Clinical Clerkship is the necessary stage from theory to clinical practice,As teaching hospital of Nanjing Medical University.we explore various kinds of methods of clinical practice quality improvement by emphasizing practice training,developing multiform teaching activities,highhghting autonomic learning and strengthening intemship management.

Objective To explore the correlation between serum level of cystatin C and coronary slow flow (CSF).Methods Thirty-four patients with CSF were enrolled in CSF group and thirty-five patients with normal coronary flow and angiographically normal coronary arteries were enrolled in control group.Coronary flow patterns was assessed by corrected thrombolysis in myocardial infarction (TIMI) frame count.The change of serum high sensitivity C-reactive protein,uric acid,cystatin C were measured.Results There was no significant difference between two groups with respect to gender,age,history of smoking,prevalence of hypertension and diabetes mellitus,family history of coronary heart disease,low density lipoprotein,α-lipoprotein (P ＞0.05).Compared with control group,the level of serum high sensitivity C-reactive protein,cystatin C,uric acid in CSF group were obviously higher [(4.85 ± 6.39) mg/L vs.(2.55 ± 2.18) mg/L,(0.87 ± 0.22) mg/L vs.(0.75 ± 0.16) mg/L,(329.68 ± 85.46) μ mol/L vs.(278.97 ± 76.74) μ mol/L] (P ＜ 0.05 or ＜ 0.01).Logistic regression analysis showed that cystatin C increased as independent risk factors for CSF (P =0.002,OR =0.009).Conclusion High level of cystatin C may play an important role in the occurrence and development of CSF.

Objective:To evaluate the effect of general anesthesia guided by bispectral index (BIS) on postoperative sleep quality in elderly patients undergoing laparoscopic gastrointestinal tumor surgery.Methods:A total of 90 patients, aged 65-80 yr, with body mass index of 18-25 kg/m 2, of American Society of Anesthesiology physical status Ⅰ-Ⅲ, without preoperative sleep disorders, undergoing elective laparoscopic gastrointestinal tumor surgery, were divided into 3 groups ( n=30 each) using a random number table method: control group (group C) and different BIS value groups (group B1 and group B2). Combined intravenous-inhalational anesthesia was used.The BIS value in group B1 was maintained at 40-49, and the BIS value in group B2 was maintained at 50-60.The fluctuation range of heart rate and blood pressure was not more than 20% of the baseline, and vasoactive agents were administered when necessary in group C. Patient-controlled intravenous analgesia was performed with sufentanil, dezocine and palonosetron after surgery.When visual analog scale score>3, acetaminophen oxycodone tablets 5 mg was taken orally or flurbiprofen 50 mg was intravenously injected as rescue analgesic.At 1 day before surgery and 1, 3, 7 and 30 days after surgery, sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI), postoperative sleep disorders were defined as PSQI scone≥6, and the development of postoperative sleep disorders was recorded.During the nighttime at 1 day before surgery and during the nighttime at 1, 2 and 3 days after surgery, sleep was monitored using body motion monitor (Honor Band 5). The intraoperative consumption of propofol and remifentanil and requirement for rescue analgesia at 48 h after surgery were recorded.The Quality of Recovery-15 (QoR-15) scores were measured at 1, 3 and 7 days after surgery.At 1 day before surgery and at 1 day after surgery, serum C-reactive protein concentrations were determined by immunoturbidimetry. Results:Compared with group C, PSQI scores were significantly decreased at 1 and 3 days after surgery, the incidence of sleep disorders was decreased at 3 days after surgery, sleep time, sleep score and proportion of rapid eye movement sleep time during the nighttime at 1 and 2 days after surgery were increased, intraoperative consumption of propofol was decreased, QoR-15 score at each time point after surgery was increased, and postoperative length of hospital stay was prolonged in group B2 and group B2 ( P<0.05). Compared with group B1, PSQI scores were significantly decreased at 1 and 3 days after surgery, sleep time, sleep score and proportion of rapid eye movement sleep time during the nighttime at 1 and 2 days after surgery were increased, intraoperative consumption of propofol was decreased, QoR-15 score at each time point after surgery was increased ( P<0.05), and no significant change was found in the incidence of sleep disorders at each time point in group B2 ( P>0.05). There was no significant difference in CPR concentrations and the number of rescue analgesia after surgery at each time point among the 3 groups ( P>0.05). Conclusion:General anesthesia guided by BIS can improve postoperative sleep quality in elderly patients undergoing laparoscopic gastrointestinal tumor surgery, and BIS value maintained at 50-60 provides better effect on postoperative sleep quality and is more helpful for postoperative recovery.