% (56/59) of cases had no local recurrence . In caseAt 4 months after RT, surrounding liver parenchyma hypervascularity during AP (100%) and perfusion defect at the PVP (100%) were observed. At 13 months after RT, tumor size reduction and reduction in tumor vascularity were not observed .In all 56 no local recurrence cases, at 13 months after RT, tumor size reduction  and decreased vascularity of the irradiated HCC  were observed by SCEUS. Of the 56 no local recurrence cases, 51 cases were available for contrast agents and were evaluated by CECT/CEMRI at 13 months after RT. In seven of the 51 cases, both the irradiated HCC and the surrounding liver parenchyma showed the hypervascularity during AP CECT/CEMRI. This enhancement disturbed the accurate assessment of tumor vascularity and tumor size. In the remaining 44 cases, tumor size reduction  and decreased vascularity of the irradiated HCC  were observed by CECT/CEMRI . In all p = 0.009 and p < 0.001, respectively). Hypervascularity of the surrounding liver parenchyma during AP and perfusion defect during the PVP were not significantly different between cases with and without local recurrence 13 months after RT.At 13 months after RT, when tumor size reduction was observed, the sensitivity, specificity, and accuracy for cases with no local recurrence were 82.1%, 100%, and 83.1%, respectively. At 13 months after RT, when reduction in tumor vascularity was observed, the sensitivity, specificity, and accuracy for cases with no local recurrence were all 100%. At 13 months after RT, tumor size reduction and reduction in tumor vascularity were significantly different between cases with and without local recurrence , having high AFP level before RT and no newly developed HCC lesions, were evaluated for changes in AFP level. At 13 months after RT, in 12 of the 19 cases without local recurrence (63.2%), the AFP level had decreased to normal range. The remaining seven cases still had a high AFP level, even though no newly developed HCC lesions were found. In contrast, in two of the three cases with local recurrence (66.7%), the AFP level remained high. However, in the remaining case, the AFP level did not increase and was recorded in the normal range. At 13 months after RFA, when the AFP level of the HCC cases with a high AFP level before RT decreased to normal range, the sensitivity, specificity, and accuracy for cases with no locally recurrent HCC were 63.2%, 66.7%, and 63.6%, respectively.All three cases of local HCC recurrence were diagnosed on the basis of imaging examinations at 13 months after RT. After the histological diagnosis of local recurrence of HCCs, these three cases underwent RFA treatment. One case without adverse events experienced local recurrence again and received additional RFA . One hadOne month after RT, four patients felt fatigue and one patient had a gastric ulcer. No patient required hospitalization. No complications were observed with SCEUS.®  in four cases [Sonazoid has been successfully investigated in many studies, showing high diagnostic accuracy, treatment response assessment, and guidance for HCC ,34,35,36ur cases . Their fur cases .p = 0.009) and reduction in tumor vascularity (p < 0.001) were significantly different between cases with and without local recurrence. Therefore, SCEUS may be useful in evaluating the efficacy of RT for HCC.We followed-up 59 patients who underwent RT, obtaining 56 cases with no local recurrence and 3 with local recurrence. Using SCEUS, in the cases with no local recurrence, reduction in tumor vascularity was observed in 87.5% of cases at 4 months, 94.6% at 7 months, 98.2% at 10 months, and 100% at 13 months after RT. Tumor size reduction was observed in 62.5% at 7 months, 73.2% at 10 months, and 82.1% at 13 months after RT. In contrast, in cases with local recurrence, neither a reduction in tumor vascularity nor tumor size was observed even at 13 months after RT. At 13 months after RT, tumor size reduction , some lesions may not be assessed by US. Fourth, in cases with HCC located near the diaphragm, we used a micro-convex probe to evaluate the tumor vascularity and tumor size, in order to avoid interference by the lung or ribs. The quality of images obtained by the micro-convex probe were slightly inferior to those obtained by the convex probe. Fifth, as this study included five cases with contraindication of CECT/CEMRI, the SCEUS findings after RT were not compared to CECT/CEMRI findings after RT in detail. Sixth, histological proof of the lack of local recurrence of HCCs was not obtained, due to the decrease in size or the impossibility to punctuate for a tumor biopsy.Based on this study, SCEUS may be useful in evaluating the efficacy of RT for HCC. SCEUS is simple, repeatable, and non-invasive, especially for patients who are unable to undergo CECT or CEMRI. However, follow-up periods are required for at least 13 months after RT, in order to evaluate the presence of local HCC recurrence.


This study was conducted to identify and compare the effects of two education programs for infection control―a simulation using standardized patients and a peer role-play―on standard precaution knowledge, standard precaution awareness, infection-related anxiety, and infection control performance. This study used a nonequivalent control group pretest-posttest design. A total of 62 undergraduate nursing students in their 3rd year participated in the study, and were assigned to the experimental and control groups, accordingly. The infection control education program was developed based on the analysis, design, development, implementation, and evaluation model. The program for the experimental group included lectures, skills training, simulation using standardized patients, and debriefing, while the control group participated in the usual infection control education, consisting of lectures, skills training, and peer tutoring practices. Both groups exhibited statistically significant increases in knowledge, awareness of standard precaution, and infection control performance after the intervention. Infection-related anxiety and infection control performance were significantly higher in the simulation using a standardized patient group. Both education programs influenced compliance with the standard precaution for infection control. The results of this study contribute to the evidence regarding effective educational methods to improve infection control. Healthcare-related infections impair an individual’s quality of life due to increased pain and mortality, deteriorated health, dysfunction, cognitive impairment, and financial loss of the health management system because of delayed recovery and extended hospital stay ,2. MoreoStandard precaution, the most basic management activity to prevent infection, was first announced in 1996 by the Centers for Disease Control and Prevention (CDC). A revised version followed in 2007, due to the emergence of new pathogens, such as Severe Acute Respiratory Syndrome, and multiple outbreaks involving blood-borne viruses (BBVs) resulting from injection practices ,9,10,11,Standard precaution requires healthcare professionals to consider all patient secretions to prevent the spread of pathogens, including blood and body fluids, as potential infection sources, and avoid being exposed to them; it is recommended that people should comply with this regarding any infection before the disease is diagnosed . In addiEducation on infection control improves health professionals’ adherence to standard precautions . For insPrevious studies with nursing students examining the level of awareness and performance of standard precaution argue that continuous and repetitive practical training of standard precaution needs to be supplemented for more efficient education ,23. In cSimulation-based education is a field-reproducible method of teaching that uses an environment similar to the actual clinical situation. It allows for safe and effective repeated learning, as desired ,29. BesiThis study aimed to grasp the effects of two education methods: (1) simulation-based education using SP, and (2) usual education using PRP, and their application in standard precaution infection control education for nursing college students.A nonequivalent control group pretest-posttest design was used to compare the effects of simulation using SP and PRP education for nursing college students.Among the 288 nursing students in their third year at C University, we included nursing students who (1) were interested in infection control education, (2) understood the purpose of the study and expressed their intention to participate voluntarily, and (3) were conveniently extracted on a first-come, first-served basis. Previous research has suggested that it is necessary to develop a module for intermediate-level students to practice infection control skills within clinical scenarios before proceeding with complex scenarios for senior-year students or graduate nurses . Accordid) of 0.8, and power (1-β) of 0.80. The effect size was in line with effect sizes used in previous studies’ effect sizes [The number of samples for the study was calculated using the G*Power 3.1.9.4 program , with a ct sizes ,36. AccoThe development of the infection control education program using SP in this study is based on the analysis, design, development, implementation, and evaluation (ADDIE) model, which is designed for the education system. For the analysis stage, the educational needs, targeted learner , and the education environment were analyzed using a questionnaire regarding the need for infection control education on standard precautions for graduate nurses. Clinical scenarios suitable for 3rd year level nursing students were selected, and an educational environment that could reproduce clinical trials was analyzed.In the design stage, to formulate educational goals, contents, and strategies, we set evaluation strategies to achieve the educational goals on knowledge, skills, and attitudes with regard to the infection control program. In addition, simulation education was selected as the educational medium. Standard precautions were defined and composed according to their educational content for each element and propagation path, as well as the simulation education and evaluation applying standard precautions. The development stage was conducted to develop the educational content by modifying and supplementing the program based on the pilot study. In this study, content validity was verified by correcting the scenarios to which the standard precautions were applied. Thereafter, SP training and simulation trial operation was conducted.In the implementation stage, we applied the developed program accordingly. In this study, 29 nursing students participated in simulation education using SP. In addition, they participated in debriefing after the simulation to share their experiences. Meanwhile, 33 nursing students participated in usual practical training using PRP. The evaluation stage was conducted to determine the appropriateness of a systematic and cyclical education program. In this study, the knowledge and awareness of standard precautions as well as the ability to perform infection control was measured to evaluate the effectiveness of the standard precautions infection program.To evaluate the effectiveness of the infection control education program, participants were classified in either of the two groups: (1) those who will undergo simulation using SP, or (2) those who will undergo PRP practice after receiving a lecture about infection and nursing skills related to infection performance .The lecture was conducted using a PowerPoint presentation provided by the researcher, which included the definition and components of standard precautions as well as the attention of each propagation path. Skill training included performing subcutaneous injection, promoting hand hygiene, using PPE (including N95 masks and gloves), and finger-stick glucose monitoring related to nursing intervention; these were then applied to the simulation scenario.Simulation using SP was conducted in the order of simulation orientation, simulation operation, and debriefing. During the orientation, we explained to the participants the study’s learning objectives, scenario situation, and simulation environment. In addition, we provided them with sufficient time to confirm the location of the items to be prepared and to familiarize themselves with the simulation environment. The simulation practice was conducted as follows: (1) participants wore their PPE before entering the simulated isolation room outside the patient’s room; (2) they assessed the patient’s condition; (3) they performed proper nursing practices, such as monitoring vital signs, checking blood sugar, and performing subcutaneous injection; (4) they exited the hospital room and took off their PPE. A total of seven teams participated, with each team consisting of four students that were equally assigned to two groups (two students per group)—one group participated in the simulation while the other observed the simulation, and vice versa. The running time of the complete simulation was 180 minutes.Debriefing was conducted in the Description-Analysis-Application stage . During The two SPs who participated in the simulation belong to the simulation center of C University and have participated in many simulation training. The patients in the scenario are in their 60s to 70s, both having the same gender and age. SP training was conducted in three steps. In the first step, they practiced introducing themselves based on their script and conducting a question-and-answer portion. In the second step, they practiced the scenario algorithm, including the questions they were required to ask to cope with unexpected situations and provide feedback from the researcher. In the third step, two nursing students who do not participate in the study involved the final practice.The participants in the PRP group received the same lecture and nursing skills practice. The group consisted of eight teams. Each team had four students that were equally assigned to two groups (two students per group) and conducted a similar practice simulation through PRP. While one group took care of the patient, one student in the other group served as the patient, while the other student recorded the group’s performance. Afterward, the two groups exchanged their roles. The control group did not receive orientation and debriefing for simulations; instead, they used the traditional hands-on training method. Each session took 120 min to complete. The program was conducted at different times and places to avoid exposing the participants to the program beforehand; that is, for the PRP group, role plays were conducted in the laboratory practice room during the afternoons, and for the Simulation group, simulations were conducted in two simulation rooms during the morning.Knowledge of standard precaution was measured using the standard precautions knowledge measurement , which wnot important”) to 5 (“very important”), with a higher score indicating higher awareness. At the time of development, the tool reliability (Cronbach’s α) value was 0.95 [The Awareness of Standard Precaution questionnaire, which was translated by Jeong  and devewas 0.95 , while iThe measurement of infection-related anxiety felt during clinical practice was composed of items corresponding to the scenario based on the 2007 revised standard precaution . The tooBased on the scenario used in our study, we measured performance on infection control using a tool developed by the researcher, which is based on the 2007 revised standard precaution , Korea CFor the preliminary survey, information regarding the general characteristics, knowledge of standard precautions, awareness of standard precautions, and participants; infection-related anxiety were collected before the education method was implemented using a self-report questionnaire. For the post-doc survey, information regarding knowledge and awareness of standard precautions and data on infection-related anxiety were collected right after the education methods were conducted. Two intensive care unit nurses with more than three years of clinical experience evaluated the infection control performance using a video that was recorded on the day of the implementation of the education methods.t-test. Regression analysis was not applicable since the variables did not satisfy the condition of normality.The collected data were analyzed using the SPSS 23.0 statistical program . First, we compared the participants’ general characteristics between the simulation with SP group and PRP group using the chi-square test and Fisher’s exact test. Second, we used the Kolmogorov-Smirnov normality test for the main four variables. We used nonparametric tests to analyze three variables; knowledge, awareness of standard precaution, and infection-related anxiety that did not support normality. Third, we examined the three variables’ homogeneity between the two groups using the Mann-Whitney U test. Fourth, the groups were analyzed using the Mann-Whitney U test, and pre-post differences were tested using the Wilcoxon signed ranks test. Also, the difference in the infection control performance between the two groups was analyzed using a This study was conducted after receiving approval (IRB No: 1041078-201802-HR-037-01C) from C University. The subjects were informed of the study’s purpose, method, and confidentiality, including the nature of their voluntary participation and autonomy to withdraw from the study. All participants provided their written informed consent for the study.A total of 62 nursing students participated and were divided into two groups―29 in the experimental group and 33 in the control group. The participants were homogeneous in age, gender, average grade in the previous semester, simulation experience and the number of experiences, and educational experience for standard precautions .SD = 1.05) and 21.7 (SD = 1.45) years in the simulation using SP group and the PRP group, respectively. Regarding gender, most participants were female―24 in the simulation using SP group (82.8%) and 26 in the PRP group (78.8%). Regarding average grade last semester, 16 (55.2%) and 20 (60.6%) participants in the simulation using SP group and the PRP group, respectively, reported having a grade of 3.5 or higher. Regarding simulation experience, 23 (79.3%) and 20 (60.6%) participants have experienced simulation in the simulation using SP group and the PRP group, respectively. Regarding educational experience of standard precautions, 22 (75.9%) and 24 (72.7%) participants showed knowledge of standard precautions in the simulation using SP group and the PRP group, respectively. As for the educational method used for standard precautions, 7 (31.8%) and 13 (54.2%) participants reported using lecture only, 14 (63.6%) and 10 (41.7%) reported using lecture and practice classes, and 1 for both (4.5% and 4.2%) the simulation using SP group and PRP group, respectively, reported using simulation.The average age was 21.41 , awareness of standard precautions , and infection-related anxiety   .z = −0.839, p = 0.401; see z = −2.885, p = 0.004), and from 17.52 ± 1.20 (pretest) to 18.12 ± 0.99 (posttest) in the PRP group .The difference in knowledge of standard precautions score was 0.83 ± 1.34 and 0.61 ± 1.22 in the simulation using SP group and PRP group, respectively, with the simulation using SP group showing a greater degree of increase in knowledge. However, we found no statistically significant difference , and from 4.57 ± 0.31 (pretest) to 4.87 ± 0.23 (posttest) in the PRP group .The difference in awareness of standard precautions score was 0.17 ± 0.40 and 0.29 ± 0.48 in the simulation using SP group and PRP group, respectively, with the PRP group showing a greater increase in degree of awareness. However, we found no statistically significant difference between the two groups , while the scores of the simulation using SP group increased from 29.17 ± 9.95 (pretest) to 32.17 ± 11.19 (posttest) .The difference in infection-related anxiety score was 3.00 ± 16.44 and −3.00 ± 15.11 in the simulation using SP group and PRP group, respectively, with no statistically significant difference between them . We found a statistically significant difference between the two in the subdomains of hand hygiene , PPE , respiratory etiquette , and worker safety   than the PRP group (14.81 ± 3.04) (< 0.001) .This study identified the effects of standard precautions infection education between two educational methods: simulation using SP and usual training using PRP. The education contents were organized to promote compliance with standard precautions, such as taking vital signs, blood sugar tests, subcutaneous injections, and wearing PPE, while carrying out nursing care. Taking vital signs is the most frequently used skill that nursing students must perform during clinical practice , while nBased on our results, both education methods increased the knowledge of standard precautions significantly, with no significant difference between them. However, the participants in this study scored lower than those in previous studies involving nursing students in their third and fourth years regarding knowledge about standard precautions ,41. and Furthermore, we believe that using the same lecture and scenario as in this study might lead to similar knowledge improvement when used in other settings. Indeed, a study  using thAwareness of standard precautions was improved in both simulation and PRP education. Prior studies on simulation-based infection control education reported that awareness was significantly increased during pre- and post-participation in the simulation . In addiAccording to previous studies, awareness of standard precautions improves performance ,57. ConsIn our study, participants’ anxiety level in the simulation using SP increased more than that of those in the PRP group. As reported in the previous studies ,60, studThe ability to perform infection control was higher among those in the group using SP. A study on safety skills reported that physiotherapy students using SP have higher confidence and preparedness regarding clinical placement in a workshop compared to those using PRP . HoweverThis study has several limitations. First, since this study only extracted convenience samples from one university on a first-come, first-served basis, careful attention should be paid to the results’ generalization. Therefore, it is recommended that further studies that are conducted for verifying the effectiveness of infection control education programs consider involving a larger sample and adopting a randomized sampling. Second, this study compared the effects of two educational methods using only one scenario. To grasp the effect of practical training on infection control, further research that considers various scenarios and diverse learning methods is needed. Third, this study did not tackle the issue on cost-effectiveness related to education methods. Thus, further studies relating to cost-effectiveness will further determine the feasibility of these various educational methods.Nevertheless, despite its limitations, it is worth noting that this is the first study that identified the effects of simulation using SP and PRP education, focusing on the effects of infection control, which is closely related to the safety of patients and students. Our findings can be used to develop various education programs that can be applied to practical training for knowledge and performance of infection control.This study identified awareness of the standard precautions regarding infection control, infection-related anxiety, and performance in simulation using SP and PRP education. Although the two practical training methods differed in degree, nursing students’ knowledge and awareness of standard precautions increased in both training groups. The simulation using SP, however, was found to be more effective in improving nursing students’ infection control performance; therefore, it is recommended that simulation-based education be included in curricula focused on performance. Based on these results, it is suggested that nursing educators select the appropriate education method according to their practice environment and educational purposes, and develop more complicated scenarios for senior-level students. Further, the findings from the study can be used to develop education programs and integrated curricula to help graduate nurses prepare for professional practice and enhance their adherence to standard precautions in health care settings. Ultimately, future nurses who have been well-trained in infection control are expected to reduce infection rates and promote patient safety.


To the Editor—Iran, struggling with the toughest sanctions, is facing serious challenges in containing the pandemic of coronavirus disease 2019 (COVID-19). As of April 9, 2020, some 66,220 confirmed cases and 4,110 deaths had been reported in Iran.1 The rise of this pandemic coincided with Nowruz (the Persian New Year) holidays, which started on March 19, 2020, and lasted ~2 weeks. Millions of Iranians travel around the country during the Nowruz holiday.2 By March 22, 2020, however, ~8,700,000 people in transit and the passengers of ~2,900,000 cars had been screened using thermal imager and gun thermometers. Among them, 6,464 were referred to clinical centers for further examination.3 Given the fact people with no symptoms might have been missed during public screening, a large number of travelers spread the SARS-CoV-2 virus across the country. The implications of virus transmission from persons with asymptomatic or very mild symptomatic cases of COVID-19 has already been considered vital for the formulation of containment strategies.4Iranian authorities urged people to stay home during Nowruz and announced that public screening to detect coronavirus would be underway at airports, railway stations, bus terminals, and the city entrances and exits.5 Apart from social and economic effects, such travel restrictions are considered less effective once the outbreak is more widespread.6 By March 9, 2020, COVID-19 cases had been reported in all provinces in Iran, at incidence rates ranging from 0.8 cases per 100,000 population in Bushehr to 61.8 cases per 100,000 population in Qom.7 It was already too late for any restriction to be effective.In a similar situation, the COVID-19 epidemic in China coincided with the peak of the Chinese spring festival holidays. The Chinese government implemented rigorous quarantine measures and locked down the epicenter of the outbreak, Wuhan City, Hubei Province, on January 23, 2020. No new confirmed cases occurred in most provinces across China and in most cities in Hubei Province for >10 consecutive days by March 1, 2020, suggesting that the lockdown had been effective in mitigating the spread of the virus.8 However, a modeling study showed that travel limitations eliminating up to 90% of the traffic have a modest effect and that such measures should be combined with public health interventions and behavioral changes to achieve a considerable reduction in disease transmission.9 The spread of SARS-CoV-2 is not yet slowing down in Iran, and the recommendation of the World Health Organization (WHO) seems more likely to result in the containment of COVID-19. These include widespread testing, quarantine of cases, contact tracing, and social distancing, which were successfully implemented by South Korea.10On March 27, 2020, the Iranian government implemented a travel ban preventing people from leaving their cities and requesting those already on trips to return at their earliest opportunity.


Although the number of newly diagnosed cases of HIV is decreasing worldwide, those in Korea have been steadily on the rise, especially among adolescents (ages 10–19 years) and young adults (ages 20–29 years). To identify the characteristics in the new diagnosis among these age groups, we analyzed HIV testing sizes and HIV prevalence under the national HIV surveillance system in Korea in the last six years. We collected data of HIV tests conducted at Blood Banks (BB), Public Health Centers (PHCs), and Military Manpower Administration (MMA) nationwide every year from 2010 to 2015, except for anonymous tests. HIV prevalence, calculated as the number of new HIV-diagnosed cases per 10,000 test-takers per year, was analyzed according to sex, age, institution, and reason for HIV testing. Data were analyzed using logistic regression. In the three testing institutes, there were new cases of HIV with 50% and 95% of cases diagnosed in young adults and adolescents, respectively. The total size of HIV tests at the three sites was approximately 3.5 million tests per year; 80% of these were conducted in BBs, 10% in PHCs, and 10% in MMA. HIV prevalence, according to age, increased across all age groups for the six years, especially prevalent in young adults doubled during that period . HIV prevalence among the “suspected” young male adults who visited PHCs for tests, was highest during the six years, increasing 6.5 times in the last two years  compared to before 2014. We identified the characteristics of growing HIV infection in Korea as the increase of HIV prevalence among the suspected of young male adults at PHCs. Further, we propose that HIV prevalence in MMA can be used as an essential index for national HIV surveillance of adolescent boys in Korea. Globally, for more than 35 years, approximately 78 million individuals have been infected with HIV, with 35 million HIV-related deaths, and 37 million people are currently living with HIV2. The first HIV-infection in Korea was identified in 1985, and over the next 30 years or so, approximately 15,000 individuals were identified as HIV-infected. It was reported that more than 99% of individuals diagnosed with HIV in Korea were infected via sexual contact, while transmission through blood transfusion, vertical transmission, and needle sharing for IDU was infrequent3. Soon after the discovery of HIV in Korea, the country initiated a prevention program focused on HIV transmission reduction by regularly performing HIV screening tests on high-risk groups for sexually transmitted infections (STI) and extending it to other groups6. Hospitals or clinics and public health centres (PHCs) have performed voluntary HIV screening, including health checkups and anonymous testing for suspected infection cases. Additionally, blood banks (BBs) and the Military Manpower Administration (MMA) have performed HIV screening for blood donors and men undergoing physical examination for conscription, respectively8. Thus far, Korea has emphasized on early diagnosis and active treatment of HIV to prevent its transmission9. As a consequence, Korea is known to have a low prevalence and slow spread of HIV infection when compared to other countries10.HIV infection, known to the public since the early 1980s, has been rapidly spreading worldwide through sexual contact, vertical transmission, blood transfusions, and needle sharing for injection drug use (IDU). The HIV epidemic has different transmission routes and the speed of spreading across countries11.For the last 40 years, numerous studies have been conducted to develop HIV therapies to eradicate HIV/AIDS among humans worldwide. However, there are obstacles to developing a preventative vaccine for HIV infection, and there is no cure. Hence, the disease burden of HIV/AIDS remains high. Accordingly, with the United Nations Program on HIV and AIDS (UNAIDS), each country has been implementing 90-90-90 and 95-95-95 strategies aiming to abolish the HIV epidemic by 2020 and 2030, respectively. Therefore, recently the global numbers of newly diagnosed HIV cases and HIV-related deaths have been decreasing graduallyIn Korea, however, since 2013, the annual number of patients newly diagnosed with HIV has exceeded 1,000, and the age at diagnosis has been decreasing. Accordingly, this study was conducted to identify the characteristics of the increase of newly diagnosed HIV cases among adolescents and young adults in Korea. Specifically, the study examined the changes over the last six years in the sizes of HIV screening and the characteristics of HIV test-takers among blood donors, visitors to PHCs nationwide, and men undergoing health examination for conscription, most of whom tend to be young. Based on the findings, we aimed to analyze HIV prevalence and trends, as well as the characteristics of newly infected adolescents and young adults.9. The study data that was collected visitors to PHCs under the National HIV Surveillance System in Korea was waived the requirement for written consent to participate.Enzyme-linked immunosorbent assays, chemiluminescence immunoassays, fluorometric enzyme-linked immunoassays, and particle agglutination assays were used for HIV screening. PHCs may use a rapid HIV test kit if the screening is performed anonymously. If an HIV screening test is positive, the first testing institute refers the case to the Regional Institute of Health and Environment (IHE). The IHE then performs a western blot test for HIV and a confirmatory test for the final determination of HIV infection. If the western blot test is positive, the office reports the case to the Korea Centers for Disease Control and Prevention (KCDC), which registers individuals on the HIV database system and requests the corresponding PHC to perform an epidemiological investigation13. The annual data provided by BBs included the number of HIV screening tests and the number of screened individuals by age, sex, occupation, and region. The annual data provided by MMA included an age-specific number of individuals screened for HIV.KCDC collects annual data on HIV screening tests conducted at BBs, PHCs, and MMA. Specifically, the annual HIV screening data from approximately 250 PHCs nationwide included the following raw data: specimen number, sex, date of birth, screening date, nationality, the reason for testing, test results, the first referring institute, classification code, specimen number for confirmatory testing, and final test results8.Study participants were the new HIV-diagnosed individuals in Korea and HIV test-takers in BBs, PHCs, and MMA between 2010 and 2015. Individuals previously diagnosed with HIV who had already registered in the HIV patient registry were excluded from the study so that we could analyze the annual trend in new HIV detections and change of HIV prevalence. Moreover, individuals who tested anonymously at PHCs were excluded from the study because epidemiological information, such as age, sex, and nationality, was not available. The participants whose data were collected from MMA were males of Korean nationality undergoing physical examinations for compulsory military service qualification determination; this information was mandatory for all males of Korean nationality under the age of 2012 as follows: health check-up, medical certificate, prenatal check-up, referral by doctor, suspected for HIV infection, patient with tuberculosis, prisoner, and STI risk group. Annual HIV prevalence was defined as the number of confirmed HIV-positive individuals per 10,000 HIV test-takers in 1 year. Those previously identified as HIV-positive were excluded from the counts of HIV test takers and those identified as HIV-positive. Statistical analysis was performed using SAS 9.4. Logistic regression analysis was conducted to examine the difference in prevalence for each variable. Statistical significance was set at 0.05 for all cases. This study was obtained approval for study design from the KCDC Institutional Review Board . Also, the informed consents from study participants were waived the requirement for written by the KCDC Institutional Review Board.All individuals undergoing physical examination at the MMA were male, while the blood donors and PHC visitors were male and female. HIV-infected patients were classified into six age groups: <20, 20–29, 30–39, 40–49, 50–59, and ≥60 years. HIV test-takers were divided into three age (years) groups: <20 (adolescents), 20–29 (young adults), and ≥30 (adults). The reason for HIV testing in blood donors and male undergoing physical examination for conscription was classified as blood donation and conscription, respectively. For PHC visitors, the reasons for HIV testing were diverse. They were classified with the same classification scheme used in a previous studyIn Korea, 837 individuals were identified as HIV-infected in 2010, and the figure has exceeded 1,000 since 2013, increasing to 1,191 and 1,152 in 2014 and 2015, respectively. The number of HIV-infected individuals identified in BBs, PHCs, and MMA was 212 in 2010, and the number almost doubled to 410 in 2015. Focusing on adolescents and young adults, the number of HIV-infected individuals was 103 in 2010 and 239 in 2015, an increase of more than twice in 6 years. These figures are approximately 50% of the total annual number of HIV infections in adolescents and young adults at a national level, and the proportion did not change year to year. Adolescents aged 10–19 years identified at the 3 institutes constituted 96% of the total number of HIV-infected individuals in the same age range; young adults aged 20–29 years constituted more than 50% of the total number of HIV infections in the corresponding age range. According to testing institutes, HIV-infected individuals identified through a physical examination at MMA accounted for approximately 50% of the total number of HIV-infected individuals in the 10–19-year age group. The proportions were approximately 18% and 28% in the case of blood donors and PHC visitors, respectively [Fig. The sizes of HIV tests administered in BBs, PHCs, and MMA and the characteristics of HIV prevalence between 2010 and 2015 were identified and analyzed and identified [Table Sex and age distributions of HIV test-takers showed different characteristics among the 3 testing institutes. Among blood donors, approximately 80% of the HIV test takers were adolescents and young adults, 70% were men, and sex distribution was similar across the years. For PHC visitors, approximately 70% were women, and 40% were adolescents and young adults. Finally, 100% of test-takers at MMA were male, and 95–99% of them were teenagers.p < 0.0001). In females, the prevalence was 0.17 in 2010 and 0.35 in 2015, showing an irregularly increasing trend for six years. By age group, HIV prevalence in 2010 was 2.10 in adults aged 30 years or older, 1.01 in young adults aged 20–29 years, and 0.23 in adolescents aged 10–19 years. HIV prevalence increased in all the age groups in 2015, with 3.01, 2.45, and 0.34, respectively. Of the three age groups, young adults showed the most considerable change, as the HIV prevalence doubled during the six years. Regarding HIV prevalence by testing institutes, the prevalence in 2010 was 4.09 per 10,000 test-takers in PHCs, 0.51 in MMA and 0.37 in BB; in 2015 it was 8.46 in PHCs, 0.83 in MMA, and 0.43 in BBs, all showing an increase (p < 0.0001) [Fig. HIV prevalence across the three testing institutes almost doubled during the study period from 0.89 per 10,000 test-takers in 2010 to 1.68 in 2015. HIV prevalence was higher in males than in females. In males, the prevalence was 1.19 per 10,000 test-takers in 2010, and it increased every year up to 2.33 in 2015 (01) Fig. . HIV pre01) Fig. . Among m01) Fig. .Figure 2p = 0.4765). Most males at MMA were teenagers, and the number of young male adults was under 6,000 until 2012 but increased to over 14,000 since then. HIV prevalence among them was the highest in 2011 (6.37). However, it decreased every year since then, to 3.40 in 2015. There were changes in the number of HIV testing among PHC visitors according to the reason for taking the HIV test. The number of individuals tested as part of a health check-up or prenatal check-up increased, while the figure among tuberculosis patients, prisoners, and individuals with a high risk of STI decreased. HIV prevalence among PHC visitors according to the reason for HIV testing was the highest in those with a suspected HIV infection, followed by those referred by a doctor or visited a PHC for a health check-up. The prevalence significantly increased annually. Mainly, among PHC visitors, HIV prevalence in young male adults with a suspected HIV infection increased by 6.5 times in 2014 and 2015 (315.79 in 2014 and 335.55 in 2015) (p < 0.0001), compared to before 2014, although the annual number of such individuals did not increase (p < 0.0001). Further, the HIV prevalence of young male adults referred by a doctor increased by 14.3 times during the same period in PHCs  (p < 0.0001) [Table For the reason for HIV testing, we analyzed data of young male adults aged 20–29 years showing the highest HIV prevalence across the 3 testing institutes and the most considerable change in annual HIV prevalence during the study period. Since 2013, the number of blood donors in young male adults increased to more than 500,000. However, HIV prevalence did not significantly change, with a range of 0.91–1.19 per 10,000 test-takers , nor did the HIV prevalence  (p = 0.5746). Therefore, it cannot be explicitly concluded that HIV infection increased in Korean teens. Every year, MMA performs HIV tests in approximately 350,000 males and has identified half of the total HIV-infected teens, the results of which can be used as a critical national-level HIV monitoring index to represent the current status of HIV infection among Korean teens. However, concerning young adults, the rate of HIV tests conducted increased by approximately 200,000 cases over the six years, and HIV prevalence increased by more than two-fold as well . Notably, for young male adults, the HIV prevalence in the “suspected for HIV infection” group, in PHCs increased rapidly (over 300 in 2014 and 2015). A large number of HIV-infected individuals were identified among PHC visitors since 2014, which was reflective of the rapid increase in HIV prevalence since 2014. It was suspected that this was due to actively introducing and expanding various opportunities for HIV testing, including rapid diagnostic tests at PHCs in Seoul since 201415. Over the past ten years, STI prevalence in Korea has been increasing among individuals in their 30 s and older16. However, this trend has changed, with the affected age group is now younger17.It has been argued that the increase in the total number of HIV-infected individuals in Korea is due to an increase in HIV infection among adolescents and young adults in recent years. According to a KCDC report, in 2006, individuals newly diagnosed with HIV were mainly in their 30 s (29.4%) and 40 s (24.3%). However, since 2012 the age group with the most significant number of HIV-infected individuals shifted to the 20 s (30.4%), followed by the 30 s (23.3%). In 2015, rates in young adults further increased, constituting as much as 33.2% of all newly identified cases of HIV. We identified the characteristics of the increase in new diagnoses of HIV among these age groups, by analyzing the changes in the rate of HIV tests taken and HIV prevalence by the reason for HIV testing, using the data from BB, PHCs, and MMA. Neither the number of HIV tests undertaken by teens across the three testing institutes changed over the six years , in 2013, young people aged between 15 and 24 years were estimated to constitute 35% of newly diagnosed cases of HIV worldwide10. Further, to prevent HIV transmission, the Korean government provides proactive and continuous treatment support to a vast majority of registered HIV-infected individuals (approximately 94%). However, this support is not available to those who test anonymously—those who do not wish to expose their personal information. To date, 15,579 Korean have registered in the HIV database, and the government continuously supports treatments for the current survivors  as of 2018.In Korea, sexual contact is the primary route of HIV transmission and prevalence, yet mortality rates have so far been low relative to other countriesOnce referred to a hospital for treatment, the government pays all costs associated with testing and treatment. With that, the survival of HIV-infected individuals has been prolonged, and the demand for various healthcare/long-term care services has increased due to an increase in old-age related chronic illnesses. HIV requires lifelong treatment as presently, there is no cure. Thus, HIV-infection in young adults can place a further economic and societal burden of the disease on the nation as well as the individual.15. In the past, most HIV infection patients were diagnosed at hospitals and clinics, but the number of HIV-infected individuals diagnosed at PHCs has increased recently. In Korea, education, health promotion, and counseling are provided to prevent HIV transmission via sexual contact. Specifically, KCDC fosters knowledge-based and behavioral changes through education in the format of musicals (targeting adolescents), promotional material contests (targeting college students), and Naver Webtoon a weekly online cartoon series that addresses AIDS prevention (targeting people in their 20 s and 30 s).Concerning the reason for HIV testing among individuals recently identified as HIV-infected in Korea, HIV testing due to suspected HIV infection was on an increasing trendIt was found that the recent overall increase in HIV infection among Koreans was due to an increase in HIV infection in young adults rather than in adolescents. Specifically, we conclude that the growing HIV infection rate in Korea is due to the increased HIV prevalence among suspected young adults at PHCs. Accordingly, we suggest specific and aggressive HIV prevention programs for adolescents before they reach the age of 20, and their exposure to sex increases. Another finding of the study was that HIV prevalence is increasing among young male adults. HIV prevalence in males undergoing physical examination at MMA can function as the best index for the status of HIV infection among Korean teens.


Triazole pesticides are widely used to control grapevine diseases. In this study, we investigated the impact of three triazole pesticides—triadimefon, tebuconazole, and paclobutrazol—on the concentrations of wine aroma compounds. All three triazole pesticides significantly affected the ester and acid aroma components. Among them, paclobutrazol exhibited the greatest negative influence on the wine aroma quality through its effect on the ester and acid aroma substances, followed by tebuconazole and triadimefon. Qualitative and quantitative analysis by solid-phase micro-extraction gas chromatography coupled with mass spectrometry revealed that the triazole pesticides also changed the flower and fruit flavor component contents of the wines. This was attributed to changes in the yeast fermentation activity caused by the pesticide residues. The study reveals that triazole pesticides negatively impact on the volatile composition of wines with a potential undesirable effect on wine quality, underlining the desirability of stricter control by the food industry over pesticide residues in winemaking. Wine has become one of the three most globally popular alcoholic beverages because of its good flavor and taste and its unique health benefits. Indeed, a decreased risk of cardiovascular disease, improved immunity, and reduced mortality rate have been reported in moderate wine drinkers . AccordiH-1,2,4triazol-1-yl)butan-2-one], tebuconazole , and paclobutrazol  -3,3-dimethyl-1- in plant-based products have been established by many countries and international organizations to regulate pesticide levels. The MRLs for pesticide residues in grapes are normally in the range of 0.01–5 mg/kg, depending on the pesticides . For exaRed wine is fermented with the existing pericarp to extract more chemical components . This is because the wine aroma originates from the substances produced by the fermentation of the grape itself and yeast. González-Álvarez et al.  reportedInstrumental analytical technologies have attracted much attention in the analysis and identification of volatile components in food because of their objectivity, high efficiency, sensitivity, and stability. Particularly, electronic nose and tongue technologies are intelligent smell and taste recognition systems that simulate the respective human physiological senses . These tWith these facts in mind, we aimed to investigate the effects of triadimefon, tebuconazole, and paclobutrazol on the flavor and quality of wine during fermentation. Sensor evaluation of wine treated with triazole pesticides was conducted by electronic nose and tongue analyses. Additionally, GC-IMS was used to analyze the differences in the volatile organic compounds (VOCs) of the triazole-pesticide-treated wine samples. SPME-GC-MS was further used to identify and quantify the flavor components present in the tested wine samples. The results from this study provide more accurate information on the wine flavor and quality changes induced by triazole pesticides.As new bionic sensing technologies for smell and taste, electronic nose and tongue sensory systems are simple, fast, nondestructive, and repeatable. Thus, they can provide an alternative to smell and taste evaluation to effectively distinguish the differences between the test samples.Saccharomyces cerevisiae × S. kudriavzevii hybrids are prized for their unique flavor profiles in beer and wine, because these hybrids have good enological properties, such as high glycerol content, decreased ethanol, improved taste, and a lower production of undesirable acetic acid [S. eubayanus and S. uvarum could create an odor, which is considered a brewery contaminant [The taste quality of the blank and triazole-pesticide-treated samples was analyzed by electronic nose technology. Principal component analysis (PCA) was applied to the data analysis as a multivariate method of generating principal component (PC) variables by investigating the correlation among several variables , which wtic acid . On the taminant . Linear p < 0.01), while the flavor of the DXZ wine was different from those of the other three groups. The electronic tongue analysis system consists of seven flavor sensors, namely AHS (sour), CTS , NMS (umami), and SCS, ANS, CPS, and PKS  sensors. In this study, the seven flavor sensors responded to the taste of the four wine samples with different sensitivities. Thus, the taste and quality of the control and triazole-treated wine samples were compared and analyzed by electronic tongue technology. Discriminant factor analysis (DFA) is a useful pattern recognition technique for multivariate data analysis , which wThe VOCs in the wine samples comprising the differently treated grapes are illustrated in The NIST and IMS databases built in the application software identified 40 signal peaks according to the retention time index of the standard substances and the standard drift time; 23 known components and 17 unknown components were determined by comparison with existing databases. Thus, to further investigate the changes in the main volatile substances, the signal peaks of all the VOCs were selected to form a fingerprint for comparison.Samples containing similar VOCs were also compared. Thus, the components in region D b comprisThese results indicated that the main volatile substances in the treated wine include ethyl hexanoate, isobutyl acetate, ethyl isobutyrate, propyl acetate, isoamyl acetate, ethyl propionate, ethyl butyrate, 1-esters , acetone, propionaldehyde, and isobutyraldehyde. The residues of pesticides may affect the uptake of microorganisms and delay the alcohol fermentation, but esters and aldehydes are still the main volatile components . SimilarThe volatile components of the wine samples were further qualitatively and quantitatively analyzed by GC-MS. The results were compared with the spectra of unknown volatile compounds using the NIST11 database and semi-quantified by the internal standard method. A 20 μL/L cyclohexanone content in the wine samples was used as an internal standard to semi-quantify the content of the volatile substances in the different triazole-pesticide-treated wine samples.The total ion chromatogram of the volatile compounds of the four wine samples are displayed in In this study, 47, 45, 46, and 54 volatile compounds were detected in the CK, SZT, WZC, and DXZ wine samples, respectively. Among them, 36 volatile substances were common to the four wine samples, including 22 esters, three acids, nine alcohols, one phenol, and one alkane . Of thesS. cerevisiae [S. cerevisiae are inhibited. Linalool and myristyl alcohol, which have lily and citrus aromas, respectively, were also detected in the WZC wine; nevertheless, since their concentrations were below the odor thresholds, it was assumed that these two compounds did not affect the flavor of the wine. Isobutanol was not detected because the biosynthesis of valine, the precursor amino acid of alcohols, may be affected by the pesticide residues [revisiae . It may residues . Additioresidues . The conresidues , which dThe total ester contents in the CK, SZT, WZC, and DXZ wine samples were 232.84, 239.17, 233.55, and 210.69 mg/L, respectively. The contents in the SZT wine were slightly higher than those of the CK and WZC wine samples. On the other hand, after paclobutrazol treatment, the ester content was significantly reduced. The formation of acetate esters is highly dependent on enzyme activity. These enzymes are responsible for both the synthesis and the hydrolysis of medium-chain fatty acid ethyl esters . The levThe total acid substance contents in the CK, SZT, WZC, and DXZ wine samples were 16.97, 16.44, 18.23, and 18.35 mg/L, respectively. Triadimefon slightly influenced the concentration of n-decanoic acid, octanoic acid, and acetic acid. On the other hand, treatment with tebuconazole increased the n-decanoic (unpleasant) and octanoic (smell of rancid butter) acid concentrations, while treatment with paclobutrazol increased the octanoic and hexanoic acid concentrations, which impart the wine with an unpleasant flavor. Only aldehyde, 2-undecenal was detected in the CK wines, giving the wine its fresh aldehyde flavor because of its polar threshold. Thus, treatment with the tested pesticides affected aldehyde synthesis, possibly because they promoted the synthesis of the corresponding alcohols during fermentation .In this study, electronic nose and tongue technologies were used to investigate the flavor of the wine samples treated with different triazole pesticides. The results revealed significant changes in the overall flavor of the wines treated with triazole pesticides, which could be effectively discriminated by electronic nose and tongue technologies.S. cerevisiae and, consequently, affecting the synthesis of volatile compounds by other metabolic pathways [GC-IMS and GC-MS methods were further used to identify and quantify the volatile components of the wine samples after different treatments. Comparison of the GC-IMS fingerprints indicated that esters are important factors in determining the wine quality. Moreover, because their concentrations are usually higher than their threshold levels, they endow the wine with a fruity aroma . Differepathways ,49.Saccharomyces cerevisiae powder was purchased from Yantai Di Boshi brewing machine Co., Ltd. . The fermentation tanks were bought from Hebei Chaoya glass products Co., Ltd. . Ultra-pure water was produced using a Millipore purification system . The grapes were obtained from Changxinghongyuan grape professional cooperative of Liaoning province and did not contain the target pesticides.Cyclohexanone analytical standards (purity ≥99.9%) were purchased from Dr. Ehrenstorfer . Commercial triadimefon 20% emulsifiable concentrate was sourced from Jiangsu Sword Agrochemicals Co., Ltd. ; tebuconazole 43% suspension was acquired from Qingdao Haina Biotechnology Co., Ltd. ; and paclobutrazol 15% wet-table powder was obtained from Jiangsu Kesheng Group Co., Ltd. . Sodium chloride (NaCl) was provided by Sinopharm Chemical Reagent Co., Ltd. . 2 and 1 g/kg yeast powder activated in 100 mL of 30 °C pure water were added into each fermentation tank, and the mixtures were stirred three times daily at the initial stage of the fermentation process. After 240 h at room temperature (25 °C), the skin residues were filtered out and secondary fermentation was performed during 192 h. Finally, the fermented grape musts were clarified and filtered by sieve to attain four groups of wine samples, bottled at 4 °C for further study; three repetitions were performed for each group. The four groups were labeled CK, representing the control group, and SZT, WZC, and DXZ representing the wines treated with triadimefon, tebuconazole, and paclobutrazol, respectively. The detailed processing procedure is illustrated in A total of 60 kg fresh and mature kyoho grapes was used, the brix was 16° and total acidity was 5 mg/g of berry, with the rotten grape particles and stems removed, and divided into 4 groups, and every 5 kg of grapes was selected and crushed into fermentation vessels; the pulp dregs, juice, and skin were all included in the fermentation tanks. The spiked levels of triadimefon, tebuconazole, and paclobutrazol were 0.3, 2.0, and 0.5 mg/kg, respectively, according to the corresponding maximum residue limits established by GB 2763-2019, and a different pesticide was added to each fermentation tank. Next, 30 mg/kg SOA PEN3.5 electronic nose  was employed for the volatile analysis. Thus, 1.0 mL each of the control and three triazole-pesticide-treated wine samples were separately placed into four 10 mL headspace sampling vials. Each sample was injected manually with a PEN3.5 electronic nose and allowed to stand for 10 min, under laboratory conditions of 25 ± 1 °C, until the volatile gases in the sample filled the headspace space of the vials. Electronic nose detection comprised respective sampling and cleaning times of 60 and 180 s and three parallel samples were set for each group.An Alpha Astree II electronic tongue system connected with an LS16 auto sampler unit  was used for the interacting chemical substances in solution. Thus, 10 mL aliquots of the control and triazole-pesticide-treated wines were collected, filtered with 0.45 μm aqueous phase filter membranes, and placed into separate 100 mL beaker with a constant volume of 120 mL. Each beaker was then placed in the spot tongue detector sample position so that it was sitting just over the electrode surface. Respective collection and cleaning times of 120 and 10 s were employed. To eliminate the interference of the unstable factors of the initial detection response signal and obtain a stable detection signal, seven parallel measurements were conducted in the study. After obtaining the analysis data, the first three circles of data were discarded, and the last four circles of stable electronic tongue response data were selected as the analysis data.®; GAS, Dortmund, Germany) was used for flavor analysis. Thus, a 1 mL wine sample was first transferred into a 20 mL headspace bottle. Then, 100 μL aliquots were automatically injected under splitless mode at 85 °C, after incubating at 60 °C and 500 rpm incubation speed for 10 min. The separation was carried out on an MXT-WAX column  at 60 °C. Nitrogen  was used as the carrier gas, and the linear pressure program was as follows: 2 mL/min for 2 min, ramped up to 100 mL/min over 18 min, and finally maintained at this rate for 10 min. The drift gas flow rate was 150 mL/min (nitrogen), and a 5 cm drift tube was operated at a constant voltage of 400 V/cm at 45 °C.A commercial GC-IMS .A gas chromatography-mass spectrometer (Shimadzu GC-MSQP 2010plus) was employed for compound separation and analysis. Thus, 5 mL wine samples were accurately measured into 15 mL headspace bottles, and 1 g NaCl was added to each bottle to promote volatilization of the volatile components. Subsequently, 50 μL cyclohexanone internal standard solution (2 μL/mL) was added and the bottles were immediately sealed with a polypropylene cap comprising a PTFE-silicone rubber septum. The headspace volatile components of the wine samples were then extracted by 65 μm divinylbenzene/polydimethylsiloxane (DVB/PDMS). After equilibration of each sample at 50 °C for 20 min, the extraction head was inserted into a headspace bottle for 40 min. Next, the DVB/PDMS fiber was placed in a 250 °C gas chromatography-mass spectrometer inlet for 2 min to allow desorption. The instrument was equipped with a DB-WAX column . Analytical conditions were set as follows: an initial column chamber temperature of 40 °C, injection port temperature of 250 °C, spitless injection mode, and a carrier gas flow rate of 1.0 mL/min. The column chamber temperature was initially set at 40 °C for 3 min, then increased to 120 °C at 5 °C /min, and finally to 230 °C at 10 °C /min where it was held for 5 min. The ion source and transfer-line temperatures were 200 and 250 °C, respectively, and the signal was collected under scan mode in the scanning range 35–500 The wine fermentation experiments were carried out in triplicate, and PCA was used for sample discrimination and classification. LDA was based on the determination of the linear discriminant functions (DFs) to extract features by maintaining class separability. DFA was used to further expand the differences between the different groups and narrow the differences within each group based on principal component analysis. The stable intervals selected for the PCA and LDA analyses were in the range 48–52 s. These analyses were used to distinguish the smell characteristics of the four groups of wine samples. Discriminant factor analysis (DFA) was conducted to compare the differences in the taste characteristics of the four wine sample groups. The instrumental analysis software includes LAV  and three plugins  as well as GC × IMS Library Search, which can be used for sample analysis from different perspectives.The main objective of this study was to explore the influence of three different triazole pesticides on wine flavor. Analysis at the molecular sensing level was based on multidimensional analysis technology. The pesticide with the greatest influence on wine flavor composition was paclobutrazol, as the wines treated with this pesticide exhibited the most significant changes in the concentrations (relative to threshold) of the flavor components . Treatment with the three pesticides mainly changed the concentrations of the esters, the main contributors to the significant differences in the wine flavors. The study demonstrated that pesticide residues on the grapes are transferred from the grape berries to the grape juice, thereby changing the flavor components and thus, the flavor quality of the final wine. Electronic nose and tongue analyses were also employed to assess the potential flavor differences caused by the triazole pesticides. Moreover, the combination of dynamic headspace sampling with GC-MS and GC-IMS allowed us to determine the compounds present in the volatile components of the wine. The results of the three tests were in agreement, which was conducive to the comprehensive analysis of the effects of the three triazole pesticides on wine flavor. Further, the application of these techniques can effectively avoid the risk of exposing traditional human sensory evaluators to chemical hazards present in target samples. Meanwhile, it is important to monitor the presence of pesticides in grapes and wines in order to improve wine flavor, and biopesticides, which are safe, less toxic, least persistent, and environmentally friendly to humans and non-target organisms, can be used as alternatives to chemical pesticides in the vineyard.


Lumbar disc herniation (LDH) is 1 of the most common diseases in orthopedics, which seriously affects people's daily life and brings a heavy burden on society and families. Chinese herbal medicine has been used in clinical practice for a long time and Duhuo Jisheng Decoction (DHJSD) is believed to help alleviate the symptoms of LDH. This systematic review aims to collect evidences from randomized clinical trials and evaluate the efficacy of DHJSD on LDH in order to provide a reference for clinicians and researchers.We will comprehensively search the 8 electronic databases until December 2019 to identify related randomized controlled trials, including 4 foreign databases  and 4 Chinese databases . The data of the World Health Organization International Clinical Trial Registry Platform and the Chinese Clinical Trial Registry also will be searched. The primary outcomes are Japanese Orthopaedic Association scores and visual analog scale scores. The risk of bias will be assessed using the Cochrane Collaboration tool. RevMan (V.5.3) software will be used for meta-analysis.This study will report the results of DHJSD for the treatment of LDH from the literature screening, the basic information of the included studies, the risk of bias of the included studies, treatment effects, safety, and so on.This systematic review will evaluate the effectiveness and safety of DHJSD for the treatment of LDH and provide the latest evidence for its clinical application.This is a literature-based study, therefore it does not require ethical approval.CRD42019147302. The incidence of L4/5 and L5/S1 is higher than other sections, even more than 90%.,3,5 With the aging of the social population and changes in people's lifestyles, the incidence of LDH has increased significantly. LDH is characterized by a high disability rate, which has brought a heavy burden on society and families.,7Lumbar disc herniation (LDH) is 1 of the most common diseases in orthopedics. It mainly manifests as low back pain and sciatica caused by nerve compression, and may also include radiating pain, motor weakness and sensory disturbances.–10 Non-surgical treatments include traction, manipulation, acupuncture, physiotherapy and medicines  and so on. Many randomized controlled trials (RCTs) or systematic reviews have proven that these methods alone or comprehensively have a certain effect for the treatment of LDH.–14At present, the methods of treatment of LDH include surgical therapy and nonsurgical therapy. Surgical treatment mainly adopts methods such as fixation, decompression and fusion  to reduce the clinical symptoms of patients, but there are problems such as wound infection, complications, and high postoperative recurrence rate.,16 DHJSD is recorded in the book “Bei Ji Qian Jin Yao fang” written by Sun Simiao of Tang Dynasty. It consists of 15 commonly used Chinese herbs, such as Duhuo (Radix Angelicae Biseratae), Sangjisheng (Herba Taxilli), Duzhong (Eucommiae Cortex), Niuxi (Achyranthis Bidentatae Radix), Xixin (Asari Radix Et Rhizoma), Qinjiao , Fuling (Poria Cocos [Schw.] Wolf.), Rougui (Cinnanmomi Cortex), Fangfeng (Saposhnikoviae Radix), Chuanxiong (Chuanxiong Rhizoma), Renshen (Panax Ginseng C. A. Mey.), Danggui (Angelicae Sinensis Radix), Baishao (Paeoniae Radix Alba), Shudihuang (Rehmanniae Radix Praeparata), and Gancao (licorice). According to the theory of TCM, it has the effects of eliminating rheumatism, analgesics, nourishing liver and kidney, nourishing Qi and blood, and channeling meridians.,18 Of course, it is also used to treat other orthopedic diseases, such as knee arthritis and osteoporosis.,20 Although there has been a systematic review on the treatment of LDH with DHJSD before, the latest standardized systematic reviews need to be carried out with the addition of a large number of clinical trials.,16 Therefore, the purpose of this study is to summarize the results of current RCTs, analyze the effectiveness and safety of DHJSD for the treatment of LDH, and provide evidence-based medicine for its better application.In recent years, more and more people have paid attention to traditional Chinese medicine (TCM) therapy. The ancient classic prescriptions represented by Duhuo Jisheng Decoction (DHJSD) have been widely used in the treatment of LDH.22.1https://www.crd.york.ac.uk/PROSPERO/#recordDetails.This systematic review protocol has been registered on the Prospective Register of Systematic Reviews (PROSPERO). The approved registration number is CRD42019147302. The details of the protocol for this systematic review can be accessed at 2.2This is a literature-based study and therefore it does not require ethical approval.2.32.3.1RCTs of all eligible published DHJSD for the treatment of LDH. Language is limited in Chinese and English. Case reports, case series, non-RCTs, quasi-RCTs, animal experiments, cell experiments and other studies will be not included.2.3.2Patients need to be clearly diagnosed with LDH and choose conservative treatment. The region, sex, age, nation, and duration of disease are not limited.2.3.3The patients in the experimental group were treated with DHJSD alone, or treated with DHJSD on the basis of the control group. The intervention methods of the control group were conventional treatments  or placebo. The patients of both groups required oral administration. The dosage and duration of treatment were not limited.2.3.4This protocol proposes to assess the effectiveness of DHJSD for LDH by using the primary outcomes of Japanese Orthopaedic Association scores, visual analog scale scores. We also use the following outcomes as secondary outcome indicators: Clinical effectiveness, symptom scores, adverse events. The clinical effectiveness standard refers to the guiding principles for Clinical Trials of New Patent Chinese Medicines.2.4The types of excluded literatures mainly include: literatures of which the complete data cannot be obtained; literatures with incorrect data; literatures with random methods or intervention methods that are incorrect, and so on. For duplicate data, only the first 1 will be retained.2.52.5.1We will comprehensively search the following electronic databases, including 4 foreign databases  and 4 Chinese databases . In addition, the data of the WHO International Clinical Trial Registry Platform and the Chinese Clinical Trial Registry also will be searched. All electronic databases will be searched without regional restrictions and the search time will start from the construction of the database to December 2019. We will not search for articles that have not been published.2.5.2 and it will be searched individually or in combination using the following terms: “Duhuo Jisheng”, “Duhuojisheng,”“Chinese herbal medicine,”“lumbar disc herniation,” “LDH,” “lumbosacral radiculopathy.” Each database will be searched according to the requirements. The specific search strategy will be as follows, such as the PubMed database: (Duhuo Jisheng [title/abstract]) OR Duhuojisheng [title/abstract]) OR Chinese herbal medicine (Title/Abstract) AND (LDH [title/abstract]) OR LDH [title/abstract]) OR lumbosacral radiculopathy [title/abstract]).The search strategy will be based on Cochrane Handbook guidelines2.5.3The 2 researchers will independently search the literatures according to the formulated requirements and use Note Express (V.3.2.0) software for management. After excluding duplicate and totally irrelevant literatures, read the full text to determine the final included literatures. When 2 researchers encounter difference, we will discuss with a third researcher together. The details of study selection will be summarized by using a PRISMA flow diagram Fig. .2.62.6.1The data extraction will be done independently by 2 researchers who will use an uniform standard form to extract the required information from each eligible original study. It contains the following information: author, year of publication, country, age, gender, sample size, random method, blind method, follow-up information, intervention method, research results, safety, and so on. Any differences in data extraction between the 2 researchers will be resolved by a third researcher.2.6.2 2 researchers will independently assess methodological quality using the following 7 aspects of the RevMan software (V.5.3): Random sequence generation, Allocation concealment, Blinding of participants and personnel, Blinding of outcome assessment, Incomplete outcome data, Selective reporting, and Other bias. Each entry will be evaluated at 3 levels: low risk of bias, unclear risk of bias and high risk of bias. As before, this will be completed under the supervision of a third researcher.We will assess the risk of literature bias using the Cochrane Collaboration's tool.2.72.7.1I2 ≤50%, we will choose fixed effect model analysis; when I2 > 50%, we will choose random effect model analysis. If the data cannot be analyzed quantitatively, we will perform a qualitative analysis of the data.We will use RevMan software (V.5.3) provided by the Cochrane Collaboration for data analysis. In view of the characteristics of the previously extracted data, for dichotomous data, we will express the results as a risk ratio with a 95% confidence intervals. For continuous data, the mean difference will be included in the meta-analysis. When 2.7.2If the included studies have greater heterogeneity, we will perform subgroup analysis to explore the source of heterogeneity, which may be explored in terms of disease course, treatment course, and so on.2.7.3If necessary, we will perform a sensitivity analysis of the results to check the stability of the analysis conclusions. For example, We will delete the studies that have a high risk of bias.2.7.4According to the results of the study, if there are enough studies for the meta-analysis (n ≥10), we will evaluate the reporting bias through funnel plots.3,26 As we all know, as a common treatment method for LDH, Chinese herbal medicine has been used in clinical practice for a long time. DHJSD is 1 of the representative prescriptions.,28 Basic research shows that it has the effects of antiinflammatory, analgesia, immune regulation, cartilage promotion, and fibrous ring repair. Liu et al discovered that DHJSD could inhibit the generation of proinflammatory mediators and extracellular matrix degradation through the SDF-1/CXCR4/NF-κB pathway. Similarly, Liu et al demonstrated that DHJSD could prevent compression-induced matrix degradation and cell apoptosis through regulating autophagy and the P38/MAPK signaling pathway in vivo and in vitro experiments. These are good results obtained in basic experiments. Unfortunately, the clinical trials of DHJSD for LDH still lack comprehensive systematic reviews and research evidences.The pathogenesis of LDH is very complicated. At present, it is considered to be related to nerve compression, chemical inflammation, autoimmunity, and biomechanics.Therefore, we aim to summarize the currently published evidences and try to evaluate the effectiveness and safety of DHJSD in treating LDH through this systematic review. Although this study may have some limitations, we hope to further promote clinical practice and provide inspiration and reference for scientific researchers and clinicians.Conceptualization: Kai Sun, Fasen Huang, Baoyu Qi.Data curation: He Yin, Bin Tang.Investigation: Bowen Yang, Lin Chen.Methodology: Xu Wei, Liguo Zhu.Resources: Bowen Yang, Minghui Zhuang.Software: Bin Tang, Minghui Zhuang.Supervision: He Yin, Lin Chen.Writing – original draft: Kai Sun, Fasen Huang, Baoyu Qi.Writing – review and editing: Xu Wei, Liguo Zhu.


As one of the major chronic diseases that seriously threaten human health, type 2 diabetes mellitus (T2DM) has become a global public health problem. Blood glucose fluctuation is a risk factor independent of hyperglycemia. At present, the measures to treat blood glucose fluctuations in patients with T2DM are insufficient in effectiveness and safety. Medical practice and clinical studies have proved that Chinese herbal medicine has obvious advantages in reducing blood glucose fluctuations. In this systematic review, we will assess the efficacy and safety of Chinese herbal medicine in the treatment of blood glucose fluctuations in patients with T2DM.We will search related literature of PubMed, Embase, Cochrane Library, Web of Science, China Biology Medicine Database, China National Knowledge Infrastructure, China Science and Technology Journal Database, and Wanfang Database, and will manually search grey documents such as literature such as conference articles and references articles. Eligible randomized controlled trials will be screened based on inclusion criteria, and data extraction, risk of bias assessment, publication bias assessment, subgroup analysis, and quality assessment will be performed. Review Manager version 5.3 software and stata version 13 software will be used for data analysis. Each process is independently conducted by 2 researchers, and if there is any objection, it will be submitted to the third researcher for resolution.This study will provide evidence for the efficacy and safety of Chinese herbal medicine in the treatment of blood glucose fluctuations in patients with T2DM. Outcome measures include mean amplitude of glycemic excursions, 24 hours mean blood glucose, standard deviations of blood glucose, mean of daily differences, coefficient of variation, glucose time in range, fasting blood glucose, 2 hours postprandial blood glucose, glycated hemoglobin, HOMA-β, HOMA-IR, quality of life questionnaire, traditional Chinese medicine syndrome score, and adverse event. Diabetes imposes a huge medical and economic burden on individuals and societies. Type 2 diabetes mellitus (T2DM) patients are prone to fluctuating hyperglycemia due to factors such as the progressive decline in islet β-cell function, impaired blood glucose regulation mechanisms, and poor treatment compliance.–5 A number of studies have found that glucose fluctuation is an independent risk factor for T2DM complications such as macrovascular disease.,7 Fluctuating hyperglycemia can promote inflammation and induce oxidative stress, and its damage degree to vascular endothelial function and atherosclerosis is greater than stable hyperglycemia.–10 Compared with diabetic patients whose coefficient of variation of fasting blood glucose is less than 16%, patients with coefficient of variation of fasting blood glucose of more than 29% have a 2.68 times higher relative risk of developing diabetic retinopathy.The diabetes atlas released by the International Diabetes Federation shows that as of 2019, there are about 463 million people with Diabetes worldwide.,13 At present, the methods of medicine for treating T2DM mainly include oral drugs such as metformin, α-glucosidase inhibitors, dipeptidyl peptidase-4 inhibitors, and injectable drugs such as insulin and glucagon-like peptide-1 receptor agonists. These drugs have a good effect on reducing blood glucose values, but the improvement of islet function is limited. Besides, the stricter the blood glucose control, the higher the incidence of hypoglycemia events and the greater the fluctuation range of blood glucose. Therefore, the regulation of blood glucose homeostasis is currently the focus and difficulty of intervening in T2DM and complications. It is necessary to find therapeutic measures to effectively regulate blood glucose homeostasis and improve islet function.The fundamental measure to reduce blood glucose fluctuation is to improve islet function.,16 For example, Shenqi compound, a Chinese herbal medicine, can steadily reduce blood glucose of patients, relieve inflammation, and provide patients with quality of life.,18 Researchers have conducted many randomized controlled trials (RCTs) on treatment of blood glucose fluctuations in patients with T2DM by Chinese herbal medicine, and there is still a lack of systematic evaluation on this topic. Therefore, in order to provide evidence-based evidence for Chinese herbal medicine to relieve blood glucose fluctuations, it is necessary to make a standard judgment on the efficacy and safety of Chinese herbal medicine in treatment of blood glucose fluctuations.In China, many patients with T2DM take Chinese herbal medicine to reduce blood glucose fluctuations. The characteristic of Chinese herbal medicine to regulate blood glucose fluctuations is to correct the internal environment instability caused by pathogenic factors and restore the body to a steady state. Its mechanism involves many pathways and targets, such as inhibiting islet β-cell apoptosis, regulating islet microcirculation.22.1https://osf.io/t76eh). This report will be based on the preferred reporting items for systematic review and meta-analysis protocols.This protocol has been registered on Open Science Framework grant number 10.17605/OSF.IO/T76EH  non-drug therapies. Participants who did not received placebo or only basic conventional treatment but no Chinese herbal medicine will be used as the control group.2.2.42.2.4.1Blood glucose fluctuations will be set as primary efficacy outcomes, including mean amplitude of glycemic excursions, 24 hours mean blood glucose, standard deviations of blood glucose, mean of daily differences, coefficient of variation, glucose time in range, and so on.2.2.4.2Secondary efficacy outcomes include fasting and 2 hours postprandial blood glucose, glycated hemoglobin, islet function index (such as HOMA-β and HOMA-IR), quality of life questionnaire , and TCM syndrome score.2.2.4.3Adverse event, such as hypoglycemia.2.3Electronic databases include PubMed, Embase, Cochrane Library, Web of Science, China Biology Medicine Database, China National Knowledge Infrastructure, China Science and Technology Journal Database, and Wanfang Database. The search terms include T2DM, blood glucose fluctuations, TCM, Chinese herbal medicine, and RCT. The search date is from establishment of the database to June 30, 2020. No restrictions on language. Besides, Clinical trial registries such as the Chinese Clinical Trial Registry, the Netherlands National Trial Register, and ClinicalTrials.gov, will be searched for ongoing studies. We will look for additional studies that may be eligible from the conference articles and references of articles identified for inclusion.2.4We will export the documents retrieved from the database to EndNote X9 software, and will use it to manage and delete duplicates. The retrieved studies will be screened by 2 researchers according to pre-established inclusion criteria. The full text will be screened to determine the eligible research. The above work process is carried out independently. If there is any objection, it will be resolved by the third researcher Fig. .2.5Two researchers will independently extract data in pre-designed format, including article title, publication time, country or region, name of first author, funding, and demographic characteristics of the subjects, sample size, interventions in the treatment group and control groups, course of treatment, severity of disease, efficacy outcome and adverse events, data analysis strategy, and so on.If the original data is insufficient or missing, the first author or corresponding author will be contacted by researchers via email and telephone. If missing data cannot be acquired, the study will only be included in narrative analysis. If there is any objection, it will be resolved by the third researcher.2.6 If there is any objection, it will be resolved by the third researcher.Risk of bias assessments, including random sequence generation, allocation concealment, blind methods, incomplete outcome data, selective outcome reports, and other biases, will be conducted by 2 researchers for all included studies. This work will be done using Cochrane collaboration tools.2.7I2 test will be used for heterogeneity assessment. If there is no heterogeneity (P > .05 and I2 ≤ 50%), the fixed effect model will be used for analysis.The data analysis of this study will be conducted through Review Manager version 5.3 software and stata version 13 software. If the extracted data is continuous data, we will use the standard mean difference and the 95% confidence interval (CI) to evaluate. If it is dichotomous data, we will use risk ratio relative and 95% CI to represent. Chi-square test and 2.8P < .05 and I2 > 50%), we will use subgroup analysis and meta-regression. We established 3 hypotheses for the subgroup analysis: islet function, course of T2DM, and type of concomitant medication. Because blood glucose fluctuations are closely related to islet function, and there is a certain correlation between islet function and course of T2DM. Further evaluate credibility of the subgroup analysis based on the guidance for credible subgroup analysis.,27If studies have significant heterogeneity (2.9In this study, we will refer to the lists used in previous meta-analysis to assess the quality of included studies. The quality of each study will be divided into high, medium, or low. Two researchers will independently assess quality based on the lists. If there is any objection, it will be resolved by the third researcher.2.10P-value of .05.Funnel plots will be used to assess publication bias if more than 10 studies will be included in the meta-analysis. Begg and Egger tests will be used to assess the symmetry of the funnel plot with a boundary of 2.11Because patient-specific data will not be used in this study, ethical approval is not required.3At present, medical researchers and clinicians around the world have reached a consensus on the management of blood glucose in T2DM, that is, precisely reduce blood glucose and achieve control goals steadily. This goal reflects the importance of reducing blood glucose fluctuations. The advantage of western hypoglycemic drugs is that they can quickly and effectively reduce blood glucose, but the main factor of islet function decline has not been improved, leading to no definite effective relief of blood glucose fluctuations. TCM has a broad prospect in relieving blood glucose fluctuations and improving islet function. Therefore, we will implement this systematic review and meta-analysis to provide clinicians with high-quality evidence. This study only included RCTs, which may improve the quality of evidence but may lead to incomplete clinical studies being included.Conceptualization: Yulin Leng, Chunguang Xie, Xiaoxu Fu.Data curation: Xiujuan Zhou, Ziyan Xie, Hong Gao.Formal analysis: Yulin Leng, Xiaoke Liu, Hongyan Xie.Funding acquisition: Chunguang Xie, Xiaoxu Fu.Methodology: Yulin Leng, Xiujuan Zhou, Ziyan Xie.Project administration: Chunguang Xie.Resources: Chunguang Xie, Xiaoxu Fu.Software: Yulin Leng, Zhipeng Hu.Supervision: Chunguang Xie.Writing – original draft: Yulin Leng.Writing – review & editing: Yulin Leng, Chunguang Xie, Xiaoxu Fu.