Standardized patient(SP)is used to simulate clinical practice for examining medical students so as to train clinical skills and promote practicality and sociality in evidence-based education,through which important information of individual patient can be gained.It is the foundation and precondition for searching the best clinical evidences and accumulating abundant clinical experiences.Evidence-based medicine emphasizes the teaching model which centers on patients.Different patients should receive distinct strategy of treatment while making evidence-based decision.

Tumor necrosis factor alpha (TNF-α) is a homotrimeric protein encoded within the major histocompatibility complex (MHC). TNF-α can bind its receptors in the body to play a role in immune regulation and to participate in the various pathophysiology processes including fever, inflammation, infection, wound healing and tumors necrosis. TNF-α, an important component of inflammatory pathways, is up-regulated in the synovial tissue, synovial fluid and serum of rheumatoid arthritis (RA) patients. In RA patients, TNF-α along with many kinds of tissue factors and matrix proteins together promotes the inflammatory response, abnormal apoptosis of synovial cells, pannus formation and cartilage and bone destruction, which maintain the sustainability of the progress of RA. Thus, TNF-α may be a clinical indicator of RA activity as well as an effective target for RA.

Objective To evaluate the value of clinical findings and different diagnostic criteria for the diagnosis of adult onset Still's disease (AOSD). Methods The AOSD patients admitted to Zhongshan Hospital affiliated to Fudan University from 2003 to 2009 were enrolled. Non-AOSD patients with fever were selected. Different diagnostic criteria of AOSD were applied to all patients. Two indenpendent samples t test and wilco-xon test were used for statistical analysis. Results The clinical features such as rash, arthralgia, arthroncus, sore throat, myalgia, lymph node enlargement, hepatomegaly, splenomegaly, leuko-cytosis, neutrophil ≥80% and serum level of ferrin≥ 2000 ng/ml hadhigher specificity (65.87%~98.41%) with 2.00～5.00 of the positive likelihood ratio.High fever ( ≥39.0℃), negative of ANA and RF had higher sensi-tivity (85.25%~93.65%). Combinations of three parameters such as high fever, rash, sore throat, leukocy-tosis, arthralgia had higher positive likelihood ratio. The specificity of ARA criteria was the highest. The sensitivity and accuracy of Yamaguchi criteria were the highest. Conclusion There is no single parameter that could be specific to the identification of AOSD. Combing with several parameters can improve the diagnostic efficiency. The results of this study have shown that the commonly used diagnostic criteria has high specificity.

Objective To investigate the effects of simvastatin on the production of interleukin (IL)-17and B-cell activating transcription factor (BATF) in the peripheral blood mononuclear cells (PBMCs) of rheumatoid arthritis (RA) patients and healthy individuals.Methods PBMCs were isolated from heparinized blood of healthy donors or RA patients using Ficoll-Hypaque density gradient centrifugation.The cells were stimulated by PMA and ionomycin in the absence or presence of simvastatin or MVA at 37 ℃ 5％CO2.The mRAN level of IL-17,BATF and GAPDH was detected by RT-PCR; the protein level of IL-17 in supernatants was assayed by ELISA kit; and the protein level of BATF was detected by Western Blotting.The comparison between the two groups was carried out by paired-t test and Chi-square test was used for muhi-group comparison.Results PBMCs of healthy donors [(69.2±12.2) vs (8.1±2.2) pg/ml,P＜0.05; (76.6±14.7) vs (10.2±7.2) pg/ml,P＜0.05] and RA patients [(79.6±12.7) vs (15.8±5.8) pg/ml,P＜0.05; (90.3±9.7) vs (12.9±7.9) pg/ml,P＜0.05] were stimulated with PMA and ionomycin to produce high levels of IL-17.After treatment with simvastatin,the expression and secretion level of IL-17 in healthy controls and RA PBMCs were markedly decreased.The inhibition of simvastatin on the production of IL-17 was reversed by mevalonic acid (MVA),but no significant changes of BATF after treating with simvastatin.Conclusion Simvastatin inhibits the production of IL-17 in the PBMCs at gene and protein levels,which is not targeted at suppressing the expression of IL-17 transcription factor BATF.

Objective To evaluate the risk of hyperuricemia in patients younger than 45 with coronary artery disease.Methods Six hundred and seventy-seven patients with coronary artery disease under 45 years old at disease onset were recruited retrospectively.The subjects were divided into hyperuricemia group (n=164) and normal uric acid group (n=513).Patients with coronary artery disease with hyperuricemia were analyzed for clinical characteristics.The risk of hyperuricemia was analyzed on the severity of coronary lesions.T-test,x2 test and Logistic regression analysis were used for statistical analysis.Results Comparing with patients with normal uric acid,patients in the hyperuricemia group were male predominant and more prevalent with hypertension [197(38.5％) and 93(56.7％) ; x2=16.85,P＜0.01],hypedipidemia [274(53.4％) and 130 (80.7％); x2=37.58,P＜0.01],and cardiac dysfunction [24 (4.7％) and 17 (10.4％); x2=7.18,P=0.01].Hyperuricemia increased the risk of coronary artery disease complicated with cardiac dysfunction [ORlcorrection=2.66,95％CI (1.28,5.53)],and it also increased the risk of coronary artery disease concurrent with cardiac arrhythmia [OR2correction=1.28,95％CI (1.00,1.65)] revealed by multivariate regression analysis.Conclusion In young patients under 45 years old with coronary artery disease,hyperuricemia is the independent risk factor for coronary artery disease complicated with cardiac dysfunction and arrhythmia.

objective To evaluate the diagnostic efficiency of magnetic resonance imaging(MRI)for rheumatoid arthritis(RA).Methods The major international databases was searched by computer and Other methods to collect control studies about MRI for the diagnosis of RA,the searching deadline was December 2009.Data were screened and extracted by inclusion criteria.Meta-disc software Was used for statistics,including sensitivity,specificity,positive likelihood ratio,negative likelihood ratio,diagnostic odds ratio(OR)and heterogeneity analysis.Results Twelve random control tests were included.Meta-analysis indicated that sensitivities of vities of synovitis,bone-erosion and tendenosynovitis were 81%~100%,48%～100%and 67%～96%while specificities of them were 64%～89%,16%~100%and 21%-74%respectively for RA patients(≤2vears).Sensitivities of synovitis and bone-erosion were 91%and 84%while specificities of them were 70%and 81%for RA Datients (>2 years).Conclusion Synovitis shown by MRI is helpful for the diagnosis of earlv and med-to-late RA.Diagnostic values of bone-erosion and tendonosynovitis demonstrated by MRI for earlv RA were not clear.The sample size of the included studies is small and some studies lack of control groupsput the conclusion of this meta-analysis liable for bias.We suggest that better designed and larger sample clinical studies are necessary.

Objective: The present study is a summary of syndrome types of gastric cancer in order of priority based on clinical practical situations, routine clinical syndrome differentiation and a large-sample clinical survey in 767 patients with gastric cancer. Methods: Based on the six-type classification of gastric cancer in a previous study, a bedside syndrome differentiation diagnosis was made simultaneously by two attending doctors of traditional Chinese medicine (TCM to avoid possible diagnostic bias. A clinical differentiation survey form designed under the direction of epidemiologists was filled out by patients with gastric cancer in multiple centers, and the results were digitally valued and statistically analyzed. Results: The symptoms and signs in each syndrome type of gastric cancer were ranked in order of priority as follows: distended pain, stringy pulse, eructation, mood-related pain, susceptibility to anger, acid regurgitation, hiccup, fullness sensation or distension after eating just a little, dizziness, thin pulse, abdominal enlargement, obstruction sensation after eating, moving pain, and uneven pulse in disharmony between liver and stomach; dark red tongue with little fur or a smooth surface, burning pain, rapid pulse, associated burning heat in anus, dry mouth, fissured tongue, thin pulse, tidal fever in the afternoon, nausea and vomiting, and night sweating in impairment of yin due to stomach heat; slender tongue fur, obstruction after eating, slow pulse, moderate pulse, rapid and irregular pulse, normal mood, abdominal pain, diarrhea, cold extremities, lower-extremity edema, cold intolerance, pale complexion, dizziness, emaciation, hiccup, silence, nausea, uneven pulse, acid regurgitation, fullness sensation or distension after eating just a little, vomiting, and constipation in deficiency-cold in spleen and stomach; uneven pulse, stabbing pain, tortuous sublingual vein, blue or purplish tongue, fixed pain, tarry stool or dark red stool, vomiting of dark red fluid, pale complexion, dry mouth without desire to drink, stringy pulse, white tongue fur, nausea, thin tongue fur, colic pain, hiccup, dizziness, acid regurgitation, bitter taste in mouth, slow pulse, rapid and irregular pulse, thin pulse, and pain relief by pressing in interior retention of toxin stagnation; slippery pulse, greasy and thick tongue fur, dry mouth without desire to drink, vomiting of bilious fluid, nausea, bitter taste in mouth, fullness sensation or distension after eating just a little, colic pain, and hiccup in stagnation of phlegm-dampness; abdominal pain relief by pressing, map-like tongue, thin pulse, weakness, yellowish complexion, dizziness, spontaneous sweating, fissured tongue, epigastric discomfort, night sweating, emaciation, cold intolerance, constipation, nausea, and dry tongue in deficiency of both qi and blood. Conclusion: The summarized syndrome types of gastric cancer from this study are consistent with the clinical situations and would prove to be more referential for TCM syndrome differentiation diagnosis and treatment of gastric cancer.

Objective To investigate the effect of different concentrations of methotrexate (MTX) on IL-17 from peripheral blood mononuclear cells(PBMCs) and To clarify the active mechanisms of MTX on RA. Methods PBMCs were isolated from heparinized blood of healthy donors or patients with RA using Ficoll-Hypaque density gradient centrifugation. The cells were pretreated with various concentrations of MTX and then stimulated by anti-human CD3/anti-human CD28 at 37℃5%CO2. The IL-17 mRAN level was detected by semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR). The supernatants were harvested and the protein level of IL-17 was tested by ELISA kit. The percentage of CD4+IL-17+cells in PBMCs was detected by flow cytometry. Results For the four different concentrations of MTX groups (0.1,1.0, 5, 25μg/ml), the IL-17 mRNA/GAPDH ratio(0.58±0.09,0.48±0.11, 0.50±0.09, 0.51±0.14) were lower than those of the non-drug group(0.76±0.08). Paired-t test or independent-samplet test showed significant difference between the MTX treatment group and the non-drug group(P＜0.01). The level of IL-17 of the four MTX groups was(121±54)pg/ml and(104±45)pg/ml and(90±36)pg/ml and(115±41)pg/ml, which was lower than the non-drug group(370±187)pg/ml(P＜0.01). The average C D4+IL-17+cell ratio was reduced, but had no statistically signficant differences(P＞0.05). Conclusion MTX can decrease Th17 cells differentiation and suppress IL-17 production of PBMCs, but no association can be found between its effect on the expression of IL-17 and the concentration of MTX.

OBJECTIVETo evaluate rates on the adverse side effect and discontinuation of second-line drugs frequently used in the treatment of rheumatoid arthritis (RA).

METHODEight hundred and sixty-four RA patients were studied in a retrospective program.

RESULTSUpper abdominal discomfort was most commonly seen when using second-line drugs. Rash was often associated with D-penicillamine (20.6%) and Sinomenium therapy (13.7%). Methotrexate (MTX) was uniquely characterized by substantial upper GI toxicity (32.2%) and Tripterygium wilfordii Hook. f. (TWH) (14.4%) by menstrual abnormality. Sulfasalazine users reported adverse events including upper abdominal trouble (39.0%), nausea (7.3%) and anorexia (7.3%) while the risk of GI malaise was greater. Patients taking hydroxychloroquine complained of blurred vision (19.6%) but no one went blind. Toxic side effects seemed to be the most common reasons for stoppages, and the patients taking MTX had the lowest discontinuation rate. Combination of D-penicillamine and Methotrexate did not increase the incidence of adverse events.

CONCLUSIONSKnowledge on these different patterns of toxicity provided choices in the selection of second line agents for particular RA patients. However, long-term monitor are required when drugs are being used.

Adult ; Anorexia ; chemically induced ; Antirheumatic Agents ; adverse effects ; therapeutic use ; Arthritis, Rheumatoid ; drug therapy ; Exanthema ; chemically induced ; Female ; Gastrointestinal Diseases ; chemically induced ; Humans ; Hydroxychloroquine ; adverse effects ; therapeutic use ; Male ; Methotrexate ; adverse effects ; therapeutic use ; Middle Aged ; Nausea ; chemically induced ; Penicillamine ; adverse effects ; therapeutic use ; Phytotherapy ; Plant Preparations ; adverse effects ; therapeutic use ; Retrospective Studies ; Sinomenium ; Sulfasalazine ; adverse effects ; therapeutic use

Objective To investigate the distribution of urate crystal as well as the relationship bet ween the features of the crystals and the attacks of joint pain and/or swollen by foot dual-energy CT.Methods Eight-four patients (68 were diagnosed as gout, 11 were patients with hyperuricemia and 5 were diagnosed as other types of arthritis) who recently experienced foot swelling and/or pain were enrolled and all of them were performed foot dual-energy CT.The relationship between the features of the urate crystals and the attacks of gouty arthritis was determined by Chi test and the potential risk factors were identified by Logistic multiple regression analysis.Results Two hundred and seventyeight urate crystal depositions were found in 68 gout patients,and the most common deposition sites were the distal parts of the first toe(18.2％),the first metatarso-phalangeal joint ( 16.8％ ),calcaneus ( 17.5％ ),the lower end of tibia ( 11.8％ ).Furthermore,patients with the urate crystals deposited in the first metatrasophalangeal joint or the lower end of of tibia were more likely to experience acute episodes of gout attack (P＜0.01,P＜0.05 respectively).In addition,the shape,size and quantity of urate crystals also affected episodes of acute attack of gout.Conclusion Dual-energy CT,which is a non-invasive method,could clearly reveal urate crystal depositions and is helpful for the diagnosis and follow-up of patients with gout.The location,shape,size and quantity of urate crystals and soft tissue swelling,bone erosion may affect the acute attack of gout.