1.Analysis of associated factors of two pertussis cluster outbreaks in primary schools of Yangzhong City in 2025
LI Taiyue, TONG Haiyuan, SHI Xiaohua, HUO Xiang, CHEN Qiang, QIN Si, ZHOU Yin
Chinese Journal of School Health 2026;47(8):1184-1188
Objective:
To analyze the epidemiological characteristics, associated factors, and vaccine effectiveness of two pertussis cluster outbreaks in two primary schools in Yangzhong City in 2025, so as to provide evidence for school based epidemic prevention and control.
Methods:
From August 26 to 30, 2025, a pertussis questionnaire was administered to the epidemic affected classes of two primary schools (school A and school B) in Yangzhong City. A descriptive epidemiological retrospective analysis was used to characterize the pertussis cluster outbreaks in Yangzhong City from March to July 2025. A 1∶5 matched case control study (79 cases, 395 controls) was performed. Multivariate Logistic regression was used to identify associated factors, and the clinical symptom incidence rates, types of pertussis containing vaccines, and timeliness of vaccination were compared between groups using Fisher s exact test.
Results:
From March to July 2025, a total of 79 pertussis cases were reported in the two schools, with attack rates of 1.33% and 1.01%, respectively. Cases were predominantly aged 7-8 years (85.37% in school A, 73.68% in school B), and the main clinical manifestation was productive cough (63.29%). The pneumonia incidence rate among hospitalized cases ( 57.14 %) was higher than that among nonhospitalized cases(4.17%)(Fisher s exact test, P <0.01). The interval from the last dose to onset was concentrated at 6 to <7 years (44 cases). Logistic regression showed that children exposed to secondhand smoke in daily life ( OR = 3.86 ), those whose desk mates or front/back desk mates took leave due to cough ( OR =4.67), and those whose dining table mates or front/back table mates took leave due to cough ( OR =3.67) had significantly higher risks of pertussis (all P <0.05). A high proportion of both the case group and the control group received the acellular DTaP vaccine (97.47% and 96.96%, respectively),while a low proportion received the pentavalent vaccine (1.27% and 3.04%, respectively). Additionally, one case received only three doses of the acellular DTaP vaccine.The difference in vaccine type distribution between the two groups was not statistically significant (Fisher s exact test, P =0.31).
Conclusions
The outbreaks represent breakthrough infections under high vaccine coverage. Close contact and secondhand smoke exposure are the main risk factors. A booster immunization strategy with diphtheria-tetanus-pertussis vaccine should be implemented for school aged children.
2.Application of DISO Index in multi-round sorting of disease surveillance data
Tian LIU ; Shuqiong HUANG ; Kaifa SONG ; Cong XIE ; Wenwen YANG ; Menglei YAO ; Quan XIANG ; Qinwen XU ; Zhou QIN ; Dexin RUAN ; Jing ZHAO
Journal of Public Health and Preventive Medicine 2026;37(5):22-25
Objective To introduce the calculation of the DISO index in multi-dimensional data ranking for disease surveillance, and evaluate its applicability. Methods Using the data from the quality supervision and inspection of infectious disease reporting in Jingzhou City in a certain year as an example, the DISO index was used to rank 16 investigated medical institutions and compared with the TOPSIS method. The consistency between the two evaluation results was analyzed using Spearman correlation. Then, The DISO index from different medical institutions was used to evaluate the ranking of 8 counties (cities, districts). The evaluation indicators for the supervision and inspection included six items: report rate, timely report rate, completeness of report card filling, accuracy of report card filling, consistency rate with network information report, and completeness of valid ID number filling. Results Among the 16 medical institutions, 8 institutions had all six evaluation indicators at 100%. Using the two methods to rank the 16 medical institutions, the two methods showed that the 8 medical institutions with all six evaluation indicators at 100% were ranked first. There was a strong correlation between the rankings of the 16 medical institutions using the two methods (rs=0.992, P=0.000). The three counties (cities, districts) with all six evaluation indicators at 100% were all ranked first, while country G was ranked seventh and country E was ranked eighth. Conclusion The results of the DISO index and the TOPSIS method were similar in one-dimensional ranking. DISO can be used for multi-dimensional ranking of disease surveillance data and deserves to be promoted and applied.
3.Youguiwan Promotes Localization and Differentiation of Embryonic Stem Cells in Mouse Ovaries via Akt/mTOR/4EBP1/P70S6K Signaling Pathway
Xiang HU ; Mingya ZHU ; Qin ZHOU ; Jiayi SUN ; Zimo LI ; Xiao WANG
Chinese Journal of Experimental Traditional Medical Formulae 2026;32(22):51-60
ObjectiveTo observe the effects of Youguiwan on the localization and differentiation of embryonic stem cells transplanted into ovaries,and to preliminarily explore whether its mechanism is related to the protein kinase B (Akt)/mammalian target of rapamycin (mTOR)/4E-binding protein 1 (4EBP1)/p70S6 kinase (P70S6K) signaling pathway. MethodsA total of 81 healthy adult female C57BL/6 mice that had received ovarian transplantation of GFP-labeled embryonic stem cells were randomly allocated into a control group,a Youguiwan group,and a positive control group. The control group received normal saline via gavage,the Youguiwan group was administered Youguiwan decoction at a clinical equivalent dose of 17.1 g·kg-1,and the positive control group received human menopausal gonadotropin (HMG) injections every 48 h. Ovarian tissue samples were collected on days 7,14,and 21 post-administration. Frozen sections were prepared to observe stem cell localization. The immunofluorescence assay was used to detect growth differentiation factor 9 (GDF9) and mTOR expression. real time polymerase chain reaction(Real-time PCR) was performed to measure the mRNA levels of follicle-stimulating hormone receptor (FSHR) and luteinizing hormone receptor (LHR). Western blotting was conducted to assess the expression and phosphorylation levels of Akt,mTOR,4EBP1,and P70S6K. ResultsFluorescence microscopy revealed that the transplanted embryonic stem cells were predominantly localized within the granular cell layer,the cell layer of the follicular structure,and the stroma. After 14 days of drug intervention,compared with the control group,the Youguiwan group showed upregulated mRNA levels of FSHR and LHR in the ovarian tissue (P<0.01),as well as elevated phosphorylation/protein ratios of Akt,mTOR,4EBP1,and P70S6K (P<0.05). After 21 days of drug intervention,compared with the control group,the Youguiwan group exhibited enhanced expression of GDF9 and mTOR in the ovarian tissue as detected by immunofluorescence (P<0.05),along with elevated mRNA levels of FSHR and LHR (P<0.01) and phosphorylation/protein ratios of Akt and 4EBP1 (P<0.05). ConclusionYouguiwan can promote the localization and differentiation of mouse embryonic stem cells within the ovary and enhance the expression of GDF9,FSHR,and LHR mRNA in the ovarian tissue by influencing the Akt/mTOR/4EBP1/P70S6K pathway.
4.Suppression of Hepatocellular Carcinoma through Apoptosis Induction by Total Alkaloids of Gelsemium elegans Benth.
Ming-Jing JIN ; Yan-Ping LI ; Huan-Si ZHOU ; Yu-Qian ZHAO ; Xiang-Pei ZHAO ; Mei YANG ; Mei-Jing QIN ; Chun-Hua LU
Chinese journal of integrative medicine 2025;31(9):792-801
OBJECTIVE:
To evaluate the anti-hepatocellular carcinoma (HCC) activity of total alkaloids from Gelsemium elegans Benth. (TAG) in vivo and in vitro and to elucidate their potential mechanisms of action through transcriptomic analysis.
METHODS:
TAG extraction was conducted, and the primary components were quantified using high-performance liquid chromatography (HPLC). The effects of TAG (100, 150, and 200 µg/mL) on various tumor cells, including SMMC-7721, HepG2, H22, CAL27, MCF7, HT29, and HCT116, were assessed. Effects of TAG on HCC proliferation and apoptosis were detected by colony formation assays and cell stainings. Caspase-3, Bcl-2, and Bax protein levels were detected by Western blotting. In vivo, a tumor xenograft model was developed using H22 cells. Totally 40 Kunming mice were randomly assigned to model, cyclophosphamide (20 mg/kg), TAG low-dose (TAG-L, 0.5 mg/kg), and TAG high-dose (TAG-H, 1 mg/kg) groups, with 10 mice in each group. Tumor volume, body weight, and tumor weight were recorded and compared during 14-day treatment. Immune organ index were calculated. Tissue changes were oberseved by hematoxylin and eosin staining and immunohistochemistry. Additionally, transcriptomic and metabolomic analyses, as well as quatitative real-time polymerase chain reaction (RT-qPCR), were performed to detect mRNA and metabolite expressions.
RESULTS:
HPLC successfully identified the components of TAG extraction. Live cell imaging and analysis, along with cell viability assays, demonstrated that TAG inhibited the proliferation of SMMC-7721, HepG2, H22, CAL27, MCF7, HT29, and HCT116 cells. Colony formation assays, Hoechst 33258 staining, Rhodamine 123 staining, and Western blotting revealed that TAG not only inhibited HCC proliferation but also promoted apoptosis (P<0.05). In vivo experiments showed that TAG inhibited the growth of solid tumors in HCC in mice (P<0.05). Transcriptomic analysis and RT-qPCR indicated that the inhibition of HCC by TAG was associated with the regulation of the key gene CXCL13.
CONCLUSION
TAG inhibits HCC both in vivo and in vitro, with its inhibitory effect linked to the regulation of the key gene CXCL13.
Animals
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Apoptosis/drug effects*
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Liver Neoplasms/genetics*
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Carcinoma, Hepatocellular/genetics*
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Humans
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Alkaloids/therapeutic use*
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Gelsemium/chemistry*
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Cell Line, Tumor
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Cell Proliferation/drug effects*
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Mice
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Xenograft Model Antitumor Assays
5.Effects of Xuesaitong Capsules(Panax notoginseng saponins)on ischemia/reperfusion injury in a mouse model of skin frostbite
Cheng QIN ; Xiang-yi KONG ; Chen-xi LIAO ; Run-li LI ; Fang WANG ; Xue-song YANG ; Jian-zhou YE
Chinese Traditional Patent Medicine 2025;47(2):430-437
AIM To investigate the effects of Xuesaitong Capsules(Panax notoginseng saponins)on ischemia/reperfusion injury in a mouse model of skin frostbite.METHODS The mice were randomly divided into the control group,the model group,the dexamethasone group(1 mg/kg),and the low-dose,medium-dose,and high-dose Xuesaitong Capsules groups(0.036,0.072,and 0.144 g/kg),with eight mice in each group.A frostbite model was established using a dry ice-cooled ceramic(ferrite)magnet.On the 2nd day after modeling,each group started its corresponding dosing by gavage for 14 consecutive days.The wound healing,histopathological changes,and serum levels of high-sensitivity C-reactive protein(hs-CRP),thromboxane B2(TXB2),6-keto-prostaglandin F1α(6-K-PGF1α),nitric oxide(NO)and endothelin(ET)were assessed using ELISA.The superoxide dismutase(SOD)activity and malondialdehyde(MDA)levels in skin tissues were measured biochemically.The protein expressions of tumor necrosis factor(TNF)-α,interleukin(IL)-1β,IL-6,Toll-like receptor(TLR)4 and phosphorylated nuclear factor-KB p65(p-NF-κB p65)in skin tissues were determined by Western blot.Additionally,LncRNA H19 mRNA expression in skin tissues was evaluated using RT-qPCR.RESULTS After the final administration,compared with the control group,the model group exhibited partial scab detachment,wound healing,and larger wound areas;hyperkeratosis with incomplete keratinization,detachment of the dermis and subcutaneous tissue,partial loss of appendages,subcutaneous edema,and dilated,congested,and hemorrhagic stromal vessels with extensive lymphocyte infiltration revealed by the histopathological examination;elevated serum levels of hs-CRP,TXB2,and ET(P<0.05,P<0.01);decreased 6-K-PGF1α and NO levels(P<0.05,P<0.01);reduced SOD activity in skin tissues(P<0.01);increased MDA levels(P<0.01);and upregulated protein expressions of TNF-α,IL-1β,IL-6,TLR4 and p-NF-κB p65,as well as LncRNA H19 mRNA expression(P<0.05,P<0.01).Compared with the model group,the group intervened with high-dose Xuesaitong Capsules displayed reduced wound areas(P<0.01);decreased serum levels of hs-CRP,TXB2 and ET(P<0.05,P<0.01);increased 6-K-PGF1α and NO levels(P<0.05,P<0.01);enhanced SOD activity(P<0.05,P<0.01);reduced MDA level in skin tissues(P<0.05,P<0.01);and down-regulated TNF-α,IL-1β,IL-6,TLR4 and p-NF-κB p65 protein expressions and suppressed LncRNA H19 mRNA expression in skin tissues as well(P<0.05,P<0.01).CONCLUSION Xuesaitong Capsules alleviate ischemia/reperfusion injury in frostbite-injured mice by exerting anti-inflammatory and anti oxidative stress effects and restoring vascular endothelial function mediated by the downregulation of LncRNA H19 expression and inhibition of the TLR4/NF-κB signaling pathway.
6.Design of new type of elastic gloves for burn scar rehabilitation
Ting SHEN ; Hai-yang ZHAO ; Xiao-chun JIAO ; Bao-li CHEN ; Zhi-juan WANG ; Li-na WANG ; Xiang-yang ZHAO ; Qin ZHOU
Chinese Medical Equipment Journal 2025;46(8):118-120
Objective To design a new type of elastic gloves for burn scar rehabilitation to solve the problems of conventional elastic gloves in pressure distribution,elasticity maintenance and absorption of sweat stains.Methods The new elastic gloves was made of non-woven fabric by spandex material,which was composed of external and internal parts.The main body of the external part was used as the primary structure of the gloves,which was provided with a sealing strip,a storage bag,a drawstring,etc.The internal part consisted of a bonding sheet,an elastic band,a fiber sheet,an absorbent sponge,some breathable holes,etc.Results The new elastic gloves designed could be used for the pressure therapy for the scars on the opisthenar,palm side,finger web and purlicue with scar proliferation inhibitted effectively,and the breathable hole and absorbent sponge contributed to the absorption of the sweat of the patient.Conclusion The new type of elastic gloves gains advantages in elasticity,wearing comfort and effectiveness of the pressure therapy for purlicue and finger web,and can be used for the pressure therapy to inhibit proliferative scarring after burns.[Chinese Medical Equipment Journal,2025,46(8):118-120]
7.Oxymatrine, a novel TLR2 agonist, promotes megakaryopoiesis and thrombopoiesis through the STING/NF-κB pathway.
Chengyang NI ; Ling ZHOU ; Shuo YANG ; Mei RAN ; Jiesi LUO ; Kui CHENG ; Feihong HUANG ; Xiaoqin TANG ; Xiang XIE ; Dalian QIN ; Qibing MEI ; Long WANG ; Juan XIAO ; Jianming WU
Journal of Pharmaceutical Analysis 2025;15(1):101054-101054
Radiation-induced thrombocytopenia (RIT) faces a perplexing challenge in the clinical treatment of cancer patients, and current therapeutic approaches are inadequate in the clinical settings. In this research, oxymatrine, a new molecule capable of healing RIT was screened out, and the underlying regulatory mechanism associated with magakaryocyte (MK) differentiation and thrombopoiesis was demonstrated. The capacity of oxymatrine to induce MK differentiation was verified in K-562 and Meg-01 cells in vitro. The ability to induce thrombopoiesis was subsequently demonstrated in Tg (cd41:enhanced green fluorescent protein (eGFP)) zebrafish and RIT model mice. In addition, we carried out network pharmacological prediction, drug affinity responsive target stability assay (DARTS) and cellular thermal shift assay (CETSA) analyses to explore the potential targets of oxymatrine. Moreover, the pathway underlying the effects of oxymatrine was determined by Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses, Western blot (WB), and immunofluorescence. Oxymatrine markedly promoted MK differentiation and maturation in vitro. Moreover, oxymatrine induced thrombopoiesis in Tg (cd41:eGFP) zebrafish and accelerated thrombopoiesis and platelet function recovery in RIT model mice. Mechanistically, oxymatrine directly binds to toll-like receptor 2 (TLR2) and further regulates the downstream pathway stimulator of interferon genes (STING)/nuclear factor-kappaB (NF-κB), which can be blocked by C29 and C-176, which are specific inhibitors of TLR2 and STING, respectively. Taken together, we demonstrated that oxymatrine, a novel TLR2 agonist, plays a critical role in accelerating MK differentiation and thrombopoiesis via the STING/NF-κB axis, suggesting that oxymatrine is a promising candidate for RIT therapy.
8.Oxymatrine,a novel TLR2 agonist,promotes megakaryopoiesis and thrombopoiesis through the STING/NF-κB pathway
Chengyang NI ; Ling ZHOU ; Shuo YANG ; Mei RAN ; Jiesi LUO ; Kui CHENG ; Feihong HUANG ; Xiaoqin TANG ; Xiang XIE ; Dalian QIN ; Qibing MEI ; Long WANG ; Juan XIAO ; Jianming WU
Journal of Pharmaceutical Analysis 2025;15(1):208-229
Radiation-induced thrombocytopenia(RIT)faces a perplexing challenge in the clinical treatment of cancer patients,and current therapeutic approaches are inadequate in the clinical settings.In this research,oxy-matrine,a new molecule capable of healing RIT was screened out,and the underlying regulatory mecha-nism associated with magakaryocyte(MK)differentiation and thrombopoiesis was demonstrated.The capacity of oxymatrine to induce MK differentiation was verified in K-562 and Meg-01 cells in vitro.The ability to induce thrombopoiesis was subsequently demonstrated in Tg(cd41:enhanced green fluorescent protein(eGFP))zebrafish and RIT model mice.In addition,we carried out network pharmacological pre-diction,drug affinity responsive target stability assay(DARTS)and cellular thermal shift assay(CETSA)analyses to explore the potential targets of oxymatrine.Moreover,the pathway underlying the effects of oxymatrine was determined by Kyoto Encyclopedia of Genes and Genomes(KEGG)enrichment analyses,Western blot(WB),and immunofluorescence.Oxymatrine markedly promoted MK differentiation and maturation in vitro.Moreover,oxymatrine induced thrombopoiesis in Tg(cd41:eGFP)zebrafish and accelerated thrombopoiesis and platelet function recovery in RIT model mice.Mechanistically,oxymatrine directly binds to toll-like receptor 2(TLR2)and further regulates the downstream pathway stimulator of interferon genes(STING)/nuclear factor-kappaB(NF-κB),which can be blocked by C29 and C-176,which are specific inhibitors of TLR2 and STING,respectively.Taken together,we demonstrated that oxymatrine,a novel TLR2 agonist,plays a critical role in accelerating MK differentiation and thrombopoiesis via the STING/NF-κB axis,suggesting that oxymatrine is a promising candidate for RIT therapy.
9.Guideline for Adult Weight Management in China
Weiqing WANG ; Qin WAN ; Jianhua MA ; Guang WANG ; Yufan WANG ; Guixia WANG ; Yongquan SHI ; Tingjun YE ; Xiaoguang SHI ; Jian KUANG ; Bo FENG ; Xiuyan FENG ; Guang NING ; Yiming MU ; Hongyu KUANG ; Xiaoping XING ; Chunli PIAO ; Xingbo CHENG ; Zhifeng CHENG ; Yufang BI ; Yan BI ; Wenshan LYU ; Dalong ZHU ; Cuiyan ZHU ; Wei ZHU ; Fei HUA ; Fei XIANG ; Shuang YAN ; Zilin SUN ; Yadong SUN ; Liqin SUN ; Luying SUN ; Li YAN ; Yanbing LI ; Hong LI ; Shu LI ; Ling LI ; Yiming LI ; Chenzhong LI ; Hua YANG ; Jinkui YANG ; Ling YANG ; Ying YANG ; Tao YANG ; Xiao YANG ; Xinhua XIAO ; Dan WU ; Jinsong KUANG ; Lanjie HE ; Wei GU ; Jie SHEN ; Yongfeng SONG ; Qiao ZHANG ; Hong ZHANG ; Yuwei ZHANG ; Junqing ZHANG ; Xianfeng ZHANG ; Miao ZHANG ; Yifei ZHANG ; Yingli LU ; Hong CHEN ; Li CHEN ; Bing CHEN ; Shihong CHEN ; Guiyan CHEN ; Haibing CHEN ; Lei CHEN ; Yanyan CHEN ; Genben CHEN ; Yikun ZHOU ; Xianghai ZHOU ; Qiang ZHOU ; Jiaqiang ZHOU ; Hongting ZHENG ; Zhongyan SHAN ; Jiajun ZHAO ; Dong ZHAO ; Ji HU ; Jiang HU ; Xinguo HOU ; Bimin SHI ; Tianpei HONG ; Mingxia YUAN ; Weibo XIA ; Xuejiang GU ; Yong XU ; Shuguang PANG ; Tianshu GAO ; Zuhua GAO ; Xiaohui GUO ; Hongyi CAO ; Mingfeng CAO ; Xiaopei CAO ; Jing MA ; Bin LU ; Zhen LIANG ; Jun LIANG ; Min LONG ; Yongde PENG ; Jin LU ; Hongyun LU ; Yan LU ; Chunping ZENG ; Binhong WEN ; Xueyong LOU ; Qingbo GUAN ; Lin LIAO ; Xin LIAO ; Ping XIONG ; Yaoming XUE
Chinese Journal of Endocrinology and Metabolism 2025;41(11):891-907
Body weight abnormalities, including overweight, obesity, and underweight, have become a dual public health challenge in Chinese adults: overweight and obesity lead to a variety of chronic complications, while underweight increases the risks of malnutrition, sarcopenia, and organ dysfunction. To systematically address these issues, multidisciplinary experts in endocrinology, sports science, nutrition, and psychiatry from various regions have held multiple weight management seminars. Based on the latest epidemiological data and clinical evidence, they expanded the guideline to include assessment and intervention strategies for underweight, in addition to the core content of obesity management. This guideline outlines the etiological mechanisms, evaluation methods, and multidimensional management strategies for overweight and obesity, covering key areas such as diagnosis and assessment, medical nutrition therapy, exercise prescription, pharmacological intervention, and psychological support. It is intended to provide a scientific and standardized approach to weight management across the adult population, aiming to curb the rising prevalence of obesity, mitigate complications associated with abnormal body weight, and improve nutritional status and overall quality of life.
10.Effect and safety of pancreatic extracorporeal shock wave lithotripsy in chronic pancreatitis with pancreatic duct stone and analysis of influencing factors of the success of lithotripsy
Xiang AO ; Yaya BAI ; Ke QI ; Taojing RAN ; Xiaonan SHEN ; Xianzheng QIN ; Yao ZHANG ; Ling ZHANG ; Chunhua ZHOU ; Duowu ZOU
Chinese Journal of Hepatobiliary Surgery 2025;31(3):172-176
Objective:To investigate the effect and safety of pancreatic extracorporeal shock wave lithotripsy (P-ESWL) in treating the chronic pancreatitis (CP) patients with main pancreatic duct (MPD) stones and to analyze the influencing factors of success of lithotripsy.Methods:Clinical data of 132 patients with CP complicated with MPD stones treated with P-ESWL in the Department of Gastroenterology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from January 2022 to December 2023 were retrospectively analyzed, including 103 males and 29 females, aged (50.3±16.9) years. The times of P-ESWL, the success rate of stone fragmentation, the necessity of combining endoscopic retrograde cholangiopancreatograhy (ERCP), clearance rate of MPD stones, and incidence of post-P-ESWL complications (acute pancreatitis, abdominal hematoma, infection, steinstrasse, perforation, etc.) were evaluated. The factors influencing the success rate of lithotripsy were analyzed using univariate and multivariate logistic regression.Results:All patients underwent P-ESWL treatment, with (2.23±0.82) times of P-ESWL per person. The success rate of stone fragmentation was 87.1%(115/132). Of 107 CP patients (81.1%, 107/132) were treated with their first P-ESWL. Of 12 patients (9.1%, 12/132) underwent single P-ESWL, and 120 (90.9%, 120/132) underwent P-ESWL combined with ERCP. There were 95 cases (72.0%, 95/132) with effective removal of stones, and 62 (47.0%, 62/132) with complete removal of stones. Post-P-ESWL complications included eight cases (6.1%, 8/132) of acute pancreatitis, two (7.6%, 2/132) of steinstrasse complicated with acute pancreatitis and one (0.8%, 1/132) of abdominal hematoma. No infection or perforation occurred. Multivariate logistic regression analysis showed that the higher CT value of stones ( OR=1.239, 95% CI: 1.040-1.477, P=0.017) was associated with the lower success rate of stone fragmentation. Conclusion:P-ESWL is safe and effective in treating patients with CP complicated with MPD stones. The CT value of stones is a risk factor for the success rate of P-ESWL.


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