Objective:To analyze the key point of client's change in counseling,and found the cognitive,emotional and other characteristics in the key point of change.Methods:Totally 14 foreign cases and 5 domestic cases with good outcome that came from the published literature in the area of assimilation model were analyzed.The secondary data analysis was used to analyze the cases'data.Results:Analysis revealed that 9 categories were generated from the data,which were understanding the causes of the problems,the accompanying feelings,the emergence of a new awareness,removing the problematic voice's threat,discovering behavior pattern,allowing the coexistence of both original conflicts,directly expressing the problematic voice desired to be expressed,viewing things with different perspectives,finding out the direction of future action.Conclusions:Behind the key point of client's change,changes in cognition could lead to changes in emotion,so that the problematic voice's threat could be removed and the coexistence of original conflict could be allowed,and then bring about the relief of the client's inner conflict.

Objective To study the drug resistance of multiple‐drug‐resistant Acinetobacter baumannii(MDR‐Ab) and its rela‐tive carbapenemases genes ,in order to provide references for rational use of antibacterial agents .Methods A total of 98 strains of Acinetobacter baumannii(Ab) were identified by using the MicroScan WalkAway96 automated microbial identification susceptibility testing system ,and the resistance genes ,including OXA‐23 ,OXA‐24 ,IMP ,VIM ,TEM and SHV ,were detected by using the poly‐merase chain reaction .DNA sequences of positive amplification products of the resistance gene were analysed .Results The drug re‐sistance rates of 98 strains of MDR‐Ab to penicillin class and cephalosporin class both were 100 .0% ,to imipenem and meropenem were 55 .1% and 54 .1% respectively ,to gentamicin ,amikacin and tobramycin were 100 .0% ,100 .0% and 87 .8% respectively ,to ciprofloxacin ,levofloxacin and gatifloxacin were 89 .8% ,91 .8% and 77 .6% respectively ,to sulfamethoxazole and rifampicin were 91 .8% and 100 .0% respectively ,to polymyxin B and polymyxin were 14 .3% and 11 .2% respectively ,to tetracycline ,minocycline and tigecycline were 100 .0% ,6 .1% and 4 .1% respectively .The results of resistance genes detection in 98 strains of MDR‐Ab showed that 70 strains carried TEM and OXA‐23 gene ,53 strains carried VIM gene ,41 strains carried IMP gene ,while OXA‐24 and SHV genes were not detected .DNA sequence analysis showed that the homology of OXA‐23 ,TEM ,IMP and VIM genes were 98% ,98% ,99% and 99% .Conclusion The condition of antibacterial resistance of MDR‐Ab in this area is very serious ,and TEM and OXA‐23 are the main drug resistance genes .Carrying multiple resistance genes is an important cause of MDR‐Ab resistance . The treatment of patients with Ab infection should be based on the results of drug sensitivity test for rational use of antibacterial a‐gents .

Background:Endoscopic ultrasonography( EUS)is the first choice for examining submucosal protuberant lesions in the gastrointestinal tract,however,it is very difficult to differentiate gastric stromal tumor from gastric leiomyoma. Photoshop software now is tried to differentiate some easily misdiagnosed diseases. Aims:To investigate the value of Photoshop software in differentiating EUS image of gastric stromal tumor from gastric leiomyoma. Methods:EUS image of 118 cases of gastric stromal tumor and 42 cases of gastric leiomyoma confirmed by pathological and immunohistochemical examination were collected,mean gray value( intensity of echo)and gray value standard deviation( uniformity of echo)of EUS image of lesion were determined by Photoshop software,and the differentiation value was analyzed. Results:The mean gray value of EUS image of gastric stromal tumor was significantly higher than that of gastric leiomyoma(71. 94 vs. 48. 99,P<0. 01). The gray value standard deviation of EUS image of gastric stromal tumor was significantly higher than that of gastric leiomyoma(16. 63 vs. 9. 80,P<0. 01). Conclusions:Under EUS,gastric stromal tumor exhibits higher intensity of echo and less uniformity of echo than gastric leiomyoma. EUS combined with Photoshop software is helpful for differentiating gastric stromal tumor from gastric leiomyoma by analyzing mean gray value and gray value standard deviation of the lesion.

Objective To improve detectable rate of gastric schwannoma by endoscopic ultrasonography (EUS). Method Clinical data and endoscopic ultrasonography (EUS) imaging features of 4 cases were retrospectively ana-lyzed which diagnosed as gastric schwannoma pathologically and immunohistochemically while diagnosed as gastric stromal tumor by EUS from May 2008 to June 2015 and reviewed the literature. Results 4 cases of gastric schwan-nomas are female and benign, all 4 lesions are solitary, 3 in gastric body, and 1 in fundus by endoscopic. By EUS, all lesions are originated from muscularis propria, hypoechoic change, even echoes and clear board without calcifica-tion or cystic changes. 2 cases have halo artifacts around the lesion. Literature review found that gastric schwannoma tended to occur in female, halo artifacts could be the feature of gastric schwannoma, calcification or cystic changes were rare in gastric schwannoma which were common in gastric stromal tumors. Conclusion It was difficult to distin-guish gastric schwannoma and gastric stromal tumors that originated from muscularis propria by EUS. For female patients with lesions originated from muscularis propria, originated from muscularis propria and occurred in gastric body, it was necessary to observe lesions whether there was being calcification or cystic and halo artifacts. Integrated all these performance, we should be in consideration of gastric stromal tumors, meanwhile, excluding the possibility of gastric schwannoma.

Objective To investigate the application value of Photoshop in grading invasive risk of gastric stromal tumors (GSTs). Methods EUS image of 97 cases of GSTs confirmed by pathological and immunohistochemical examination were collected. GSTs were divided into four groups (very low risk, low risk, intermediate risk, high risk) by tumor size, mitotic count and rupture of tumor. Mean gray value (intensity of echo) and gray value standard deviation (uniformity of echo) of EUS images of the lesions were determined by Photoshop and then the differences of each group were found by statistical analysis. Results It is difficult to differentiate EUS images of GSTs from each group by visual observation. The mean gray value of EUS image of very low risk group,low risk group, intermediate risk group and high risk group of GSTs respectively were (56.54 ± 6.10), (59.20 ± 7.51), (77.77 ± 10.90) and (83.43 ± 12.47). There was no significant difference between very low risk group and low risk group (P > 0.05). There was no significant difference between intermediate risk group and high risk group (P > 0.05). In addition, the others all had significantly different from that of each group (P < 0.05). The mean gray value standard deviation of EUS image of very low risk group, low risk group, intermediate risk group and high risk group of GSTs respectively were (8.46 ± 2.59), (12.57 ± 5.89), (12.84 ± 4.15) and (16.69 ± 4.69). There was no significant difference between low risk group and intermediate risk group (P > 0.05). In addition, the others all had significantly different from that of each group (P < 0.05). Conclusions The higher risk of GSTs, the higher of echo intensity and the worse of echo uniformity under EUS. Photoshop combined with EUS is helpful for differentiating different risk of GSTs by analyzing mean gray value and gray value standard deviation of the lesions.

Objective:To develop the Suicide Outcomes Scale for Undergraduates with Suicidal Ideation(SO-SUSI)and test its validity and reliability.Methods:Based on semi-structured interview,literature review and expert discussion,main aspects and indicator system were defined.The initial version of SOSUSI was formed,and items were either modified from existing scales targeting the relevant constructs,or compiled according to previous inter-view results.A total of 607 undergraduates with suicidal ideation were enrolled.The sample was randomly divided in half,one half(n=317)was used for item analysis and exploratory factor analysis,and another half(n=290)for confirmatory factor analysis.All data were used for reliability analysis.The Self-rating Depression Scale(SDS)and Suicidal Intent(SI)were used for criterion validity.Results:The SOSUSI included 39 items in 4 dimensions(nega-tive reinforcement of suicide,negative consequences of suicide,loss of suicide,and positive reinforcement of sui-cide)which explained 50.10％of the total variance.Confirmatory factor analysis showed that the four-factor struc-ture model fitted well(x2/df=3.27,CFI=0.92,TLI=0.91,IFI=0.92,SRMR=0.09).The scores of negative re-inforcement and positive reinforcement of suicide were positively correlated with the SDS and SI scores(ICC=0.15-0.33,Ps＜0.05),while the scores of negative consequences and loss of suicide were negatively correlated with the SI scores(ICC=-0.42--0.56,Ps＜0.05).The Cronbach's α coefficients of each dimension ranged from 0.79 to 0.91.Conclusion:The Suicide Outcomes Scale for Undergraduates with Suicidal Ideation(SOSUSI)has good validity and internal consistency reliability.

Objective ToinvestigatethevalueofpreoperativeMRIforplacentapreviainpredictionofmassivepostpartumhemorrhage. Methods AretrospectiveanalysisoftheclinicalhistoryandprenatalMRIfeaturesof362patientswithplacentapreviawereperformed. Ofthese,54casesexperiencedseverepostpartum hemorrhage.Results Univariateanalysisshowedthattheageofpregnantwomen (χ2＝3.951,P＝0.047),gestationalage(χ2＝6.257,P＝0.012),numberofcesareansections(χ2＝36.372,P＝0.001)andgemellary pregnancy(χ2＝7.933,P＝0.005)wereassociated with massivepostpartum hemorrhage.Amongthe MRIsigns,Uterinebulging (OR,46.712;95%CI,13.067－166.987),placentalprotrusionsign (OR,22.787;95% CI,4.595－113),andintroplacentalT2dark band(OR,14.757;95%CI,7.149－30.461)indicatedhighriskwithmassivepostpartumhemorrhage.Myometrialthinningorlocalized interruption,unevenplacentalsignal,abnormalbloodvesselsbelowtheplacenta,abundantbloodvesselsinloweruterusandcervix, cervicalshorteningandothersignsfortheevaluationofseverepostpartumhemorrhagewerealsostatisticallysignificant.Conclusion MRIcanpredictmostoftheseverepostpartumhemorrhagebeforesurgeryandisveryhelpfultoimprovethepatientprognosis.

Objective To explore the relation between genetic polymorphisms and the expression in colonic tissues of solute-linked carrier family 26 member A3 (SLC26A3) and susceptibility of Crohn's disease (CD) in Han population of Zhejiang Province.Methods A total of 265 CD patients and 566 gender-and age-matched healthy individuals were enrolled.Alleles and genotypes of SLC26A3 (rs17154444,rs7810937,rs7785539,rs2108225,rs6951457) were examined by SNaPshot.The linkage disequilibrium (LD) and haplotype were also analyzed.Eight patients with colonic CD and eight genderand age-matched patients with benign colonic polyps (control group) were selected.The expression level of SLC26A3 protein in the colonic tissue was detected by immunohistochemistry.T test and rank-sum test were performed for statistical analysis.Unconditional Logistic regression analysis was used to analyze the distributions of SLC26A3 polymorphisms and their effects on the clinicopathological features of CD patients.Results The frequencies of mutant allele of rs2108225,rs7785539 and rs6951457 of the CD group were 53.77％ (285/530),4.72％ (25/530) and 2.83％ (15/530),and the frequencies of mutant genotype were 76.23 ％ (202/265),9.43 ％ (25/265) and 5.66 ％ (15/265),which were lower than those of the control group (60.95％,690/1 132;8.13％,92/1 132;6.10％,69/1 132;83.92％,475/566;15.37％,87/566 and 11.84％,67/566),and the differences were statistically significant (all P＜0.05).The frequencies of mutant allele of rs17154444 and rs7810937 of the CD group were 10.19％ (54/530) and 34.91 ％ (185/530),and the frequencies of mutant genotype were 18.49 ％ (49/265) and 56.23 ％ (149/ 265),compared with those of the control group (8.30％,94/1 132;30.92％,350/1 132;15.55％,88/566 and 51.77％,293/566),the differences were not statistically significant (all P＞0.05).The frequency of mutant allele G of rs2108225 in patients with ileal CD was 47.89 ％ (91/190),and the frequency of mutant genotypeAG+GG was 65.26％(62/95),which were both lower than those of colonic CD (61.62％,122/198 and 85.86％,85/99),and the differences were statistically significant (both P＜0.012 5).rs7810937,rs7785539 and rs2108225 were in a strong linkage disequilibrium.The frequencies of haplotypes AGG and ACA of the CD group were 53.96％ (286/530) and 4.34％ (23/530),which were lower than those of the control group (60.07％,680/1 132 and 7.51％,85/1 132),and the differences were statistically significant (52 =5.534,P=0.019;x2 =5.967,P=0.015).And the frequency of haplotype AGA of the CD group was 8.30％ (44/530),which was higher than that of the control group (1.15％,13/1 132),and the difference was statistically significant (x2 =7.793,P＜0.01).Furthermore,the expression level of SLC26A3 protein in colonic tissues of eight colonic CD patients was 0.19±0.07,which was lower than that of patients with benign colonic polyps (0.26 ±-0.03),and the difference was statistically significant (t=2.55,P=0.023).In addition,the expression levels of SLC26A3 protein in patients carrying genotype GG or AG of rs2108225 were 0.19±0.03 and 0.10±0.01,respectively,which were lower than that of patients carrying genotype AA (0.26± 0.02),and the differences were statistically significant (t=3.19,P=0.033;t=9.06,P=0.003).Conclusions The genetic polymorphismns and their haplotypes of SLC26A3 (rs7785539,rs2108225 and rs6951457) are associated with the susceptibility of CD,and SLC26A3 (rs2108225) polymorphism may affect the expression level of SLC26A3 protein in the colonic tissues.

Objective To investigate the relationship between forkhead/winged helix transcription factor (Foxp) 3 gene polymorphisms and susceptibility and phenotype of Crohn's disease (CD) in Han nationality in Zhejiang province.Methods From January 2007 to December 2015,268 diagnosed CD patients and 490 healthy controls were enrolled.The four single nucleotide polymorphism (SNP) of Foxp3 rs3761547,rs2232365,rs2294021 and rs3761548 were examined by a SNaPshot technique,and their relation with the efficacy of infliximab was evaluated.The linkage disequilibrium (LD) and haplotype were also analyzed.Unconditional Logistic regression analysis was performed for statistical analysis.Results There was no significant difference in the four mutant alleles and genotype frequencies between 31 patients with effective infliximab treatment and 19 patients with ineffective treatment (all P＞0.05).The results of LD analysis indicated that the above four SNP were in a tight linkage.The frequency of haplotype GCGC of male CD group was 29.20％ (40/137),which was higher than that of male healthy control group (19.37％,43/222),and the difference was statistically significant (odd ratio (OR)=1.717,95％ confidence interval (CI) 1.045 to 2.820,P=0.032).The frequency of haplotype ACGA of female CD group was 13.36％ (35/262),which was lower than that of female healthy control group (19.03％,102/536),and the difference was statistically significant (OR=0.656,95％CI 0.433 to 0.995,P=0.046).The frequency of haplotype ATAC of male colon (L2) type was 25.93％ (7/27),which was lower than that of ileocecal colon (L3) type (75.38％,49/65),and the difference was statistically significant (OR=0.114,95％CI 0.041 to 0.320,P＜0.01).The frequency of haplotype GCGC of male L2 type was 51.85％ (14/27),which was higher than that of L3 type (9.23％,6/65),and the difference was statistically significant (OR=10.590,95％CI 3.423 to 32.758,P＜0.01).The frequency of haplotype ATAC of male stenotic (B2) type was 73.21％ (41/56),which was higher than that of nonstenotic and nonpenetrated (B1) type (47.30％,35/74),and the difference was statistically significant (OR=0.328,95％CI 0.156 to 0.693,P=0.003).The frequency of haplotype GCGC of male B2 type was 17.86％ (10/56) which was lower than that of nonstenotic and nonpenetrated (B1) type (39.19％,29/74),and the difference was statistically significant (OR=2.946,95％CI 1.295 to 6.784,P=0.009).The frequency of haplotype ACGA of male penetrated (B3) type was 71.43％ (5/7),which was higher than that of nonstenotic and nonpenetrated (B1) type (12.16％,9/74),and the difference was statistically significant (OR =0.055,95％ CI 0.009 to 0.329,P ＜ 0.01).Conclusion Foxp3 (rs3761547,rs2232365,rs2294021,rs3761548) gene polymorphisms are associated with the susceptibility and phenotype of CD in Chinese Han patients,but not related with the efficacy of infliximab.

Objective:To analyze the distribution of pathogenic bacteria in bile culture in patients with common bile duct stones and biliary tract infections, in order to guide clinical optimization of antibiotics application.Methods:From March 30, 2017 to December 31, 2021, at Affiliated Hospital of Qingdao University, 753 patients with common bile duct stones and biliary tract infections and received endoscopic retrograde cholangiopancreatography were selected. Bile samples were obtained for bacterial culture, strain type identification and drug sensitivity test in order to analyze bile pathogenic bacteria distribution, change trend and drug resistance. Chi-square test was used for statistical analysis.Results:From 2017 to 2021, the total positive rate of bile culture in 753 patients with choledocholithiasis complicated with biliary tract infection was 90.17% (679/753). From 2017 to 2021, the positive rates of bile culture were 82.05% (64/78), 88.81% (119/134), 88.03% (125/142), 93.87% (199/212), and 91.98% (172/187), respectively, and the difference was statistically significant ( χ2=10.78, P=0.029). The positive rate of bile culture in 2017 was lower than those in 2020 and 2021, and the differences were statistically significant ( χ2=9.43 and 5.57, P=0.002 and 0.018). There were no significant differences in the positive rates of bile culture among the other years (all P>0.05). A total of 1 033 pathogenic bacteria were detected in the 679 bile specimens with positive bile culture results. Among which the total proportion of Gram-negative bacilli was 57.02% (589/1 033), and from 2017 to 2021 the proportions were 66.38% (77/116), 66.47% (111/167), 59.43% (104/175), 54.75% (173/316), and 47.88% (124/259), respectively. The total proportion of Gram-positive cocci was 41.05% (424/1 033), and from 2017 to 2021 the proportions were 31.90% (37/116), 31.74% (53/167), 38.86% (68/175), 44.30% (140/316), and 48.65% (126/259), respectively. The total proportion of fungus was 1.94% (20/1 033), and from 2017 to 2021 the proportions were 1.72% (2/116), 1.80% (3/167), 1.71% (3/175), 0.95% (3/316), and 3.47% (9/259), respectively. From 2017 to 2021, the proportion of Gram-negative bacilli gradually decreased, while the proportion of Gram-positive cocci gradually increased, and the differences were statistically significant ( χ2=20.14 and 17.91, P<0.001 and =0.001). From 2017 to 2021, the change in the proportion of fungus was not statistically significant ( P>0.05). The main Gram-negative bacilli in the bile culture were Escherichia coli (31.36%, 324/1 033) and Klebsiella pneumoniae (12.68%, 131/1 033); the main Gram-positive cocci were Enterococcus faecalis (14.04%, 145/1 033) and Streptococcus salivarius (4.36%, 45/1 033). From 2017 to 2021, the proportions of Escherichia coli were 39.66% (46/116), 38.92% (65/167), 33.14% (58/175), 28.48% (90/316), and 25.10% (65/259), respectively, with gradual decrease and the difference was statistically significant ( χ2=14.34, P=0.006). From 2017 to 2021 the detection rates of extended-spectrum β-lactamase (ESBL) in Escherichia coli and Klebsiella pneumoniae were 30.43% (14/46), 26.15% (17/65), 29.31% (17/58), 38.89% (35/90), 40.00% (26/65), and 4/15, 20.00% (5/25), 20% (5/25), 24.32% (9/37), and 31.03% (9/29), and there were no significant differences in the detection rates of ESBL between different years (both P>0.05). Conclusions:From 2017 to 2021, the positive rate of bile culture in patients with choledocholithiasis complicated with biliary tract infection showed an overall increasing trend. Gram-negative bacilli were still dominated in bile pathogenic bacteria, while the proportion of Gram-positive cocci remarkably increased, and the bile bacterial spectrum significantly changed. Clinicians should adjust the antibiotic dosing regimens according to the variation of bacterial spectrum and drug resistance.