Taking a national continuing education program with hand in hand mode as an example, the advantages and disadvantages of hand in hand mode and traditional mode are com-pared. Hand in hand mode realizes a door-to-door teaching, and the curriculum is more targeted. Moreover, the time and physical power of trainees are saved, so the training effect is better. The na-tional continuing medical education program withhand in hand is worthy of promotion in the teach-ing practice.

Objective To explore the impact of atrial fibrillation (AF) recognized at primary diagnosis on clinical features and outcomes of patients with AF in emergency service.Methods Data were collected from consecutive patients admitted in resuscitation room in the Department of Emergency (ED) of a major comprehensive teaching hospital,from January 1,2011 through December 31,2015.Patients were checked by electrocardiogram examination and / or monitored in resuscitation room after admission,and were divided into patients with AF recognized at a primary diagnosis and those with AF judged by alternative primary diagnoses in ED.The main criteria of prognosis were the length of resuscitation room stay,number of repeated ED visits,and outcome scale (such as death,transferred to intensive units,transferred to general wards,or direct discharge).Non-paired student t test,x2,and circular distribution analysis were performed using SPSS 10.0 and EXCEL 2007 software.Results A total of 929 patients with mean age of (70.3 ± 12.7) years,and 502 (54.0％) female were enrolled.There were 122 cases with AF not recognized at primary diagnosis but by an alternative primary diagnosis (non-primary group,NPG),and 807 cases with AF recognized at primary diagnosis (primary group,PG).Compared with the PG,the patients were older [(76.9 ±9.3) vs.(68.7 ± 14.4),P ＜0.01],had more comorbidities [(1.75 ± 1.26) vs.(0.08±0.39),P＜0.01],higher APACHE Ⅱ scores [(17.89±8.19) vs.(8.64±4.15),P＜ 0.01],longer resuscitation room stay (P ＜ 0.01),higher mortality (11.5％ vs.0.2％,OR =52.176,95％ CI:11.698-232.710,x2 =78.928,P ＜ 0.01) and a higher percentage of transferring to intensive careunit (14.8％ vs.5.1％,OR=3.234,95％CI:1.791-5.838,x2 =16.674,P＜0.01) in NPG.There were no significant difference in number of repeated-visits in ED between the PG and the NPG.Conclusion Patients with AF in the ED judged by alternative primary diagnosis are older and have more comorbidities,higher mortality and higher probability to be transferred to intensive care unit than patients with AF directly recognized by a primary diagnosis.This cohort of patients with special characteristics should be meticulously cared for and be distinguished from the patients with AF crystal clear at a primary diagnosis.Future studies are needed to examine the specific impact of AF on outcomes in the setting of primarydiagnoses in ED.

Emergency specialist training in our country is still in its infancy and perfecting stage. The United States has perfect emergency specialist training system. From training target, access system, program personnel, training content and assessment and evaluation, this study explores the difference of the emergency physician training program of the University of Michigan and the emer-gency physician training rules of Beijing University. The emergency specialist training program in the United States has a strict elimination mechanism and a more rigorous training system for the training parties, making the training plan can be implemented and worth learning from.

Objective To explore the relationship between content of fine particulate matter (PM2.5) in atmospheric and the number of emergency room (ER) visits with acute coronary syndrome (ACS).Methods Daily data of ER visits to Peking University Third Hospital for ACS was collected from December 1st,2013 to November 30th,2014.All patients were resident population of Haidian District,Beijing.The daily meteorological data and contents of air pollutants in Beijing were also collected in the same time period.Generalized Additive Model (GAM) was fitted to estimate the association between the ambient PM2.5 and the ER visits for ACS,under controlling for time trends,holiday effect,day of week effect and weather conditions.Results The annual average amount of PM2.5 was 85.44 μg/m3 over the study period.There were 619 cases with ACS as ER visits.PM2.5 was positive related with PM10,NO2 and SO2.The corresponding correlation coefficients were 0.87,0.48 and 0.67,respectively (P ＜ 0.05).But PM2.5 was negative related with mean temperature (r =-0.04,P ＜ 0.05).In the polluted model,there was positive association between PM2.5 and ER visits with ACS.When each increament in PM2.2 with 10 μg/m3,the relative risk strength of ER visits with ACS was 1.019 (95％ CI:1.000-1.038).PM2.5 concentrations had a delayed effect on the onset of ACS occurred on the next day.This lagged 1 day phenomenon showed the most significant influence of PM2.5 on ER visits for ACS.Conclusions The ambient concentrations of PM2.5 are positively associated with ER visits for ACS.And there is a lag effect.

AIM: Recent studies have identified the importance of inflammation in the development and progression of heart failure.Chemokines are essential factors in the recruitment and activation of leukocytes.They are closely related with inflammation.So the relation between chemokines expression and lymphocytes recruitment and cardiac function after acute myocardial infarction(AMI) was studied.METHODS: Ligating left interventricular branch induced AMI.Experimental rats were divided into three groups: heart failure group(MI-HF),non-heart failure group(MI-NF) and sham group(sham).Sham group was made by the same procedure only without ligation.The blood dynamics of rats was examined after 3 days,1 week and 2 weeks following ligation.Rats,which had a left ventricular end-diastolic pressure(LVEDP) above 15 mmHg,were considered to be in heart failure.Reverse transcription polymerase chain reaction(RT-PCR) was used to analyze the mRNA expression of chemokines,including monokine induced by IFN-?(MIG),macrophage inflammatory protein-1 alpha(MIP-1?) and regulated upon activation,normal T cell expressed and secreted(RANTES),in the infarcted region(circumjacent region included).The numbers of lymphocytes infiltrated in the infarcted region were also counted.RESULTS: MIP-1?,RANTES and MIG mRNA increased at 3 days and reached the peak at 1 week after AMI,significantly higher in MI-HF group than those in MI-NF group(RANTES,0.83?0.05 vs 0.51?0.19,P

AIM: The study explored the significance of the imbalance of Th1/Th2 function after acute myocardial infarction (AMI). METHODS: Peripheral blood mononuclear cells from 33 AMI patients, 22 unstable angina (UA) patients and splenocytes from 35 AMI rats were collected. Cytokine-producing Th cells were monitored by 3-color flow cytometry after stimulated with phorbol myristate acetate (PMA) and ionomycin. IFN-? and IL-4 mRNA in the rat myocardium and chemokine receptors CCR3, CCR5 and CXCR3 mRNA on the surface of rat T lymphocytes after AMI were measured by RT-PCR. RESULTS: Th1 associated cytokine IFN-? significantly increased in patients with AMI and UA within 24 hours after the onset of symptom. the high ratio of IFN-?-producing T cells lasted short in patients with UA and recovered 1 week after the onset. In AMI patients, the high ratio of IFN-?-producing T cells could be examined 1 week and even 1 month after the onset. There was no significant difference on the frequencies of IL-4-producing peripheral T cells between each group. 1 week, 2 weeks and 1 month after AMI, IFN-? mRNA increased in the myocardium of rats, but there was no significant change on cytokine-producing Th cells and chemokine receptors on the surface of rat T lymphocytes. CONCLUSIONS: The Th1/Th2 functional imbalance and up-regulation of Th1 cell-functions exist after AMI and perhaps participate in the onset of AMI. Th1/Th2 functional imbalance may participate in the immune-mediated myocardial injury and ventricular remodeling after AMI as one of the pathogenesises of autoimmune disease.

Objective To analyze the correlation between neutrophil-to-lymphocyte ratio(NLR),platelet-to-lymphocyte ratio(PLR) in peripheral blood and the therapeutic effect and prognosis of patients with advanced lung adenocarcinoma treated with tyrosine-kinase inhibitors.Methods Retrospective analysis was utilized to measure the clinical pathological characteristics and follow-up data of 40 cases with advanced lung adenocarcinoma definitely diagnosed by pathology.Correlation analysis was performed by Spearman test,and comparison of the sample rate was measured by the chi square test.Survival analysis was performed by Kaplan-Meier method,Log-rank test was used to compare patients survival difference among different groups.COX regression model was utilized to analyze the prognostic factors of patients with lung cancer.Results Through the ROC curve,the optimal cut-off points of NLR and PLR were calculated to be 3.74 and 205.1 respectively.In NLR<3.74 group,objective response rate(ORR),the median progression-free survival(PFS) and the median overall survival(OS) were 86.9%(20/23),9.02 months and 12.37 months respectively.In NLR ≥3.74 group,ORR,the median PFS and the median OS was ORR were 35.2%(6/17),3.15 months and 5.12 months respectively.Compared with NLR ≥ 3.74 group,NLR<3.74 group had a higher ORR(P=0.036),PFS(P=0.011) and OS(P=0.021),the difference was statistically significant.In PLR<205.1 group,ORR,the median PFS and the median OS was ORR were 85.7%(18/21),9.67 months and 14.35 months respectively.In PLR ≥ 205.1 group,ORR,the median PFS and the median OS was ORR were 42.1%(8/19),3.21 months and 9.25 months respectively.Compared with group PLR ≥ 205.1,PLR<205.1 group had a higher ORR(P=0.045) and PFS(P=0.018),the difference was statistically significant.COX multivariate analysis showed that NLR was an independent prognostic factor for PFS(RR=1.091,95%CI:1.004-1.185,P=0.039) and OS(RR=0.986,95%CI:0.932-1.148,P=0.021).PLR was an independent prognostic indicator of PFS(RR=1.100,95%CI:0.996-1.005,P=0.024).Conclusion NLR and PLR may be independent prognostic factors in patients with advanced lung adenocarcinoma.

Objective To explore the clinical risk factors of ventilator-associated fungal pneumonia (VAFP) in emergency intensive care unit.Methods One hundred and ninety-seven consecutive patients with 121 males and 76 females,aged from 17 to 98 years met the criteria of ventilator-associated pneumonia in emergency intensive care unit admitted from July 2009 to June 2014,were retrospectively evaluated.Those with mechanical ventilation less than 48 hours or treatment discontinued were excluded.Patients were divided into VAFP group and ventilator-associated non-fungal pneumonia group according to the results of fungal culture and microscopy.Univariate analysis was used to find out preliminary risk factors for VAFP,and then the ultimate independent risk factors were determined with multivariate stepwise logistic regression analysis.Results The occurrence of VAFP was 32.0 ％ (63 cases) out of 197 patients with ventilatorassociated pneumonia.In those 63 patients,there were 71 species found from fungus culture.Candida albicans counted for 33 (46.5％),Candida glabrata for 11 (15.5％),other Candida Albicans for 26 (36.6％).The preliminary univariate analysis showed that 19 factors were statistically significant,while multivariate stepwise logistic regression analysis revealed that acute physiology and chronic health evaluation Ⅱ score≥ 22,radiotherapy or chemotherapy,mechanical ventilation ≥14.11 days,use of antibiotics ≥14 days,use of glucocorticoid and other immuno-suppressants were independent predictors of VAFP,and the adjusted odds ratios with 95％ confidential intervals were 4.133 (2.831-6.033),2.977 (1.942-4.564),2.305 (1.439-3.736),1.988 (1.441-2.741),1.528 (1.337-1.746),respectively.Conclusion Higher APACHE Ⅱ score,radiotherapy or chemotherapy,prolonged use of mechanical ventilation,prolonged use of antibiotics,use of glucocorticoid and immunosuppressants are independent risk factors of VAFP.The incidence rate of VAFP may be reduced by improving patients' overall clinical setting,shortening the duration of mechanical ventilation and employment of antibiotics,and more strict guidelines to the application of glucocorticoid and immunosuppressants.

Objective To explore the clinical characteristics and outcomes of patients with atrial fibrillation (AF) and repeated emergency department (ED) visits.Methods Patients with AF were examined and analyzed retrospectively.Data were collected from consecutive patients from resuscitation room in the Department of Emergency of a large-scale general teaching hospital,from January 1,2011 to December 31,2015.The patients were verified by electrocardiographic examination and/or monitoring.The main outcomes were length of resuscitation room stay and outcome scales (defined as death,transfer to intensive units,to ordinary wards,or direct discharge).Results 908 patients were enrolled in the study with a mean age of 70.3 ± 12.8 years,and 494(54.4％) were female.There were 262(28.9％) cases visited ED for more than one time,and 646(71.1％) visited ED without repetition.Compared with the patients without repeated visit,patients with repeated visits were older (73.0 ± 9.8 years versus 69.2 ± 13.6 years,t=4.705,P＜0.001),and had a larger proportion of patients with CHADS2-VASc score greater or equals to 2(70.6％ versus 60.2％,x2 =8.660,P=0.003),whereas those patients had a shorter stay in the resuscitation room (13.6 ± 27.1h versus 27.0 ± 89.7h,t=3.370,P=0.001),and a higher percentage of directly discharge (73.3％ versus 61.9％,x2=10.607,P=0.001).In multiple logistic regression analysis,a higher CHADS2-VASc score and a lower quartile of the resuscitation room stay were independently predictive factors of repeated ED visits.Conclusion Patients with AF and repeated ED visits would have relatively complex condition and more comorbidities.High CHADS2-VASc score and short ED stay are independently predictive factors for repeated ED visits.

AIM: To explore the molecular mechanisms about fibrosis and transforming growth factor (TGF) - β1 as well as inflammation in rats heart after acute myocardial infarction (AMI). METHODS: AMI model in rats was produced by left coronary artery ligation. Samples of rat cardiac tissue were collected at the end of 1 week, 4 weeks and 8 weeks. Hemodynamics had been performed before rats were sacrificed. Reverse transcription polymerase chain reaction (RT- PCR) and immunohistochemical methods were used to analyze mRNA expression and protein production of TGF- β1, respectively. Hydroxyproline was determined by chloramines T method. HE staining was resorted to analyze pathological myocardium after AMI. RESULTS: There were remarkable differences in hemodynamics between AMI groups and sham group (P＜0.01). Compared with sham group, TGF-β1mRNA expression and protein production and hydroxyproline quantification were enhanced greatly. Among them, the levels of TGF -β1 and hydroxyproline at 1 week were higher than those at 4 weeks or 8 weeks. A positive correlation between TGF- β1 protein and hydroxyproline was presented (r=0.75 - 0.99, P＜0.05). In microscope, leucocytes infiltrated significantly in the infarcted and border myocardium at 1 week after AMI, and were rarely seen at 4 weeks and 8 weeks. TGF - β1 protein were detected in cytoplasm of cardiac myocyte and leucocytes at 1 week, and at 4 and 8 weeks in myofibroblast and interstitial. CONCLUSIONS:TGF- β1 is upregulated and found in cytoplasm of cardiac myocyte and leucocytes as well as myofibroblast in heart after AMI,which is associated with dynamic changes of hydroxyproline content and inflammation. TGF - β1 is showed to play an important role in myocardial inflammatory repair and ventricular remodeling after AMI.