Volume 102 ·  Issue 06 ·  2022

Hyperglycemia in pregnancy (HIP) is the most common pathological obstetric disease. However, there is no uniform standard in the world for classification of HIP and diagnosis of gestational diabetes mellitus(GDM). This article will analyze this issue and support the International association of diabetes and pregnancy study group(IADPSG) criteria as a global standard for diagnosing GDM,also support HIP should be divided into four categories: PGDM, ODM, GDM and prediabetes, so as to refine clinical management.

To explore the effect of neoadjuvant immunotherapy on pulmonary function and the efficacy in patients with resectable non-small cell lung cancer.

Data of 30 patients with non-small cell lung cancer (NSCLC) who received neoadjuvant immunotherapy before surgery in the Chest Hospital of Shanghai Jiaotong University from March 2018 to September 2021 were retrospectively collect. The efficacy and safety of neoadjuvant immunotherapy in the perioperative period and changes in pulmonary function of patients before and after neoadjuvant treatment were valuated.

The patients were all-male with age of (61±8)years old, The major pathological response (MPR) rate of patients receiving neoadjuvant immunotherapy was 43%(13 cases), the pathologic complete response (pCR) rate was 37% (11 cases), disease control rate (DCR) was 97% (29 cases), objective response rate (ORR) was 67% (20 cases). The forced expiratory volume in one second (FEV1) after treatment was (2.59±0.63) L, and the ratio of FEV1 to the predicted value (FEV1%pred) was 85.27%±15.86%, which were significantly higher than those before treatment [(2.48±0.59)L, 81.73%±15.94%, respectively] (P=0.013, 0.022, respectively). Forced vital capacity (FVC) after treatment was (3.59±0.77) L, which was also significantly higher than before [(3.47±0.76) L,P=0.036]; while there were no statistical difference in FEV1/FVC and FVC accounted for the proportion of predicted values (FVC%pred) between before and after treatment (P=0.084, 0.344, respectively). The ratio of carbon monoxide dispersion (DLCO) to the predicted value (DLCO%pred) decreased from 83.61%±13.10% to 78.69%±13.85% after treatment (P=0.023). There was no significant difference in the incidence of postoperative complications between the DLCO%pred decreased group and the non-decreased group (3/18 vs 0/6; P=0.546).

Neoadjuvant immunotherapy can increase the rate of MPR and PCR, significantly increase FEV1 and FEV1%pred, but also lead to a decrease in DLCO%pred; neoadjuvant immunotherapy does not increase the incidence of postoperative complications.

To explore the prognosis of patients with leptomeningeal metastasis (LM) and epidermal growth factor receptor mutated (EGFRm) non-small cell lung cancer (NSCLC) treated with different kinds of tyrosine kinase inhibitors (TKIs).

From January 2016 to June 2021, the clinicopathological data of 70 patients confirmed by histologically or cytologically EGFRm LM who received different types of TKIs in Cancer Hospital of Chinese Academy of Medical Sciences were retrospectively analyzed. According to treatment patterns, patients were divided into the first-and second-generation EGFR-TKIs treatment group and the third-generation EGFR-TKIs treatment group [Osimertinib 80 mg once a day], and the prognosis and prognostic factors (with Cox proportional hazards model) of patients in different treatment group were assessed. The next-generation sequencing (NGS) of paired samples of cerebrospinal fluid (CSF) and plasma from 64 patients at the time of LM diagnosis was performed simultaneously.

There were 20 males and 50 females in 70 EGFRm NSCLC patients with LM. The age ranged from 35 to 69 years, with a median age of 56 years. A total of 24 patients received the first-and second-generation EGFR-TKIs treatment, and 46 received the third-generation EGFR-TKIs treatment. Twenty-four patients developed disease progression on the first-and second EGFR-TKIs treatments, followed by treatment with the third-generation EGFR-TKIs (Osimertinib) in 12 cases, chemotherapy or anti-angiogenesis therapy in 4 cases, and the optimal supportive treatment in 8 cases. Among the 70 patients, 18 had partial response (PR), 48 had stable disease (SD), and 4 had progressive disease (PD). The objective response rate (ORR) and disease control rate (DCR) were 26% (18/70) and 94% (66/70), respectively. The median follow-up time was 16.5 months. The median progression-free survival (PFS) was 5.3 months(95%CI: 2.8-7.8)in the first-and second-generation EGFR-TKIs and 10.8 months (95%CI: 7.9-13.6) in the third-generation EGFR-TKIs, and the difference was statistically significant (P=0.019). The median overall survival (OS) was 14.9 months (95%CI: 9.7-20.0) and 15.7 months (95%CI: 13.3-18.1) in the two groups, respectively, but no statistical differences was observed (P=0.713). Univariate analysis showed that the PFS of patients with EGFRm LM were related to gender and different types of EGFR-TKIs (P˂0.05). Multivariate analysis demonstrated that male (HR=2.30, 95%CI: 1.31-4.03, P=0.004) and the first-and second-generation EGFR-TKIs (HR=2.03, 95%CI: 1.20-3.41, P=0.008) were independent risk factors for PFS in patients with EGFRm LM. The EGFR mutation was detected in 61 (95%) CSF and in 27 (42%) plasma samples.

In EGFRm NSCLC patients with LM, the dose of Osimertinib 80 mg (once a day) has a significant PFS benefit compared with the first-and second-generation EGFR-TKIs.

To explore the expression of programmed cell death ligand 1 (PD-L1) in patients with locally advanced and non-EGFR-mutated non-small cell lung cancer (LA-NSCLC) undergoing concurrent chemoradiotherapy (cCRT) and its association with clinical outcome of patients.

The basic clinical information of 19 patients with unresectable, non-EGFR mutated LA-NSCLC receiving radical cCRT in Cancer Hospital Chinese Academy of Medical Sciences from January 2016 to December 2017 was retrospectively analyzed. The rabbit monoclonal antibody SP263 was used for immunohistochemical analysis to detect the expression of PD-L1 in LA-NSCLC tissues and the tumor proportion score (TPS) equal to or greater than 1% was defined as PD-L1 positive. The associations between PD-L1 ≥1% and PD-L1 ≥25% with the clinical characteristics and clinical outcome of LA-NSCLC patients were evaluated respectively.

Among 19 LA-NSCLC patients, 13 had PD-L1 positive expression, and 4 had PD-L1 expression greater than or equal to 25%. No significant difference was observed between patients with PD-L1 positive and negative expressions regarding the distribution of age, smoking history, pathological classification, and TNM staging (P>0.05). A total of 15 patients could be evaluated for therapeutic effect, including 7 patients with partial response (PR), 7 patients with stable disease (SD), and 1 patient with progressive disease (PD). In the group with PD-L1 expression<1%, 3 patients were in objective response, and 4 patients were in disease control. In the group with PD-L1 expression ≥1%, 4 patients were in objective response, and 10 patients were in disease control. When the PD-L1 expression was less than 25%, 6 patients gained the objective response, and 11 patients gained the disease control. When the PD-L1 expression was greater than or equal to 25%, 1 patient gained the objective response, and 3 patients gained the disease control. The median overall survival (OS) was 35 (95%CI: 12.7-57.3) months for patients with PD-L1 ≥1% and 40 (95%CI: not reaching the end point) months for patients with PD-L1<1% (P=0.284). Patients with PD-L1 ≥25% had a median survival time of 12 (95%CI:0.0-34.5) months, and patients with PD-L1<25% had a median survival time of 40 (95%CI: 27.4-52.6) months (P=0.241).

The prognosis of LA-NSCLC patients with PD-L1 positive and no-EGFR mutation receiving concurrent chemoradiation has a trend of poor prognosis. A larger sample size study is warranted to explore the prognostic value of PD-L1 expression in inoperable LA-NSCLC patients and to further explore the effect of immunotherapy on patients with different PD-L1 expression levels.

To investigate the clinical features and the value of different diagnostic indices for etiology in reproductive age women with hyperandrogenism.

The medical records of 96 reproductive age women with hyperandrogenism in the multi-disciplinary team of Peking University First Hospital from January 2020 to April 2021 were collected. The patients were divided into four groups based on final diagnosis: congenital adrenal hyperplasia (CAH) (n=8), polycystic ovary syndrome (PCOS) (n=67), idiopathic hyperandrogenism (n=13) and other specific diseases (n=8), respectively. The indices related to androgens in different groups were compared, and then their efficiency for diagnosis of CAH and PCOS were analyzed with receiver operator characteristic curve (ROC curve).

A total of 96 patients with hyperandrogenism were recruited, with the age of 19-45 (29±6) years old. Overall, 4.2% (4/96) of the patients were with single clinical hyperandrogenism, 56.3% (54/96) were with single laboratory hyperandrogenaemia and 39.6% (38/96) were with both. The breakdown into laboratory hyperandrogenaemia subtypes was as follows: only T elevation 22.8% (21/92), only A2 elevation 7.6% (7/92), none DHEAS elevation, only FAI elevation 5.4% (5/92) and elevation of more than one of the androgen indices mentioned above accounted for 64.1% (59/92). In the reasons of consultation, simple irregular menstruation (36.0%, 32/89) or accompanied by clinical hyperandrogenism with or without infertility (36.0%, 32/89) were the most common. As for primary visiting departments, Obstetrics and Gynecology accounted for 53.2% (51/96), and then Endocrinology as 39.5% (38/96). The 17-OHP level of CAH, PCOS and idiopathic hyperandrogenism group was 20.0 (8.2, 33.1), 1.1 (0.8, 1.4), 0.9 (0.8, 1.3) ng/ml, respectively. The androstenedione level in these groups was 6.3 (4.6, 8.7), 3.8 (2.9, 4.8) and 3.2 (2.7, 3.7) ng/ml, respectively. The 17-OHP and androstenedione levels of CAH group were significantly higher than that in PCOS or idiopathic hyperandrogenism group (all P<0.05). The ratio of LH and FSH in these three groups was 0.8(0.5, 1.0), 1.3(0.6, 1.9) and 0.6(0.3, 0.7), respectively. The ratio of LH and FSH was significantly higher in PCOS than that in idiopathic hyperandrogenism group (P=0.024), but yet there was no significant difference compared with CAH group (P>0.05). The AUC of ROC curve of 17-OHP for CAH diagnosis was 0.94, followed by androstenedione 0.83, whereas LH/FSH for PCOS diagnosis was only 0.63.

Among the reasons of consultation in reproductive age women who visited our multi-disciplinary team for female hyperandrogenism, simple irregular menstruation or accompanied by clinical hyperandrogenism with or without infertility are the most common. PCOS accounts for the majority of different androgen excess disorders. 17-OHP is the most valuable parameter for the diagnosis of CAH and secondly androstenedione.

To investigate the risk factors for gestational diabetes mellitus (GDM) in elderly multipara women in the next pregnancy.

A total of 219 elderly multipara women with 2 consecutive delivery records in Tianjin Binhai New Area Tanggu Obstetrics and Gynecology Hospital from January 2018 to May 2019 were included. Among them, 141 had normal glucose tolerance (NGT) and 78 of them had GDM. The clinical data of the previous and current pregnancy were collected to analyze the risk factors of GDM in elderly multipara women.

The average ages of 219 elderly women in previous pregnancy and this pregnancy were (31.9±2.2) and (36.7±1.5) years old, and the prevalence of GDM was 35.62% (78 cases). Compared to NGT group, GDM patients had higher fasting blood glucose(previous (5.51±1.43) vs (4.63±0.62) mmol/L; current (5.26±0.63) vs (4.59±0.30) mmol/L, 1 h blood glucose(previous (11.74±2.36) vs (9.50±1.82) mmol/L; current (11.03±2.03) vs (9.51±1.14) mmol/L) in 75 g oral glucose tolerance test (OGTT) in both previous and current pregnancy. The rates of cesarean section, in both previous and current pregnancy were higher in GDM group (previous 34.6% vs 4.3%; current 52.6% vs 22.0%). Furthermore, prenatal weight and body mass index (BMI) of the previous pregnancy, pre-pregnancy weight and BMI, and prenatal BMI of this pregnancy were also higher in GDM group, and the differences were all statistically significant (all P<0.05). Logistic multivariate regression analysis indicated cesarean section history (OR=10.80, 95%CI: (4.09-28.54)), GDM history of previous pregnancy (OR=10.64, 95%CI: (4.02-28.20)), 75 g OGTT fasting blood glucose≥ 4.86 mmol/L (OR=2.70, 95%CI: (1.27-5.70)), 1 h blood glucose after glucose administration ≥ 8.45 mmol/L (OR=1.78, 95%CI: (1.37-2.31)) were risk factors for GDM in elderly multipara women of this pregnancy.

The risk of GDM in elderly multipara women with a history of cesarean section and GDM increases significantly. Results of OGTT in previous pregnancy also has predictive value.

To analyze the pregnancy-related adverse outcomes in patients with severe hypothyroidism during pregnancy.

Using cross-sectional study, a total of 47 pregnant women with severe hypothyroidism in the Peking University First Hospital from January 2007 to December 2020 were retrospectively collected by electronic case system. According to the occurrence of adverse pregnancy events (defined as any pregnancy complication or adverse maternal-fetal/neonatal outcomes), the patients were divided into pregnancy-related adverse outcomes group (n=33) and no pregnancy-related adverse outcomes group (n=15). The demographic data, thyroid function and thyroid autoantibody levels during pregnancy, pregnancy complications and maternal-fetal/neonatal outcomes of the two groups were recorded and analyzed.

The age of severe hypothyroidism women was (30.5±4.1) years. The median of gestational week at delivery was 38.6 (36.3, 39.9) weeks, the median of gestational week for diagnosis was 7.0 (6.0, 8.8) weeks, the median of the highest TSH level was 32.7(23.1,60.2)mU/L and the period of reaching the target TSH level for the first time was 6.0(4.0, 10.0)weeks. Most cases (82.5%, 33/40) had thyroid autoimmunity. All women were treated with levothyroxine (L-T₄) during pregnancy. A total of 37 cases (77.1%, 37/48) of them obtained the recommended target values. Fourty cases (83.3%, 40/48) gave birth. The birth weight of newborns was (3 041±452) g, the body length was (49.4±2.1) cm, and the head circumference was (33.6±0.7) cm. The period of reaching to target TSH level for the first time in patients without pregnancy-related adverse outcomes was shorter [5.0 (3.0, 9.0) vs 8.0 (4.5, 12.5) weeks) ] (P=0.033), and the times of thyroid function monitoring were more frequent [ (8.2±3.5) vs (6.0±3.6) times] (P=0.049) than the group with pregnancy-related adverse outcomes.

The incidence of pregnancy complications and adverse maternal-fetal/neonatal outcomes is high in patients with severe hypothyroidism during pregnancy. Intense follow-up, treatment and restoration of euthyroidism as prompt as possible may improve pregnant outcomes.

To investigate the treatment options for breast cancer patients aged 65 and over, and analyze the influencing factors.

The clinical data of 521 elderly patients aged 65 years or older,who underwent surgery in Peking Union Medical College Hospital from January 2009 to December 2015, were collected. They were all female and 65-98 years old. The patients were divided into 65-74 years old group (n=353) and ≥ 75 years old group (n=168). The differences of variables including age, functional status, treatment methods, pathological characteristics, comorbidities and survival time between the two groups were compared, and the differences of comprehensive treatment methods and their impact on clinical efficacy were analyzed.

The main operation methods of the two groups were modified radical mastectomy [39.1% (138/353) and 33.9% (57/168), respectively], breast conserving surgery [56.9% (201/353) and 61.3% (103/353), respectively]. Among the patients choosing adjuvant therapy, there was no significant difference between the two groups except chemotherapy (all P>0.05). Univariate analysis showed that the choice of chemotherapy was related to age, surgical methods, pathological types, tumor burden, molecular typing, functional status and comorbidities (all P<0.05). The Eastern Cooperative Oncology Group (ECOG) score and the number of comorbidities were independent factors affecting the choice of chemotherapy for breast cancer in the elderly: [ECOG score: adjusted OR=0.45 (95CI: 0.26-0.75), number of comorbidities: adjusted OR = 0.63 (95CI:0.41-0.98); all P<0.05]. The 5-year disease-free survival rate of 521 elderly patients with breast cancer was 86.3%, 5-year overall survival rate was 88.8%, and the breast cancer specific survival rate was 94.3%.

The comprehensive treatment of breast cancer patients aged 65 and above is not affected by age, but is associated with tumor burden, pathological type, molecular typing, comorbidities and ECOG score. Among them, ECOG score and the number of comorbidities are the independent factors influencing the choice of adjuvant chemotherapy.

To explore the time trends of H. pylori infection and related drug use in patients with peptic ulcer bleeding (PUB) in recent ten years.

PUB patients in Peking University Third Hospital from 2010 to 2019 were included. Time trends of H. pylori infection, related drugs (non-steroidal anti-inflammatory drugs, aspirin, antiplatelet drugs, anticoagulant drugs, glucocorticoids) use and non-H. pylori-non-drug ulcer in PUB patients were analyzed.

A total of 1 140 PUB patients were included from 2010 to 2019 (including 925 males and 215 females). The age M(Q₁,Q₃)was 53.5 (33.0, 66.0) years, with 833 patients <65 years old. The positive rates of H. pylori were 79.3%, 75.7%, 73.1%, 71.6%, 77.0%, 70.4%, 69.7%, 63.1%, 51.4%, 50.9%, respectively, showing a decreasing trend (χ²=32.386, P<0.001), and the decreasing trends were significant in different ulcer location, age and gender subgroups(all P<0.05). The proportions of PUB patients using at least one of the above drugs were 23.1%, 28.6%, 34.0%, 39.5%, 33.8%, 35.9%, 28.7%, 39.8%, 40.9%, 41.8%, respectively, showing an increasing trend (χ²=6.857, P=0.009), and the proportions of patients with antiplatelet drugs and anticoagulant drugs history showed increasing trends. The proportions of non-H. pylori-non-drug patients were 12.3%, 22.1%, 14.6%, 13.2%, 7.7%, 13.0%, 16.9%, 18.7%, 22.6% and 20.9%, respectively, showing an increasing trend (χ²=4.808, P=0.028). Accordingly, the proportions of elderly (≥65 years old) patients (χ²=4.608, P=0.032) and large ulcer (≥2 cm) patients (χ²=8.173, P=0.004) showed increasing trends.

In the last decade, the positive rate of H. pylori in PUB patients showed a decreasing trend, while the proportions of patients with antiplatelet drugs and anticoagulant drugs history and the proportion of non-H. pylori-non-drug patients showed increasing trends.

This article reported the clinical diagnosis and treatment experience of two cases of fetal goiter in Graves′ disease (GD) complicated with pregnancy. Two GD patients took antithyroid drugs regularly during pregnancy and their thyroid functions were well controlled, but the levels of thyrotropin receptor antibody (TRAb) of the two cases were still above the upper limit in the second and third trimester. Two fetuses had fetal goiter in the middle and late stages of pregnancy. After continuously controlling maternal thyroid function and closely monitoring fetal ultrasound, there was no aggravation of the fetal goiter, and the delivery went smoothly. One case had neonatal hyperthyroidism. It is suggested that although the thyroid function was well controlled during pregnancy in patients with GD, the high level of serum TRAb still needs to be alert to the occurrence of fetal goiter, and fetal ultrasound is the most direct non-invasive monitoring method.

Hyperandrogenism is a common endocrine disease in women of childbearing age. Female hyperandrogenism is known to increase adverse pregnancy outcomes while affecting the normal development of the progeny reproductive system. Recent studies have found that maternal hyperandrogenism also affects the development and function of the glucose metabolism system of offspring. This paper will focus on combing the research evidence on the influence of maternal hyperandrogenism during pregnancy on blood glucose level, insulin sensitivity and β cell function of offspring, and put forward the prospect of future research.

The obesity of women of childbearing age is related to the health of mother and son, and bariatric metabolic surgery is an effective means to solve obesity and its complications. In recent years, the number of women of childbearing age undergoing bariatric metabolic surgery is increasing. After bariatric metabolic surgery, whether obesity-related infertility can be improved, pregnancy safety, perinatal and long-term postpartum outcomes, which surgical method is the most beneficial, and when the risk of pregnancy is the lowest after surgery are all important issues that affect the surgical choice of women of childbearing age. This article reviews the literature at home and abroad on the above issues, in order to provide more evidence for clinical practice.

In recent years, tumor immunotherapy represented by immune checkpoint inhibitors (ICIs) is revolutionizing the treatment of cancer. However, more and more reports and studies have found that active tuberculosis (TB) occurs during the use of ICIs, and current tuberculosis infection will also affect the use of ICIs. Combined with domestic and foreign literature and clinical experience, this review briefly describes the incidence of TB in immunotherapy, the role of programmed death receptor 1 (PD-1) and programmed death ligand 1 (PD-L1) pathways in immunization against Mycobacterium tuberculosis infection, and the mechanism of active TB. It emphasizes the screening of TB before immunotherapy, the timing of prophylactic anti-TB therapy, the selection and adjustment of treatment plan before and after TB diagnosis during anti-tumor therapy, so as to provide new ideas for clinical diagnosis and long-term management of advanced lung cancer.

Thyroid-associated ophthalmopathy (TAO) is a refractory complication of Graves' disease (GD). Stimulatory thyrotropin receptor (TSAb) can bind to the TSH receptor (TSHR) /insulin-like growth factor Ⅰ receptor (IGF-IR) complex expressed by GD-orbital fibroblasts (GD-OF) to promote the development OF TAO. IGF-IR is a necessary component for TSHR to initiate cell signaling. teprotumumab, as a monoclonal antibody that blocks IGF-IR, was approved by the U.S. Food and Drug Administration for the treatment of TAO in 2020, but the potential mechanism of this drug for the treatment of TAO still needs to be further clarified.

To further evaluate the effect of iron nutrition status on thyroid function in pregnant women in areas with mild iodine deficiency, this study used a multi-stage, scale-proportional stratified and cluster sampling method in Belgium to detect blood triiodothyronine (T3), free T3 (fT3), tetraiodothyronine (T4), free T4 (fT4), TSH, urine iodine concentration (UIC), hemoglobin (Hb), serum ferritin (SF, SF<15 μ g/L suggests iron deficiency) and soluble transferrin receptor (sTfR) levels, and the body iron reserve (BIS) was calculated by formula as a more sensitive index to judge iron deficiency. The median UIC of women included in the first and third trimester of pregnancy was 117 and 132 μ g/L, respectively, suggesting mild iodine deficiency. Multiple linear regression analysis suggested that UIC was an important predictor of Tg, rather than fT4, T4, fT3 or TSH levels during pregnancy. Among the enrolled women in first and third trimester pregnancy, SF<15 μ g/L patients accounted for 6.2% and 39.6%, respectively. BIS in the third trimester of pregnancy showed that the proportion of hypoFT4aemia in patients with iron deficiency was significantly higher than that in patients with iron sufficiency (24% vs 14%, P<0.05）。 Furthermore, the predictive value of SF, BIS and Hb on thyroid function indexes was analyzed by multiple linear regression. The results showed that SF and BIS were important predictors of fT4 and T4 levels in the first trimester, while Hb was a predictor of fT4 levels in the first and third trimester and T4 levels in the third trimester.

Over the past 40 years, the rate of childhood obesity has increased more than 3-fold and persists at a high rate into adulthood, significantly increasing the risk of metabolic-related diseases. Previous studies have suggested that children with intrauterine exposure to gestational diabetes mellitus (GDM) or obese mothers have a higher predisposition to obesity, but little is known about the mechanisms underlying this phenomenon. Therefore, the researchers designed this study to investigate the relationship between daily energy intake (EI), brain reward area response to food cues, and obesity in children who had been exposed to GDM or obese mothers. A total of 159 children aged 7 to 11 years were enrolled, and daily EI was calculated for two visits within 24 h. Among them, 102 patients underwent MRI scans to explore responses to food cues in the reward areas of the brain, including the anterior orbit, frontal cortex (OFC), insula, amygdala, ventral striatum, and dorsal striatum. BMI Z-score, body fat percentage, waist-to-height ratio (WtHR), and waist-to-hip ratio (WHR) were used to assess the degree of obesity. The results of this study found that exposure to GDM significantly increased daily EI and WHR, and an increase of 1,000 calories in daily EI was associated with an increase of 0.028 in WHR; Children exposed to GDM before 26 weeks had higher responsiveness to OFC food cues (OFC had a strong motivating effect on food rewards). Differences remained significant after adjusting for children's age/sex, mother's education and race/ethnicity, mother's pre-pregnancy BMI, and children's physical activity levels. It was ultimately suggested that children exposed to GDM ate 165 more calories per day than unexposed individuals, while early exposed individuals ate the most calories per day and also had a higher WHR, with daily EI explaining a 36% association between children's GDM exposure and WHR. Maternal obesity was not significantly associated with daily EI or brain reward area responsiveness to food cues. However, maternal pre-pregnancy BMI was significantly associated with all obesity indicators, and the results of BMI Z-score, WtHR and WHR remained significant after adjusting for the above important factors.