The key point of development of emergency medicine is professional training. What we need are "emergency physicians who have well-knit theory and comprehensive technique" but "the internal physicians who could do some resuscitation". This is the goal of emergency medical education. To realize the goal, we need to improve our condition of training-bases, the curriculum,the academic level of trainer and training method. Besides, we should balance the effectivness and safety of training. We believe that the "four steps" course should be the most important and most effective method of emergency medical training.

Objective To investigate the relationship between carotid artery atherosclerosis and risk factor in a young and middle-aged population in China who received health checkup.Methods A total of 762 cases of young and middle-aged adult were recruited between April and October in 2013.These subjects had no hypertension,diabetes,coronary heart disease,cerebrovascular disease,and connective tissue disease,etc.Their Blood pressure,serum glucose (Glu),total cholesterol (TC),triglyceride (TG),and low density lipoprotein cholesterol (LDL-C) were measured and carotid artery ultrasonography was performed.Of the 762 cases,589 were male,173 were female,mean age was (46 ± 9) years.For blood pressure,blood lipids,the t test was performed to detect the difference between arteriosclerosis group and non arteriosclerosis group in different age groups.Logistic regression was performed to reveal the risk factors with carotid arteriosclerosis.Results Of the 762 subjects,205 had carotid artery atherosclerosis; 30.2％ (178/589) of them were men and 15.6％(27/173) of them were women,with a significant difference between two groups,(x2=14.522,P=0.000).In the younger than 40 years old group,the diastolic blood pressure has statistical significance between carotid arteriosclerosis and non carotid arteriosclerosis group (t=-2.789,P＜ 0.05); blood sugar had statistically significant difference between the two groups (t value was-2.256,-2.930,-2.174,respectivly,P＜0.05).Multiple regression analysis revealed that the independent risk factors for carotid artery arteriosclerosis were age,sex,DBP,and Glu.The regression coefficients were 0.993,0.711,0.047,0.334 seperately.The ROC curve of age was analyzed,the area under the ROC curve was 0.731,cut-off was 51 years old.Conclusions Routine carotid artery ultrasound should be performed for older than 50 healthy middle-aged men,to determine whether arteriosclerosis exists,especially for people with abnormal blood glucose or elevated DBP.

Bring your own device (BYOD) has become popular as it empowers medical practitioners to use their own devices for communication,mobile rounds,real-time EMR query,selflearning and auxiliary diagnosis.Based on implementation experiences of BYOD at home and overseas healthcare institutions,this paper recommended domestic institutions on BYOD planning and deployment as follows:restructuring of their wireless networks and access control;better device supervision;open BYOD portal;and protection of both staff privacy and data security.This effort provides insights for BYOD development in China's healthcare institutions.

Objective To study risk factors associated with predisposition to Lm -ABM in adult patients and to evaluate the clinical features,management and out in this cohort of patients because Listeria monocytogenes (Lm) is the third most common cause of acute community acquired bacterial meningitis (Ac-ABM),after Streptococcus pneumoniae and Neisseria meningitides aetiologies.Methods A descriptive,prospective study carried out in a tertiary grade medical center emergency department in Beijing over a 10 -year period.During the study period,15 patients of Lm- ABM were included.Comparison of episodes of Lm - ABM versus other aetiologies was made.Results Fifteen episodes of Lm - ABM were identified in327 adult Ac - ABM patients.Three cohorts of individuals were vulnerable to Lm - ABM:the elderly ( RR=3.14; 95％ CI 1.84-5.35),the immunocompromised (RR =3.34; 95％ CI2.08-5.38),and pregnant women ( RR 12.48 ; 95％ CI 3.29 ～ 47.39 ).The classic triad of fever,neck stiffness,and altered mental status was present in 40％ (6 of 15) Lm - ABM patients.Similarly,40％ patients had at least one of cerebrospinal fluid (CSF) samples with features met the criteria of typical bacterial meningitis.The coverage of empirical antimicrobial therapy was microbiologically inadequate for 13 ( 86.7％ ) patients.The mortality rate was 33.3％ (5 of 15),and 7 (46.7％ ) of 15 patients led to an unfavorable outcome ( GOS ＜ 4),both of which were significantly higher than those in other aetiologies of Ac - ABM ( P =0.015P =0.009 respectively). Conclusions Our study showed the elderly,the immunocompromised patients,and pregnant women predisposed to Ac - ABM most likely to be Listeria monocytogenes aetiology.In contrast with similar previous reports, the current study showed that patients with meningitis due to Listeria monocytogenes did not present with atypical clinical features.A high proportion of patients received empirical antimicrobial therapy that did not cover Listeria monocytogenes.Lm - ABM is still a serious disease that leads to high morbidity and mortality rates.With these important caveats in mind,our findings have implications for clinical practice and food safety policy makers.

Objective Emergency department overcrowding (EDO) is an increasingly international occurrence which affects the quality and access of health care across the globe.We assessed perceptions of EDO by a detailed and comprehensive surveying of current international research literatures.Methods Through PubMed and BMC electronic literatures search engines from 1974 to 2012,1587 papers of original articles,reviews and comments with key wordsemergency departmentANDcrowding OR overcrowding are selected.Results 52.6％ (835/1587) all selected literatures is original research articles.21.2％ (n =337) of these papers involved the disciplinary construction of emergency medicine,and editorial comment (included viewpoints) holds almost one fifth (302,19.0％).Most common types of study methods in all original researches is single-center cohort study (722/835,86.5％),and none of them was multi-center,randomized control clinical trial.The number of papers on EDO is 8 during 1974 and 1988,and gradually elevated to 325 during 1989 and 2002.Yet the number has climbed up to 1254 dramatically (account for 79％) during 2003 and 2012.Together,USA,Canada and Austria,these three countries generated more than three-quarters of all published literatures (81.0％).So far,the authors in 48 countries and areas gave forth initial contributions in the field of EDO.Conclusions The studies and papers about EDO are steadily increasing in recent years.But the investigation shows the research quality still remain need to improve.This systemic review on EDO studies showed that the standardized measurement of EDO has become the bottleneck of EDO study.It is very important and urgent for ED staff to establish an objective and effective EDO evaluation system.

Objective To provide a framework for understanding the need for a structured assessment of altered mental status (AMS) to better understand underlying causes of the mental status changes in adults and therefore potentially improve diagnostic skills and eventually management.Methods This is a prospective cohort observational study.We recruited consecutive adult patients with undifferentiated AMS at a single center tertiary care academic emergency department over 24 months.Demographical,clinical presentations,assessment approaches,cause factors,emergency treatments and outcomes were collected prospectively.Results One thousand nine hundred and thirty-four patients with AMS were recruited,this number of patients represented 5％ of the total ED census.Out of 1934 patients,1026 (53.1％) were male,908 (46.9％) were female.Mean age was (51.95 ± 15.71) years.Etiologic factors included neurological (n =641,35.0％),pharmacologic & toxicologic (n =421,23.0％),systemic and organic (n =266,14.5％),infectious (n =167; 9.1％),endocrine/metabolic (n =145,7.9％),psychiatric (n =71,3.9％),traumatic (n =38,2.1％),gynecologic and obstetric (n =35,1.9％).Total mortality rate was 8.1％ (n =156).The death rate was higher in elderly patients (≥ 60) than that in younger patients (10.8％ vs.6.9％,P =0.003).Conclusions The patient with AMS poses a challenge to physicians in ED.The most frequently encountered diagnostic category causing AMS were primary CNS disorders,intoxication,organ system dysfunction and endocrine/metabolic diseases.Fatality rate is very high.Prompt evaluation and treatment are essential to decrease the morbidity and mortality associated with this condition.

Objective To establish a practicable and easily mastered emergency department overcrowding (EDO) assessment system suitable for domestic ED setting by determining the validity and usefulness of the national emergency department over-crowding study (NEDOCS) tool in a 2000-bed tertiary care academic institution in China in comparison with visual analogue scale (VAS) in order to address the worldwide grave concern of EDO.Methods In a period of 6 months,data of subjective and objective EDO assessed simultaneously three times a day (1:00,9:00,17:00) were collected.The data were analyzed by using Bland-altmann method and Kappa test to determine the coincidence between VAS and NEDOCS assessments.Results The VAS-p value evaluated by physicians was significantly lower than VAS-n value evaluated by nurses [(6.49 ± 1.82) vs.(7.12 ± 1.78),P ＜ 0.01].The reliability analysis showed that Kappa value was as low as 0.112 (P ＜0.01) suggesting there was a great discrepancy between VAS-p value and VAS-n value.VAS-m (average value of VAS-p and VAS-n) was taken for comparing different evaluation systems.The significant correlation was found between the VAS-m and NEDOCS (r =0.7l4,P ＜0.01).However,the Bland-Altman plot showed the 95％ limit of coincidence was in an extensive range (-32.47 to 71.42) suggesting discrepancy existed between two methods.Conclusions The present study suggested there was a significant discrepancy between the two subjective assessments of ED crowding (VAS-p vs.VAS-n).There might be a fatal flaw existed in the assumptions of the original VAS method for EDO measurement.Using the Bland-Altman plot analysis,the results showed that NEDOCS did not authentically reflect the staff' s sense of overcrowding in the ED.It is very important and urgent to establish an objective and effective EDO evaluation system for ED management.

Objective To investigate the expression level of Gas6 in patients with Immune Thrombocytopenia (ITP) and its clinical significance.Methods The experimental group was peripheral blood samples collected from 35 cases diagnosed with ITP in hematology department of Changhai Hospital in Shanghai from October 2013 to December 2015.Control group was peripheral blood from 35 healthy examined individuals at the same time.After separating plasm from the two group samples,the protein level of Gas6,IFN-α,IL-4,IFN-γ and IL-17 were measured by Enzyme-linked immunosorbent assay (ELISA),comparison of expressional level of the two groups was measured by t test.Pearson correlation analysis was used to decide the relation between Gas6 and cytokines such as IFN-α.Results The expression level of Gas6 in experimental and control groups was 27.28±7.56 ng/ml vs 20.51±5.39 ng/ml (t=4.314,P＜0.000 1);IFN-γ was 221.67±57.64 pg/ml vs 45.32 ±16.79 pg/ml (t=17.38,P＜0.000 1);IL-4 was 113.86±26.48 pg/ml vs 49.87±14.98 pg/ml (t=12.44,P＜0.000 1);IL-17 was 168.96±47.88 pg/ml vs 109.56±28.97 pg/ml (t=6.28,P＜0.000 1);IFN-α was 34.83±8.12 pg/ml vs 29.89 ± 5.76 pg/ml (t=2.936,P=0.004 5),all with statistical differences (P＜0.05).Pearson analysis showed that Gas6 was positively related with IL-17,IL-4,IFN γ (r=0.564,0.486,0.449,P＜0.05) and there was difference statistically,but Gas6 was not correlated with IFN-α.Conclusion Gas6 may participate in the disease formation of ITP through affection on cytokines secreted by Th cell subsets,and it was the potential therapeutic and predicted target for this disease clinically.

Objective To analyze the affection and clinical significance of CD26/DPP4 on CD4+T cells and its cytokines in patients withCrytococcalMeningitis.Methods Peripheral blood was collected from 36 patients diagnosed withCrytococcal Meningitis in Changhai Hospital and Changzheng Hospital,Shanghai from August,2011 to December,2015,meanwhile 36 health controls’was also acquired.Peripheral blood mononuclear cell (PBMC)was separated by density gradient centrifuga-tion,CD26+CD4+T and CD26-CD4+T cell groups were classified by Flow Cytometry,the expression level of cytokines was tested by reverse transcriptase-polymerase chain reaction (RT-PCR).The correlation between DPP4 activity,CD26+CD4+T (%)and APACHE II score,IL-17,TNF-α,IL-4,IFN-γwas measured by Pearson coefficient.Results CD26+CD4+T(%)between experimental and control groups was 13.35±3.83 vs 8.39±2.14 (t=6.78,P<0.000 1).DPP4 activity was 50.89±17.21 mU/ml vs 73.83±20.24 mU/ml (t=5.18,P<0.000 1),with statistically significant differences.In ex-perimental groups,CD26+CD4+T (%)was positively related with APACHE II score,IL-17,TNF-α(r=0.431,0.564, 0.688,P=0.003 8,0.001,0.004 6).DPP4 activity was negatively interrelated with APACHE II score,IL-17,TNF-α,IFN-γ(r=-0.544,-0.489,-0.678,-0.734;P<0.001).Conclusion CD26/DPP4 may be involved in the pathogenesis of Crytococcal Meningitis through regulation of Th subgroups,and it was the potential therapeutic target and the predicted marker of the disease.

Objective To study the variation in numbers of patients attended in the Emergency Department (ER) of a large - scale teaching hospital during weekends or holidays and workdays in order to find out an objective criterion for the assessment of ER overcrowding and the regularity of ER overcrowding.Methods It was a prospective observational study of variation in number of.patient attended in ER during different periods of time round the clock observed from May 1 through October 31 in 2008 -2010 with 110000 emergency patients annually.The roles of diurnal rhythm,holiday phenomenon and medical coverage in the variation in numbers of patients were observed.The multiple logistic regression analysis was used to define the criterion of ED overcrowding.Results During workdays,the regularity of variation in number of critically ill patients seen to in ER was distinctive,the number of patients peaked in the period of 20:00 -22:00 and bottomed out in the period of 4:00 -6:00,while overcrowding scores of both peak and bottom were carried out 2 hours later.The number of emergency patients significantly increased at weekends and long holidays in a form of double peaks,from 10 am to 12 pm and 8 pm to 10 pm.The number of emergency patients was obviously determined by the provisions of medical coverage,but it was only true to non - critical patients,while the number of critical patients did not noticeably change during weekends or holydays.Multivariate regression analysis showed that the number of emergency patient attended in ER ( B =0.027,P ＜0.01 ) and the rate of emergency bed occupancy ( B =5.25,P ＜0.01 ) in the period of two hours significantly correlated with the ER overcrowding in the coming period of two hours (B =0.027,P ＜0.01,B =5.25,P ＜ 0.01,respectively).Conclusions The demand for critical care resources varies up and down all the time.The variation in volume of critical patients is quite regular during workdays and weekdays or holydays.It is important to separate critical patients from non - critical patients in order to divert non - critical patients quickly.Prediction of overcrowding in ER can be made with knowledge of the number of patient attended and the rate of bed occupancy,if the provisions of medical coverage unchanged.This regularity of variation in number of patients can be used as a practical guidance to rational allocation of critical care resources and improvement of patient throughput.