Objective:To analyze the risk factors associated with difficult weaning in mechanical ventilation for pediatric patients and investigate the predictive value of utilizing lung ultrasound assessment to optimize preparation for weaning and enhance success rates, thereby establishing a scientific foundation.Methods:A multi-center, prospective observational study, convenience sampling was utilized to select 97 pediatric patients who underwent endotracheal intubation at the Shanghai Children's Medical Center affiliated with Shanghai Jiao Tong University School of Medicine and Fujian Provincial Children's Hospital between September 2022 and May 2023. Lung ultrasound scores (LUS), Pediatric Critical Illness Score (PCIS), indicators related to respiratory oxygenation function and follow-up weaning outcomes were collected within 48-72 hours post-mechanical ventilation and prior to the first spontaneous breathing trial. The predictive efficacy of LUS in conjunction with risk factors associated with weaning difficulty on pediatric weaning outcomes was evaluated independently.Results:Among the 97 children studied, there were 57 boys and 40 girls, with ages ranging from 1 month to 14 years. By following up with weaning outcomes, the pediatric patients were divided into 55 cases of successful weaning group and 42 cases of difficult weaning group. During 48-72 hours of mechanical ventilation, LUS ( OR=2.05, 95% CI 1.43-2.94, P<0.05) and PCIS ( OR=0.68, 95% CI 0.50-0.92, P<0.05) were early risk factors for subsequent difficulties in weaning. And meantime, the combination of LUS(≥20 points) and PCIS(≤72 points) could effectively predict the risk of difficult weaning with a sensitivity of 61.90%, specificity of 96.36%, and an area under curve value of 0.84. Furthermore, before the first spontaneous breathing test, LUS ( OR=4.29, 95% CI 2.36-7.81, P<0.05) and rapid shallow breathing index (RSBI) ( OR=1.84, 95% CI 1.01-3.36, P<0.05) were identified as risk factors for pediatric difficult weaning, and their combination LUS (≥16 points) and RSBI (>6.4) could predict the risk of difficult weaning more accurately with a sensitivity of 76.19%, specificity of 90.91%, and an area under curve value of 0.92. Conclusions:The application of pediatric ICU specialist nurses, based on bedside LUS combined with PCIS and RSBI, can effectively assess and identify the risk of children with difficult weaning in the early stage, and identify the risk factors, providing a scientific basis for implementing individualized pulmonary rehabilitation nursing and helping children successfully weaning.

Objective:To explore the relationship between white matter integrity and cognitive function in first-episode children and adolescents with schizophrenia by diffusion tensor imaging (DTI).Methods:Totally 84 children and adolescents with first-episode schizophrenia who were hospitalized in the Department of Child and Adolescent Psychiatry at the Second Affiliated Hospital of Xinxiang Medical University from September 2017 to June 2021 were selected as the study group, and 35 healthy children and adolescents matched with the study group were selected as the control group. Positive and negative symptom scale (PANSS) was used to assess the patient's mental symptoms. Diffusion tensor imaging (DTI) scans were performed, and the structural integrity of white matter fibers in the brain was measured by tract-based spatial statistics (TBSS), with the indicators including fractional anisotropy (FA). The Chinese version of measurement and treatment research to improve cognition in schizophrenia consensus cognitive battery (MCCB) and the Stroop color-word test were used to evaluate the cognitive function of all subjects. SPSS 26.0 software was used to analyse the data by analysis of variance, independent sample t-test, Mann Whitney U-test and Pearson correlation analysis. Results:(1)The FA values of the right superior longitudinal tract (MNI: x=49, y=-40, z=31) and the left corticospinal tract (MNI: x=-27, y=-22, z=-19) in the study group were higher than those in the control group(both P<0.05). The FA values of the bilateral cingulate gyrus (MNI: x=-7, y=25, z=14; x=20, y=-50, z=25) and the occipital part of the corpus callosum radiation line (MNI: x=-19, y=-50, z=21) in the study group were lower than those in the control group(both P<0.05).(2)The trail making test score of the study group was higher than that of the control group( t=4.344, P<0.01), and the scores of the symbol coding, Hopkins verbal learning test-revised( HVLT-R), brief visuospatial memory test-revised(BVMT-R), word fluency test, number span, maze, Stroop word, Stroop color and Stroop color words were lower than those in the control group( t=-13.041--3.204, all P<0.05). (3) The FA value of right cingulate gyrus (hippocampus) was negatively correlated with the number span ( r=-0.269, P=0.023).The FA value in occipital part of the corpus callosum radiation line was positively correlated with the symbol code ( r=0.237, P=0.047).The FA value of the left lower longitudinal bundle was negatively correlated with the Stroop color and maze ( r=-0.289, -0.275; P=0.010, 0.020).The FA value of the right inferior longitudinal fasciculus was negatively correlated with the score of maze ( r=-0.254, P=0.032). The FA value of occipital part of the corpus callosum radiation line was positively correlated with positive symptom score ( r=0.170, P=0.040). Conclusion:Cognitive dysfunction in children and adolescent with first-episode schizophrenia may be related to abnormal white matter integrity in the brain.

Objective To detect the expression difference of dynactin 2(DCTN2)and cell-cycle-related and expression-elevat-ed protein in tumor(CREPT)in gastric cancer and paracancer tissues,and to explore the relationship between DCTN2 and CREPT ex-pressions and the clinicopathological characteristics and prognosis of gastric cancer patients.Methods A total of 90 patients who received gastric cancer surgery from March 2014 to September 2015 in Affiliated Hospital of Xuzhou Medical University and were confirmed by his-tology were enrolled.The expression levels of DCTN2 and CREPT in gastric cancer tissues and paracancer tissues were detected by immu-nohistochemistry,and the Spearman correlation analysis was used to analyze the relationship between DCTN2 and CREPT in gastric cancer tissues;the relationship between their levels and clinicopathological characteristics were analyzed;Kaplan-Meier and Log-rank analysis were used to analyze the relationship between the expression levels of DCTN2 and CREPT and the overall survival time of gastric cancer patients;univariate and multivariate COX regression analysis were used to analyze the independent risk factors influencing prognosis of gastric cancer patients.Results The expression levels of DCTN2 and CREPT in gastric cancer tissues were significantly higher than that in paracancer tissues,and DCTN2 was positively correlated with CREPT in gastric cancer tissues(P<0.05).The expression levels of DCTN2 and CREPT were correlated with the tumor differentiation,TNM stage,invasion depth,lymph node metastasis(P<0.05),but were not significantly correlated with gender,age and distant metastasis(P>0.05);the results of prognosis analysis showed that the 1-year,3-year and 5-year cumulative survival rate and overall survival rate of gastric cancer patients in the DCTN2high-expression group were significantly lower than those in the DCTN2 low-expression group,and the 5-year cumulative survival rate and overall sur-vival rate of gastric cancer patients in the CREPT high-expression group were significantly lower than those in the CREPT low-expres-sion group(P<0.05).Univariate and multivariate COX regression analysis showed that both DCTN2 and CREPT were independent risk factors on the prognosis of gastric cancer patients.Conclusion DCTN2 and CREPT are highly expressed in gastric cancer tissues and their high expression were closely related to the poor prognosis of gastric cancer patients.DCTN2 and CREPT were expected to be potential markers and new therapeutic targets for gastric cancer diagnosis,and help to judge the prognosis of gastric cancer patients.

An 86-year-old male patient with acute exacerbation of chronic heart failure developed diuretic resistance due to long-term use of diuretics, and was added tolvaptan 3.75 mg once daily orally, with significant diuretic effect. The next day, the dose was increased to 7.5 mg once daily orally. After taking medication, the patient′s urine volume increased and the symptoms of heart failure were improved. On the third day, the patient developed frequent dry mouth, thirst, transient restlessness, and convulsion of extremities. Laboratory tests showed pH 7.51, partial pressure of blood oxygen (PaO 2) 67.4 mmHg, standard bicarbonate concentration (SB) 28.4 mmol/L, actual bicarbonate concentration (AB) 28.5 mmol/L, blood potassium 3.0 mmol/L, blood sodium 143 mmol/L, and blood chlorine 104 mmol/L. It was considered that the metabolic alkalosis and respiratory acidosis were caused by tolvaptan. Tolvaptan was stopped and arginine injection, 0.9 % sodium chloride, potassium supplementation, and other symptomatic treatments were given, and the patient′s water drinking was not restricted. On the day of tolvaptan discontinuation, the patient′s dry mouth and thirst were significantly reduced, his mental state was improved, with no convulsion of extremities, and lower limb and facial edema subsided. After 1 day of drug withdrawal, the laboratory tests showed pH 7.49, SB 31.1 mmol/L, AB 31.4 mmol/L, and blood potassium 3.6 mmol/L. After 3 days of drug withdrawal, the patient developed drowsiness, poor mental state, and weakened breathing compared to before, which was considered that the patient suffered from metabolic alkalosis combined with respiratory acidosis and secondary type II respiratory failure. Intravenous pumping of nikethamide was given. After 5 days of drug withdrawal, the patient′s 24-hour urine volume was 3 285 ml, and the levels of AB, SB, and pH slightly decreased. However, the patient′s condition was not improved significantly. After 13 days of drug withdrawal, symptomatic and supportive treatments such as tracheal intubation and ventilation assistance were given, but the patient′s condition continue to worsen.

An 86-year-old male patient with acute exacerbation of chronic heart failure developed diuretic resistance due to long-term use of diuretics, and was added tolvaptan 3.75 mg once daily orally, with significant diuretic effect. The next day, the dose was increased to 7.5 mg once daily orally. After taking medication, the patient′s urine volume increased and the symptoms of heart failure were improved. On the third day, the patient developed frequent dry mouth, thirst, transient restlessness, and convulsion of extremities. Laboratory tests showed pH 7.51, partial pressure of blood oxygen (PaO 2) 67.4 mmHg, standard bicarbonate concentration (SB) 28.4 mmol/L, actual bicarbonate concentration (AB) 28.5 mmol/L, blood potassium 3.0 mmol/L, blood sodium 143 mmol/L, and blood chlorine 104 mmol/L. It was considered that the metabolic alkalosis and respiratory acidosis were caused by tolvaptan. Tolvaptan was stopped and arginine injection, 0.9 % sodium chloride, potassium supplementation, and other symptomatic treatments were given, and the patient′s water drinking was not restricted. On the day of tolvaptan discontinuation, the patient′s dry mouth and thirst were significantly reduced, his mental state was improved, with no convulsion of extremities, and lower limb and facial edema subsided. After 1 day of drug withdrawal, the laboratory tests showed pH 7.49, SB 31.1 mmol/L, AB 31.4 mmol/L, and blood potassium 3.6 mmol/L. After 3 days of drug withdrawal, the patient developed drowsiness, poor mental state, and weakened breathing compared to before, which was considered that the patient suffered from metabolic alkalosis combined with respiratory acidosis and secondary type II respiratory failure. Intravenous pumping of nikethamide was given. After 5 days of drug withdrawal, the patient′s 24-hour urine volume was 3 285 ml, and the levels of AB, SB, and pH slightly decreased. However, the patient′s condition was not improved significantly. After 13 days of drug withdrawal, symptomatic and supportive treatments such as tracheal intubation and ventilation assistance were given, but the patient′s condition continue to worsen.

Objective:This study aims to analyze the structural characteristics and fibrous structural integrity of the white matter of the brain and their relationship with obsessive-compulsive symptoms in children and adolescents with first-onset obsessive-compulsive disorder (OCD).Methods:Thirty-eight patients with OCD (OCD group) and 35 age-, sex-, and education-matched controls (control group) were included. The brain white matter volume was measured using voxel-based morphometry (VBM) with diffusion tensor imaging (DTI) scans. The tract-based spatial statistics (TBSS), including fractional anisotropy (FA), mean diffusivity (MD), and axial diffusivity (AD), were applied to measure the structural integrity of white matter fibres. The independent samples t-test was used to compare FA, MD, and AD values in differential brain areas between the 2 groups. The clinical characteristics of the patients were assessed using the Yale-Brown Obsessive-Compulsive Symptom Scale for Children. Pearson′s correlation analysis was used to analyze the relationship between the severity of the obsessive-compulsive symptoms and the white matter volume of the brain and the FA, MD, and AD values of the significantly different brain areas in the OCD group. Results:Compared to the control group, the OCD group had lower white matter volumes in the left inferior frontal gyrus, right inferior temporal gyrus, right inferior frontal gyrus, left parietal gyrus, and left limbic lobe ( t=-3.67, -4.21, -3.58, -3.70, -4.34, all P<0.01); had higher FA, MD, and AD values in the left corticospinal tract, left superior longitudinal tract; had higher MD and AD values in the right corticospinal tract, right and left anterior thalamic radiations, right and left inferior fronto-occipital gyrus, and left inferior longitudinal gyrus; had higher FA, MD, and AD values in the occipital and frontal part of the corpus callosum radiation; had a lower FA value in the left and right anterior thalamic radiation, left and right inferior frontal gyrus, left cingulate gyrus, left and right inferior longitudinal gyrus, and right superior longitudinal gyrus (temporal); and had a lower AD value in the left hook gyrus and right superior longitudinal gyrus. In the OCD group, the Pearson′s correlation analysis showed that the white matter volume of the right inferior frontal gyrus was negatively correlated with the obsessive-compulsive thinking factor score ( r=-0.355, P<0.05), and the left parietal gyrus was negatively correlated with the total obsessive-compulsive score, the obsessive-compulsive thinking factor score, and the obsessive-compulsive behavior factor score ( r=-0.361, -0.350, -0.376, all P<0.05); that the FA value in the occipital part of the corpus callosum radiation was negatively correlated with the total obsessive-compulsive score and the obsessive-compulsive behavior factor score ( r=-0.410, -0.411, both P<0.05), the MD values in the left and right anterior thalamic radiation were both negatively correlated with total compulsive scores ( r=-0.389, P<0.05; -0.489, P<0.01), the AD values in the left and right anterior thalamic radiation were both negatively correlated with total compulsive scores ( r=-0.446, -0.405, both P<0.05),the MD and AD values in the left and right anterior thalamic radiation were both negatively correlated with compulsive behavior factor scores ( r=-0.558, -0.631, -0.530, -0.539, all P<0.01), and the AD value in the left subfrontal occipital tract was negatively correlated with compulsive total score and compulsive thinking factor score ( r=-0.359, P<0.05; r=-0.499, P<0.01). Conclusion:Children and adolescents with OCD have reduced white matter volume and impaired structural integrity of white matter fibres, involving the cortico-striato-thalamo-cortical circuit and several brain regions, such as the parietal lobe, limbic lobe, corpus callosum, corticospinal tract, and inferior longitudinal tract. The abnormalities in white matter structure and structural integrity of fibres are correlated with the severity of OCD symptoms.

Objective:This study aims to analyze the structural characteristics and fibrous structural integrity of the white matter of the brain and their relationship with obsessive-compulsive symptoms in children and adolescents with first-onset obsessive-compulsive disorder (OCD).Methods:Thirty-eight patients with OCD (OCD group) and 35 age-, sex-, and education-matched controls (control group) were included. The brain white matter volume was measured using voxel-based morphometry (VBM) with diffusion tensor imaging (DTI) scans. The tract-based spatial statistics (TBSS), including fractional anisotropy (FA), mean diffusivity (MD), and axial diffusivity (AD), were applied to measure the structural integrity of white matter fibres. The independent samples t-test was used to compare FA, MD, and AD values in differential brain areas between the 2 groups. The clinical characteristics of the patients were assessed using the Yale-Brown Obsessive-Compulsive Symptom Scale for Children. Pearson′s correlation analysis was used to analyze the relationship between the severity of the obsessive-compulsive symptoms and the white matter volume of the brain and the FA, MD, and AD values of the significantly different brain areas in the OCD group. Results:Compared to the control group, the OCD group had lower white matter volumes in the left inferior frontal gyrus, right inferior temporal gyrus, right inferior frontal gyrus, left parietal gyrus, and left limbic lobe ( t=-3.67, -4.21, -3.58, -3.70, -4.34, all P<0.01); had higher FA, MD, and AD values in the left corticospinal tract, left superior longitudinal tract; had higher MD and AD values in the right corticospinal tract, right and left anterior thalamic radiations, right and left inferior fronto-occipital gyrus, and left inferior longitudinal gyrus; had higher FA, MD, and AD values in the occipital and frontal part of the corpus callosum radiation; had a lower FA value in the left and right anterior thalamic radiation, left and right inferior frontal gyrus, left cingulate gyrus, left and right inferior longitudinal gyrus, and right superior longitudinal gyrus (temporal); and had a lower AD value in the left hook gyrus and right superior longitudinal gyrus. In the OCD group, the Pearson′s correlation analysis showed that the white matter volume of the right inferior frontal gyrus was negatively correlated with the obsessive-compulsive thinking factor score ( r=-0.355, P<0.05), and the left parietal gyrus was negatively correlated with the total obsessive-compulsive score, the obsessive-compulsive thinking factor score, and the obsessive-compulsive behavior factor score ( r=-0.361, -0.350, -0.376, all P<0.05); that the FA value in the occipital part of the corpus callosum radiation was negatively correlated with the total obsessive-compulsive score and the obsessive-compulsive behavior factor score ( r=-0.410, -0.411, both P<0.05), the MD values in the left and right anterior thalamic radiation were both negatively correlated with total compulsive scores ( r=-0.389, P<0.05; -0.489, P<0.01), the AD values in the left and right anterior thalamic radiation were both negatively correlated with total compulsive scores ( r=-0.446, -0.405, both P<0.05),the MD and AD values in the left and right anterior thalamic radiation were both negatively correlated with compulsive behavior factor scores ( r=-0.558, -0.631, -0.530, -0.539, all P<0.01), and the AD value in the left subfrontal occipital tract was negatively correlated with compulsive total score and compulsive thinking factor score ( r=-0.359, P<0.05; r=-0.499, P<0.01). Conclusion:Children and adolescents with OCD have reduced white matter volume and impaired structural integrity of white matter fibres, involving the cortico-striato-thalamo-cortical circuit and several brain regions, such as the parietal lobe, limbic lobe, corpus callosum, corticospinal tract, and inferior longitudinal tract. The abnormalities in white matter structure and structural integrity of fibres are correlated with the severity of OCD symptoms.

Objective:To investigate the related factors that affect the timing and prognosis of early tracheostomy in patients with multiple rib fractures.Methods:A retrospective case series study was conducted on medical data of 222 patients with multiple rib fractures who underwent tracheostomy in Affiliated Hospital of Yangzhou University from February 2013 to October 2019，including 160 males and 66 females，with the age of 18 to 85 years ［（49.5 ± 16.3）years］. According to the practice management guidelines for tracheostomy timing and the use of propensity score matching technology，there were 118 patients with tracheostomy within 7 days of tracheal intubation （early group） and 104 patients with tracheostomy after 7 days of tracheal intubation （late group） before matching，and there were 87 patients in early group and 87 patients in late group after matching. Data were compared between groups including the gender，age，underlying disease，injury severity score （ISS），Glasgow coma score （GCS），number of fractured ribs，total number of rib fractures （NTRF），first rib fracture，flail chest，traumatic brain injury，combined injuries （spine，maxillofacial，sternum），acute respiratory distress syndrome （ARDS），volume fraction of pulmonary contusion（VPC），blood lactic acid （within 24 hours of admission），hemothorax，pneumothorax，mechanical ventilation time，duration of tracheostomy，time from tracheal intubation to incision，length of hospital stay，length of stay in ICU，closed thoracic drainage，number of fiberoptic bronchoscopy，multi-drug resistant bacteria infection，ventilator-associated pneumonia，antibiotic use time，duration of sedative and analgesic drugs used and 28-day mortality. The multivariate Logistic regression analysis was used to predict independent risk factors for early tracheostomy. The Pearson method was used to compare the relationship between multiple factors. The receiver operating characteristic （ROC） curve was used to predict indicators that affect the prognosis of patients with early tracheostomy，and calculate the best cut-off value. The Kaplan-Meier single factor and COX multivariate survival were used to analyze the relevant factors affecting the 28-day mortality of patients.Results:（1） In early group，the NTRF，ARDS and VPC were higher than those in late group，and the time from tracheal intubation to incision and 28-day mortality rate were lower than those in late group （ P < 0.05），while the two groups showed no significant differences in the gender，age，underlying diseases and ISS （ P > 0.05）. （2） The multivariate Logistic regression analysis showed that there was statistical significance in NTRF （ OR = 1.775，95% CI 1.439-2.188），ARDS（ OR = 3.740，95% CI 1.441-9.711），VPC （ OR = 1.087，95% CI 1.052-1.124） （ P < 0.05）； the Pearson method analysis showed a significant correlation between VPC and NTRF （ r = 0.369， P < 0.05） and a low degree of correlation between ARDS and VPC （ r = 0.179， P < 0.05），but there was no significant correlation between ARDS and NTRF （ r = 0.132， P > 0.05）. （3） The ROC curve analysis showed that the area under the curve （AUC） of the VPC and NTRF ［AUC = 0.832 （95% CI 0.770-0.893），AUC = 0.804 （95% CI 0.740-0.868）］ were significantly higher than those of the number of rib fractures ［AUC = 0.437（95% CI 0.352-0.523），GCS ［AUC = 0.519 （95% CI 0.432-0.605）］ and ISS ［AUC = 0.484 （95% CI 0.398-0.571）］ （ P < 0.05）. After calculating the Yorden index，the best cut-off value for VPC was 23.9，and the best cut-off value for NTRF was 8.5. （4） The Kaplan-Meier single factor and multivariate COX model survival analysis showed that the 28-day survival ratio of patients with early tracheostomy was significantly better than that of late tracheostomy （ P < 0.05）. Conclusions:The NTRF，ADRS and VPC are independent risk factors for the timing and prognosis of early tracheostomy. There is a significant correlation between VPC and NTRF. The VPC ≥ 23.9% and or NTRF ≥ 8.5 can be used to predict early tracheostomy in patients with multiple rib fractures. Early tracheostomy may benefit the 28-day survival of patients with multiple rib fractures.

Objective:To investigate the seasonal changes of fasting plasma glucose (FPG) levels in patients with acute ischemic stroke.Methods:Patients with acute ischemic stroke who were hospitalized in the Department of Neurology, the Second Hospital of Tianjin Medical University and had fasting blood glucose data from January 1, 2016 to December 31, 2020 were enrolled retrospectively. The general data and FPG results of all patients were collected, and the seasonal changes of various indexes were analyzed. Multiple linear regression analysis was used to determine the influencing factors of FPG.Results:A total of 1 323 patients with acute ischemic stroke who had FPG data were enrolled, of whom 519 patients (39.2%) had diabetes mellitus and 804 (60.8%) had no diabetes mellitus. The baseline National Institutes of Health Stroke Scale score, body mass index, systolic blood pressure, diastolic blood pressure and FPG in the winter group were significantly higher than those in the summer group (all P<0.05). Further subgroup analysis of gender and age showed that the FPG level of elderly patients aged 65-80 years had significant seasonal changes ( P<0.05). Multiple linear regression analysis showed that age, season, body mass index, whether complicated with diabetes mellitus, whether using insulin and/or oral hypoglycemic drugs were the independent influencing factors of FPG levels. Conclusion:The FPG levels in patients with acute ischemic stroke have the characteristics of seasonal fluctuation, which is more obvious in elderly patients aged 65-80 years.

Objective:To investigate the seasonal changes of glycated hemoglobin (HbA1c) in patients with acute ischemic stroke in Tianjin.Methods:Acute ischemic stroke patients with available HbA1c data admitted to the Department of Neurology, the Second Hospital of Tianjin Medical University from January 1, 2011 to December 31, 2020 were enrolled retrospectively. The demographic data, vascular risk factors, baseline clinical data and routine blood test findings were collected. The seasonal changes of various indexes were investigated. Multiple linear stepwise regression analysis was used to determine the influencing factors of HbA1c.Results:A total of 2 721 acute ischemic stroke patients with available HbA1c data were included, of whom 1 779 (65.4%) also had diabetes mellitus, 942 patients (34.6%) did not have diabetes mellitus. The baseline National Institutes of Health Stroke Scale score, body mass index, systolic blood pressure, diastolic blood pressure, fasting blood glucose, total cholesterol and uric acid in the winter group were significantly higher than those in the summer group (all P<0.05). HbA1c had seasonal difference in acute ischemic stroke patients without diabetes mellitus ( P<0.05). For acute ischemic stroke patients with diabetes mellitus, HbA1c showed seasonal fluctuations only at HbA1c >7% ( P<0.05). Multiple linear stepwise regression analysis showed that combined with diabetes mellitus, using insulin and/or oral hypoglycemic drugs, fasting blood glucose, uric acid, creatinine and season were the independent infuencing factors of HbA1c. Conclusions:HbA1c in patients with acute ischemic stroke in Tianjin is characterized by seasonal fluctuations, which is high in winter and spring and low in summer and autumn. This difference is related to the level of HbA1c.