[Impact of lipopolysaccharide-induced inflammation on sperm quality in male rats and its possible mechanisms].

OBJECTIVE: To investigate the influence of lipopolysaccharide (LPS)-induced inflammation on sperm quality in male rats and its possible mechanisms. METHODS: Thirty-six male SD rats were randomly divided into groups A (control), B (12 h LPS), C (24 h LPS) and D (72 h LPS), the former group injected intraperitoneally with sterile saline, and the latter three with LPS at 5 mg/kg and sacrificed at 12, 24 and 72 hours respectively after treatment. Then the left epididymides of the rats were harvested for detection of the sperm count and motility in the cauda epididymis, measurement of the relative sperm count value, examined the content of malondialdehyde (MDA) and activity of superoxide dismutase (SOD) in the epididymal plasma, and determined the apoptosis rate of spermatogenic cells by flow cytometry (FCM). RESULTS: Compared with the parameters in group A, sperm motility in the cauda epididymis was decreased in groups B (ï¼»68.01 ± 1.80ï¼½% vs ï¼»62.28 ± 4.06ï¼½%, P < 0.05), C (ï¼»68.01 ± 1.80ï¼½% vs ï¼»45.35 ± 3.39ï¼½%, P < 0.05) and D (ï¼»68.01 ± 1.80ï¼½% vs ï¼»34.85 ± 4.42ï¼½%, P < 0.01), and so was the sperm count in the cauda epididymis (ï¼»38.94 ± 4.08ï¼½ vs ï¼»37.15 ± 2.54ï¼½ ×106/ 100 mg, P > 0.05; ï¼»38.94 ± 4.08ï¼½ vs ï¼»31.97 ± 2.81ï¼½ ×106/ 100 mg, P < 0.05; ï¼»38.94 ± 4.08ï¼½ vs ï¼»28.60 ± 4.03ï¼½ ×106/ 100 mg, P < 0.01), while the content of MDA in the epididymal plasma significantly increased (ï¼»4.66 ± 1.49ï¼½ vs ï¼»15.95 ± 3.26ï¼½ nmol/mg prot, P < 0.01; ï¼»4.66 ± 1.49ï¼½ vs ï¼»12.93 ± 2.54ï¼½ nmol/mg prot, P < 0.01; ï¼»4.66 ± 1.49ï¼½ vs ï¼»9.67 ± 1.68ï¼½ nmol/mg prot, P < 0.05), the activity of SOD reduced (ï¼»879.335 ± 105.089ï¼½ vs ï¼»729.265 ± 93.783ï¼½ U/mg prot, P > 0.05; ï¼»879.335 ± 105.089ï¼½ vs ï¼»694.126 ± 58.530ï¼½ U/mg prot, P < 0.05; ï¼»879.335 ± 105.089ï¼½ vs ï¼»655.352 ± 115.215ï¼½ U/mg prot, P < 0.05), and the apoptosis rate of spermatogenic cells dramatically elevated (ï¼»4.21 ± 1.67ï¼½% vs ï¼»11.01 ± 3.30ï¼½%, P < 0.05; ï¼»4.21 ± 1.67ï¼½% vs ï¼»23.88 ± 4.58ï¼½%, P < 0.01; ï¼»4.21 ± 1.67ï¼½% vs ï¼»41.28 ± 2.28ï¼½%, P < 0.01). CONCLUSION: LPS-induced inflammation damages spermatogenic cells and the quality of epididymal sperm in male rats in a time-dependent manner, which is associated with oxidative stress injury and cell apoptosis in the reproductive system.

[Transcutaneous electrical acupoint stimulation improves pregnancy outcomes of in vitro fertilization- embryo transfer : A meta-analysis of randomized controlled trials].

OBJECTIVE: To evaluate the effect of transcutaneous electrical acupoint stimulation (TEAS) on the pregnancy outcomes of in vitro fertilization-embryo transfer (IVF-ET) based on the available clinical evidence. METHODS: We searched PubMed, MEDLINE, EMBASE, Cochrane Library, CNKI, VIP, CBM and Wanfang Database up to February 2021 for published randomized controlled trials (RCT) relevant to TEAS for the improvement of the pregnancy outcomes of IVF-ET. We performed literature screening, data extraction and quality evaluation according to the inclusion and exclusion criteria, followed by a meta-analysis with the RevMan 5.3 software. RESULTS: A total of 2 206 cases of IVF-ET from 9 RCTs were included, 1 018 in the TEAS group and 1 188 in the control. The clinical pregnancy rate was significantly higher in the TEAS than in the mock TEAS and non-TEAS control groups (RR = 1.85, 95% CI: 1.42－2.42, P < 0.001; RR = 1.23, 95% CI: 1.10－1.39, P = 0.0004), and so was it before and after oocyte retrieval (RR = 1.50, 95% CI: 1.03－2.17, P = 0.03; RR = 1.47, 95% CI: 1.12－1.92, P = 0.005). The TEAS group also showed dramatically improved embryo implantation rate (RR = 1.49, 95% CI: 1.24－1.79, P < 0.0001) and live birth rate (RR = 1.44, 95% CI: 1.04－1.98, P = 0.03) compared with the control. CONCLUSIONS: As a safe and non-invasive treatment, TEAS can significantly improve the pregnancy outcomes of IVF-ET, with definite effectiveness. /.

[Effect of saw palmetto extract on the reproductive function of male rats with chronic prostatitis].

OBJECTIVE: To investigate the effect of saw palmetto extract (SPE) on the reproductive function of rats with chronic prostatitis (CP). METHODS: Forty male SD rats were equally randomized into groups A (blank control), B (blank control + SPE, C (CP model control) and D (CP model + SPE), and the CP model was made by injection of 1% λ-carrageenan solution into the prostate. The animals in groups A and C were gavaged with normal saline while those in groups B and D with SPE at 0.10 g/kg/d, all for 30 successive days. After drug withdrawal, the rats were mated with female ones in the ratio of 1∶1) and sacrificed 7 days later, their bilateral epididymides collected for detection of sperm count and motility. The numbers of pregnancies and fetuses were recorded and compared among different groups. RESULTS: Compared with the rats in group A, those in group C showed a marked decrease in epididymal sperm motility (ï¼»68.01 ± 1.80ï¼½% vs ï¼»62.59 ± 4.82ï¼½%, P < 0.05), but those in groups B and D exhibited no statistically significant difference (ï¼»67.69 ± 4.06ï¼½% and ï¼»67.93 ± 3.39ï¼½%, P > 0.05). There were no statistically significant differences in the count of epididymal sperm, rate of pregnancy and number of fetuses between group A and the other groups (P > 0.05). CONCLUSIONS: SPE can improve the semen parameters of CP rats, and has no adverse effect on the rate of pregnancy and number of fetuses.

[Efficacy and safety of low-intensity extracorporeal shock wave therapy in the treatment of ED: A meta-analysis of randomized controlled trials].

OBJECTIVE: To evaluate the clinical efficacy and safety of low-intensity extracorporeal shock wave therapy (LI-ESWT) in the treatment of ED based on the available clinical evidence. METHODS: We searched PubMed, MEDLINE, EMBASE, Cochrane Library, CNKI, VIP, CBM and Wanfang Database up to June 2018 for published randomized controlled trials on the treatment of ED by LI-ESWT. We performed literature screening, data extraction and quality evaluation according to inclusion and exclusion criteria, and conducted a meta-analysis of the data obtained using the RevMan 5.3 software. RESULTS: A total of 595 ED cases in 8 double-blind randomized controlled trials (RCT) were included in this study, 362 in the LI-ESWT and 233 in the control group. Compared with the controls, the patients treated by LI-ESWT showed significantly improved IIEF (WMD = 1.70, 95% CI: 0.44－2.96, P = 0.008) and erection hardness score (EHS) (RR = 11.72, 95% CI: 5.13－26.80, P < 0.01). The IIEF scores of the patients were markedly increased at 4 and 24 weeks after LI-ESWT (WMD = 1.43, 95% CI: 0.10－2.75, P = 0.03; WMD = 3.09, 95% CI: 1.49－4.68, P = 0.0002), as well as after the 10th to 12th treatment (WMD = 1.81, 95% CI: 0.31－3.31, P = 0.02) though not after the 5th to 6th (WMD = 1.88, 95% CI: －2.10 to 5.86, P = 0.35). LI-ESWT also significantly increased the IIEF scores in the patients with the baseline IIEF ≥12 (WMD = 2.13, 95% CI: 0.51－3.75, P = 0.01) but not in those with the baseline IIEF ≤11 (WMD = 1.04, 95% CI: －0.96 to 3.03, P = 0.31). No significant adverse events were reported in the 8 RCTs. CONCLUSIONS: As a non-invasive treatment, LI-ESWT is safe and effective and can significantly improve IIEF and EHS in ED patients.

[Fosfomycin tromethamine inhibits the expressions of TNF-α, IL-8 and IL-6 in the prostate tissue of rats with chronic bacterial prostatitis].

OBJECTIVE: To investigate the effects of fosfomycin tromethamine (FT) on the expressions of tumor necrosis factor-α (TNF-α), interleukin-8 (IL-8), and interleukin-6 (IL-6) in the prostate tissue of the rats with chronic bacterial prostatitis (CBP). METHODS: We randomly divided 70 male SD rats into 7 groups of equal number: blank control, CBP model control, positive control, 14 d low-dose FT, 7 d low-dose FT, 14 d high-dose FT, and 7 d high-dose FT. The CBP model rats in the latter five groups were treated intragastrically with levofloxacin at 100 mg/kg/d for 30 days and FT at 200 mg/kg/d for 14 and 7 days and at 300 mg/kg/d for 14 and 7 days, respectively. Then we collected the prostate tissue from the animals for determination of the levels of TNF-α, IL-8 and IL-6 by ELISA. RESULTS: Compared with the blank controls, the CBP model rats showed significantly increased levels of TNF-α (ï¼»19.83 ± 6.1ï¼½ vs ï¼»32.93 ± 6.21ï¼½ ng/g prot, P <0.01), IL-8 (ï¼»8.26 ± 0.52ï¼½ vs ï¼»16.2 ± 2.84ï¼½ ng/g prot, P <0.01) and IL-6 (ï¼»1.55 ± 0.11ï¼½ vs ï¼»2.51 ± 1.06ï¼½ ng/g prot, P <0.05) in the prostate tissue. In comparison with the CBP model controls, the levels of TNF-α and IL-8 were remarkably decreased in the groups of positive control (ï¼»20.54 ± 5.78ï¼½ ng/g prot, P <0.01; ï¼»12.43 ± 4.02ï¼½ ng/g prot, P <0.05), 14 d low-dose FT (ï¼»21.95 ± 6.48ï¼½ ng/g prot, P <0.01; ï¼»11.11 ± 2.86ï¼½ ng/g prot, P <0.01), 7 d low-dose FT (ï¼»23.8 ± 6.93ï¼½ ng/g prot, P <0.05; ï¼»12.43 ± 4.02ï¼½ ng/g prot, P <0.05), 14 d high-dose FT (ï¼»19.97 ± 2.58ï¼½ ng/g prot, P <0.01; ï¼»8.83 ± 1.32ï¼½ ng/g prot, P <0.01), and 7 d high-dose FT (ï¼»21.97 ± 3.38ï¼½ ng/g prot, P <0.01; ï¼»12.68±1.97ï¼½ ng/g prot, P <0.05). No statistically significant differences were observed between the positive control and FT groups in the contents of TNF-α, IL-8 or IL-6 (P >0.05). The expression of IL-6 was markedly reduced in the 14 d high-dose FT group as compared with the model controls (ï¼»1.76 ± 0.46ï¼½ vs ï¼»2.51 ± 1.06ï¼½ ng/g prot, P<0.05) but exhibited no significant difference between the CBP model control and the other groups (P >0.05). CONCLUSIONS: Fosfomycin tromethamine inhibits the expressions of TNF-α, IL-8 and IL-6 in the prostate tissue, suppresses its inflammatory reaction, promotes the repair of damaged prostatic structure, and thus contributes to the treatment of chronic bacterial prostatitis in rats.

[Effects of Xialiqi Capsules on the expressions of PCNA and caspase-3 in rats withbenign prostatic hyperplasia].

OBJECTIVE: To explore the effects of Xialiqi Capsules(XLQ) on the expressions of the proliferating cell nuclear antigen (PCNA) and caspase-3 in the prostate tissue of the BPH rat model. METHODS: Fifty male SD ratswereequally randomized into groups A (sham operation control), B (BPH model control), C (high-dose XLQ), D (low-dose XLQ), and E (finasteridecontrol) andthe BPH modelswere established by subcutaneous injection of testosterone propionate at 0.5 mg per kilogram of the body weight per day for 30 days after castration. After modeling, the animals in groups A and B were treated intragastricallywith normal saline, while those in C, D, and E with XLQ at 1.20 and 0.61 g per kilogram of the body weight per day or finasterideat 0.8 mg per kilogram of the body weight per day, respectively, all for 30 days. Then,the bilateral prostates were harvestedfrom the rats for calculation of the prostatic index (prostate wet weight/ body weight) and determination of the expressions of PCNA and caspase-3 in the prostate tissue by immunohistochemistry and immunofluorescence staining, respectively. RESULTS: The prostate wet weight and prostate index were significantly increased in group B as compared with group A, (ï¼»1326±60ï¼½ vsï¼»471±17ï¼½ g, P<0.01; ï¼»2.89±0.18ï¼½ vs ï¼»1.06±0.06ï¼½ mg/g, P<0.01), but decreased in groups C (ï¼»914±36ï¼½ g;ï¼»2.02±0.08ï¼½ mg/g), D (ï¼»1 099±46ï¼½g;ï¼»2.39±0.11ï¼½ mg/g), and E (ï¼»817±53ï¼½ g;ï¼»1.83±0.10ï¼½ mg/g)in comparison with B (P<0.01), with statistically significant differences among groups C, D, and E(P<0.01) and most significantly in E.The PCNA level in the prostate tissue wasremarkably higher in group B than in A, but lower in groups C, D and E than in B. The expression of caspase-3 was down-regulatedin group B as compared with A, but up-regulated in groups C, D and E in comparison with B, most significantly in E. CONCLUSIONS: Xialiqi Capsules can effectively reduce the prostate wet weight and prostatic index of in rats with BPH by inhibiting the level of PCNA and promoting the expression of caspase-3.

[Association of sperm DNA integrity with seminal plasma oxidative stress and its influence on in vitro fertilization in infertile males].

OBJECTIVE: To investigate the association of sperm DNA integrity with semen routine parameters and seminal plasma oxidative stress and its influence on in vitro fertilization (IVF) in males with infertility. METHODS: Using sperm chromatin dispersion (SCD), we detected sperm DNA damage in 433 infertile men undergoing IVF. Based on the sperm DNA fragmentation index (DFI), we divided the patients into a low DFI (lt;30%) and a high DFI ( ≥30%) group and then compared sperm concentration, the percentage of progressively motile sperm (PMS), the contents of malondialdehyde (MDA) and total antioxidant capacity (TAC) in the seminal plasma, and the rates of fertilization, cleavage and high-quality embryos between the two groups of patients. RESULTS: Compared with the low DFI group, the high DFI group showed significantly decreased rates of PMS (ï¼»48.6±16.7ï¼½ vs ï¼»29.2±16.8ï¼½%, P<0.01) and fast PMS ï¼»19.0±9.1ï¼½ vs ï¼»9.4±6.6ï¼½%, P<0.01), but no statistically significant difference in sperm concentration (ï¼»51.4±30.9ï¼½ vs ï¼»52.3±32.4ï¼½ ×106/ml, P>0.05). The content of MDA in the seminal plasma was markedly higher in the high DFI than in the low DFI group (ï¼»2.28±0.26ï¼½ vs ï¼»0.95±0.18ï¼½ nmol/L, P<0.01) but that of TAC remarkably lower in the former than in the latter (ï¼»10.2±3.5ï¼½ vs ï¼»33.2±7.9ï¼½ U/L, P<0.01). The rate of fertilization was significantly lower in the high DFI than in the low DFI group (ï¼»58.9±30.0ï¼½ vs ï¼»77.2±25.0ï¼½%, P<0.01), but there were no significant differences between the two groups in the rates of cleavage (ï¼»70.7±35.6ï¼½ vs ï¼»80.4±15.6ï¼½%P>0.05) and high-quality embryos (ï¼»40.4±31.3ï¼½ vs ï¼»41.7±29.4ï¼½%,P>0.05). CONCLUSIONS: Sperm DNA damage is associated with seminal oxidative stress and may affect the outcomes of IVF by reducing the rate of fertilization.

[Phosphodiesterase type 5 inhibitors for premature ejaculation: advances in studies].

Premature ejaculation (PE) is a common male sexual disorder with an incidence rate of 20-30%. Recent clinical trials have demonstrated that phosphodiesterase type 5 inhibitors (PDE5i), as the first-line drug for erectile dysfunction (ED), can improve ejaculatory function probably by acting on the peripheral and central adrenergic nerves. The possible action mechanisms of PDE5i may involve lessening of the central sympathetic output, modulation of the contractile responses from the vas deferens, seminal vesicles, prostate and urethra, induction of peripheral analgesia, and prolonging of the total erectile duration, increasing the confidence of ejaculation control, and reducing the post-ejaculation refractory time. This review discusses the possible mechanisms and clinical application of PDE5i in the treatment of PE.

[Fosfomycin for urogenital tract infections: Advances in studies].

Fosfomycin (FOM) is an antibiotic with a small relative molecular weight (138.1) and a long half-life, and has a unique chemical structure and antibacterial mechanisms. It exerts a bactericidal activity by inhibiting the early synthesis of bacterial cell walls. It is also a broad-spectrum antibiotic with a good drug tolerance and compliance and a low pressure to bacterial resistance, but no cross-resistance with other antibiotics. Recent studies show the effectiveness of FOM in the treatment of acute uncomplicated urinary tract infections and urogenital tract infections as well, such as prostatitis and epididymitis. This review focuses on the clinical application of FOM in the treatment of infectious diseases of the urogenital tract.

[Effect and safety of L-carnitine in the treatment of idiopathic oligoasthenozoospermia: a systemic review].

OBJECTIVE: To evaluate the effect and safety of L-carnitine in the treatment of idiopathic oligoasthenozoospermia based on current clinical evidence. METHODS: We searched the Cochrane Library, PubMed, MEDLINE, EMBASE, CNKI, VIP, CBM and Wanfang Database from the establishment to April 2014 for the published literature on the treatment of idiopathic oligoasthenozoospermia with L-carnitine. We conducted literature screening, data extraction, and assessment of the methodological quality of the included trials according to the inclusion and exclusion criteria, followed by statistical analysis with the RevMan 5. 2 software. RESULTS: Seven randomized controlled trials involving 751 patients with idiopathic oligoasthenozoospermia met the inclusion criteria, and 678 of them were included in the meta-analysis. L-carnitine treatment achieved a significantly increased rate of spontaneous pregnancy as compared with the control group (RR = 3.2, 95% CI 1.74 to 5.87, P = 0.0002). After 12-16 and 24-26 weeks of medication, total sperm motility (WMD = 5.21, 95% CI 2.78 to 7.64, P < 0.0001 and WMD = 9.29, 95% CI 1.28 to 17.29, P = 0.02) and the percentage of progressively motile sperm (WMD = 12.44, 95% CI 4.58 to 20.31, P = 0.002 and WMD = 9.76, 95% CI 3.56 to 15.97, P = 0.002) were remarkably higher than those in the control group, but no statistically significant differences were observed in sperm concentration between the two groups (WMD = 4.91, 95% CI -2.63 to 12.45, P = 0.2 and WMD = 0.93, 95% CI -3.48 to 5.34, P = 0.68). After 12-16 weeks of treatment, the percentage of morphologically abnormal sperm was markedly decreased in the L-carnitine group as compared with the control (WMD = -2.48, 95% CI -4.35 to -0.61, P = 0.009), but showed no significant difference from the latter group after 24-26 weeks (WMD = -4.38, 95% CI -9.66 to 0.89, P = 0.1). No statistically significant difference was found in the semen volume between the two groups after 12-16 or 24-26 weeks of medication (WMD = -0.13, 95% CI -0.43 to 0.18, P = 0.42 and WMD = 0.28, 95% CI -0.02 to 0.58, P = 0.07). No serious L-carnitine-related adverse events were reported in 4 of the randomniized controlled trials. CONCLUSION: The current evidence indicates that L-carnitine can improve spontaneous pregnancy and semen parameters in the treatment of idiopathic oligoasthenozoospermia, with no serious adverse reactions.

[Lipopolysaccharide affects testicular histology and reproductive endocrine function in male rats].

OBJECTIVE: To study the influence of lipopolysaccharide (LPS)-induced inflammation on the testicular histology and reproductive endocrine function in male rats and investigate the possible mechanism of inflammation affecting male fertility. METHODS: Thirty-six male SD rats were randomly divided into a control group (A) and three LPS intervention groups (B, C, and D) to receive saline and LPS (5 mg/kg i. p, once), respectively. The animals in groups B, C, and D were killed by anesthesia at 12, 24, and 72 hours after treatment. Histopathological changes in the left testis of the rats were observed by HE staining and the levels of the reproductive hormones T, FSH, and LH in the serum were determined by ELISA. RESULTS: Compared with group B, group A showed clear structure of seminiferous tubules, orderly arrangement of spermatogenic cells, a slightly decreased number of sperm in some seminiferous tubular lumens, and shed spermatogenic cells in the rat testis tissue; group C exhibited thinner seminiferous epithelia, disordered structure of seminiferous tubules, irregular arrangement of spermatogenic cells, decreased number of mature sperm and obvious shedding of spermatogenic cells in seminiferous tubular lumens; group D manifested similar findings to those of group C, with even more shed spermatogenic cells that blocked the tubular lumens. The levels of serum T, LH, and FSH were (0.490 +/- 0.028) ng/ml, (6.290 +/- 0.515) ng/L, and (1.837 +/- 0.127) IU/L in group A, (0.460 +/- 0.024) ng/ml, (5.881 +/- 0.124) ng/L, and (1.707 +/- 0.098) IU/L in group B, (0.417 +/- 0.021) ng/ml, (5.123 +/- 0.271) ng/L, and (1.620 +/- 0.115) IU/L in group C, and (0.378 +/- 0.021) ng/ml, (4.504 +/- 0.279) ng/L and (1.562 +/- 0.216) IU/L in group D, all decreased in group B as compared with A (P > 0.05). The decreases of T and LH were extremely significant (P < 0.01) and that of FSH was significant in groups C and D (P < 0.05) in comparison with A. CONCLUSION: LPS-induced inflammation affects the testicular tissue and reproductive endocrine function of male rats, resulting in decreased levels of serum T, LH, and FSH.

[Reproductive hormone levels and relevant parameters in middle-aged and older men in the urban area of Nanjing].

OBJECTIVE: To investigate the status of male reproductive health among middle-aged and older men in the urban area of Nanjing. METHODS: We collected the laboratory results of 884 middle-aged and older men aged 55 - 89 years from the Xuanwu District of Nanjing present for routine physical examinations, including those of blood routine tests, liver and kidney function, blood glucose, blood lipid, and total prostate specific antigen (TPSA), as well as such reproductive hormone indexes as total serum testosterone (TT), free serum testosterone (fT), and sex hormone binding globulin (SHBG). We also obtained the above reproductive hormone indexes from 119 young and middle-aged men aged 20 - 39 years as controls. RESULTS: Aging-related changes were found in the 50 percentiles of all the reproductive hormones and relevant parameters but those of TT and E2, with gradual increases in LH, FSH and SHBG and decreases in fT, TSI and fTI. Comparison of reproductive hormones and relevant parameters by Mann-Whitney U test did not show any statistically significant differences in the TT level between any two of the five age groups (20 - 39, 55 - 59, 60 - 69, 70 - 79, and > or = 80 yr) (P > 0.05) except between the control and > or = 80 yr groups and the 60 - 69 and > or = 80 yr groups (P < 0.05), nor in the E2 level between any two groups, nor in the levels of LH and FSH except between the 55 - 59 and 60 - 69 yr groups and the 70 - 79 and > or = 80 yr groups, and nor in the levels of fT and TSI except between the 55 - 59 and 60 - 69 yr groups. However, there were significant differences in the levels of SHBG and fTI between any two age groups. Spearman correlation analysis revealed that fT, TSI, and fTI were correlated negatively with aging and LH (P < 0.05, I r I > 0.5) but weakly positively with cholesterol, blood glucose and hemoglobin (P < 0.05, /r/ < 0.5), SHBG and LH positively with aging, SHBG weakly negatively with blood glucose and hemoglobin, LH weakly negatively with hemoglobin, and TT weakly negatively with aging but positively with hemoglobin. CONCLUSION: The levels of serum testosterone, particularly that of fT, declined with aging in middle-aged and older men in the urban area of Nanjing, which may contribute to abnormal lipid metabolism, low hemoglobin and high blood glucose.