With the human development and social progress,the task of reform in educa-tion and teaching has become more urgent and increasingly heavy. The article discusses the education reform of clinical medicine in the content of courses,construction of teaching materials, teaching methods,teaching assessment and teaching management areas,in combination with the pracice of the current clinical teaching reform in medical school.

As an important part of medical education,clinical practice teaching is an im-portant period for medical students to become doctors,in which they integrate theory with practice.So,in clinical practice teaching process,it is important to cultivate students’ innovative ability and practical ability,and emphasize quality-oriented education.For clinical skills training center,it is of great significance to reform management of clinical skills teaching,establish scientific and effective teaching methods,develope the correct clinical thinking and innovative aware-ness.

Objective To investigate the treatment methods of tissue defects in nose and lower eyelid area.Methods Based on the impaired area,combined pre-expansion of forehead and facial region was adopted.The volume of soft tissue expander was determined.150-170 ml expander was implanted between frontalis muscle and periosteum of forehead,while at the facial region,and the volume of expander should be determined by the normal skin area as large as possible.The excision of impaired tissue was performed after sufficient expansion,and then skin flap or transposition skin flap were advanced at the facial region.At forehead,ortho-position skin flap based on supratrochlear vessels was designed for repairing the nose and palpebra inferior region.Three weeks later division of the ortho-position skin flap was carried out.With the flattened pedicle,the rest part of impaired area was replaced.Results Six cases were performed with this method.For all the cases,the survival rate of flap was 100％.Esthetic appearance and satisfying color-match were achieved,without appearance of lower eyelid ectropion.Conclusions Combined pre-expansion of forehead and facial region is an ideal method in treatment of the defects in nose and lower eyelid area.

OBJECTIVETo observe the effects of surgical delay procedure on the survival of perforator flap with three angiosomes in rat, and to explore its possible mechanism.

METHODSThe flap model was a perforator flap with three angiosomes which located on the right dorsal side of a rat based on the right deep circumflex iliac vessel. The two connection areas between the three angiosomes were successively named choke zone (CZ) 1 and CZ 2 beginning from the pedicle to the remote area. A total of 110 SD rats were divided into routine flap group (RF, n = 40), delay only group (DO, n = 30), and delay flap group (DF, n =40) according to the random number table. (1) In group RF, 30 rats were selected according to the random number table, and flap surgery was performed directly. Six rats were sacrificed on post operation day (POD) 0, 1, 2, 3, 7 respectively to collect the full-thickness skin samples at both CZs for HE staining to measure the vascular density and diameter. The rest 10 rats underwent flap surgery immediately after a catheter was successfully implanted into their external jugular vein. A volume of 1.5 mL sodium fluorescein solution (100 g/L) was injected to the 10 rats on POD 0 (5 rats) or POD 1 (5 rats) each time with a 2-day interval to learn the change in flap circulation. Each rat was injected for 4 times. The flap survival rate of the 10 rats was calculated on POD 7, and the configuration and distribution of the vessels in the flap were observed through angiography with the improved perfusion method of lead oxide-gelatin. (2) In group DO, the right thoracodorsal perforators of all the rats were surgically ligated through a small skin incision, and 6 rats were sacrificed on POD 0, 1, 2, 3, 7 respectively. The skin samples of each rat at the same area as in group RF were harvested to measure the vascular density and diameter. (3) In group DF, rats were treated with ligation surgery as in group DO, and then they were assigned and treated as in group RF on POD 7 with corresponding indexes detected later. Data were processed with group t test, analysis of variance with factorial design, and SNK test.

RESULTS(1) Significant differences of vascular density at both CZ 1 and CZ 2 were found on POD 7 among the three groups ( with F values respectively 2. 69 and 2. 76, P values below 0.05). The vascular density values of CZ 1 and CZ 2 of rats in group DF were (29 ± 7) and (31 ± 8) per mm on POD 7, which were significantly higher than those of group RF [(23 ± 5) and (23 ± 3) per mm2, with q values respectively 5.67 and 6.01, P values below 0.05] and those within group DF on POD 0 (with q values respectively 6.42 and 7. 14, P values below 0. 05). On POD 3 and 7, the vascular diameter values of CZ 1 of rats in groups RF and DF were significantly higher than those of group DO (with q values from 8. 15 to 11.13, P values below 0.05). The vascular diameter values of CZ 2 of rats in group DF onPOD 0, 1, 2, 3,7 [(65 ± 8), (63 ± 13), (69 ± 9), (67 ± 8), (64 ± 13) 230m] and in group DO on POD 3 and 7 were significantly higher than those in group RF [respectively (46 ± 10) , (40 ± 9), (43 ± 13), (46 ± 12), (47 ± 11) µm on POD 0, 1,2, 3, 7 ] at corresponding time point (withqval- ues from 7.29 to 10.79, P values below 0.05). The difference in vascular diameter between CZ 1 and CZ 2 was statistically significant in groups RF and DO on POD 3 and 7, and in group DF on POD 0, 1 , and 2 (with q values from 5.32 to 9.56, P values below 0.05). Compared with that on POD 0 within each group, the vascular diameter of CZ 1 in groups RF and DF and that of CZ 2 in group DO increased significantly on POD 3 or 7 (with q values from 6.12 to 8.13, P values below 0.05). (2) In groups DF and RF, blood from the pedicle ran through CZ 1 and covered the dynamic territory successfully within POD 7. On POD 0, the blood within all flaps was blocked for about 3 min after going through CZ 1 at 1 cm distal from CZ 2 in group DF and around CZ 2 in group RF. (3) Flap survival rate of rats in group DF was (95 ± 12) % , which was statistically higher than that of group RF [(80 241 9) % , t = 2.91, P <0.01]. All the partial flap necrosis occurred in potential territory. (4) Compared with the vessels in the left dorsal side without surgery, the vessels of CZ 1 in group RF were dilated obviously, and the boundary between vascular trees became indistinct, but the vessels in CZ 2 changed slightly; the vessels in both CZs in group DF were dilated dramatically.

CONCLUSIONSThe delay method could enhance the survival of potential territory in perforator flap with three angiosomes, and it acted mainly by dilating the choke vessels in CZ 2 before flap surgery.

Angiography ; Animals ; Graft Survival ; physiology ; Male ; Necrosis ; Perforator Flap ; blood supply ; physiology ; Rats ; Skin ; blood supply ; Surgical Flaps ; blood supply ; physiology ; Time Factors

OBJECTIVETo investigate the clinical application of expanded flap based on cutaneous branch of transverse cervical artery for reconstruction of cervical cicatricial contracture.

METHODSBased on the clinical anatomy of cutaneous branch of transverse cervical artery flap, we design the corresponding subclavicular area for expansion. The incision was usually located at the anterior axillary fold, 5-8 cm in length. The expander was implanted under the deep fascial layer, without injury of the vascular pedicle. Fixation sutures were put about 1 cm apart from the incision to prevent the expander from transposition and exposure. After expansion, the cervical cicatricial contracture was excised and released. According to the defect, the expanded flap based on the cutaneous branch of transverse cervical artery was designed, with the pedicle located at the posterior margin of sternocleidomastoid and 1. 8 cm above median point of clavicle. "S" shape incision was made at the location of vascular pedicle. Subcutaneous dissection was performed 1.5 cm in width along the incision on both sides. Then the flap was harvested under the deep fascial layer and rotated to cover defect without tension. It was not necessary to dissect the vascular pedicle further. The defect at donor site was closed directly.

RESULTS17 cases were treated with the island flap. The contracture of the cervical scar was corrected completely with aesthetic appearance.

CONCLUSIONSExpanded flap based on cutaneous branch of transverse cervical artery has reliable blood supply. It' s an ideal flap for the treatment of cervical cicatricial contracture.

Arteries ; Cicatrix ; surgery ; Clavicle ; Contracture ; surgery ; Dissection ; methods ; Fasciotomy ; Humans ; Neck ; blood supply ; Neck Muscles ; anatomy & histology ; Surgical Flaps ; blood supply

Objective To discuss the repairing methods of the wound after upper lip lesion excision.Methods The wound after upper lip lesion excision was repaired by expanded pedicled submental flap.The 3 cm-long incision was located in 1 cm to sub-mandible.The 100 ml expander was placed beneath the platysma,and the aqueducts and spigots of the expanders were laid out of the skin.After complete expansion,the spastic scars of the upper lip and nasal bottom were resolved,the nasal columella and upper lip were put back to the normal position.The pedicled submental flap was transferred to the wound after upperlip excision according to the size of the wound.The pedicle was severed after 3 weeks.Results There were 5 cases of the expanded pedicled submental flap to repair the wound after upper lip excision.The flap survived without complications.The appearances were satisfied by the patients.Conclusions The method of the expanded submental flap is suitable for the wound after upper lip excision.

Objective:The aim of this study was to investigate the mechanism underlying transforming growth factor-β1 ( TGF-β1 ) induced differentiation of bone marrow-derived mesenchymal stem cells (BMSCs)into myofibroblasts.Methods:Primary mouse BMSCs were isolated from bone marrow by flushing the tibias and femurs of mice , and passage 3 to passage 5 of BMSCs were used in the experiments . BMSCs differentiation into myofibroblast was induced by different doses of TGF-β1.In addition, reactive oxygen species (ROS) inhibitor (N-acetylcysteine, NAC) was added to test its effect on the action of TGF-β1.Expressions of BMSCs differentiation parameters , α-smooth muscle actin (α-SMA), collagenα1(Ⅰ) [Col α1(Ⅰ)] and collagen α1(Ⅲ) [Col α1(Ⅲ)] were measured by real-time quantitative PCR (RT-qPCR) and Western blot analysis.BMSCs were preloaded for 15 min with 2’, 7’-dichlorohydro-fluorescein diacetate ( DCFH-DA) , then stimulated with TGF-β1 for different times , and fluorescence of ROS was measured using high content analysis .Results:TGF-β1 stimulated differentiation of BMSCs into myofibroblasts and up-regulated expression of α-SMA, Col α1(Ⅰ) and Col α1(Ⅲ) in a dose-dependent manner , which blocked by ROS inhibitor NAC .In addition , TGF-β1 could induce a significant rapid and transient increase in ROS production in BMSCs , and the effect of TGF-β1 on ROS production was peaked at 30 min.Conclusion:TGF-β1 induced differentiation of BMSCs into myofibroblasts via production of ROS.

Objective To explore the method of total nasal reconstruction when the forehead skin for expanding is unavailable.Methods According to the principle of total nasal reconstruction,total nasal scar and deformity were repaired with expanded random forearm falp.All the expanders were placed in flexor side of forearm.The incision sides were placed in proximal,distal,or lateral part of the forearm according to different pedicles.After expansion,the nares were enlarged,eversion of ala nasi corrected,the contracture scars sufficiently released,and the size and shape of the reconstructive nose designed according to face size.The scar of nasal dorsum and capsule of the expanded flap could be used for reconstructing nasal dorsum.Donor sides could be sutured directly,the pedicle could be cut 3 weeks later.Results All the flaps survived with good appearances,and 3 of the 15 cases with proximal,11 with distal,and 1 with lateral pedicle.The effect of distal pedicle group was better than that in proximal and lateral pedicle group because of comfortable posture longer pedicle,and providing more tissue for reconstruction.Conclusions Total nasal reconstruction with expanded random forearm flap is an option when the forehead skin for expanding is unavailable.

Objective To summarize the experience of surgical treatment of venous drug-induced infective endocarditis(IE). Methods The 17 cases of drug-induced IE were found to have valvular vegetations,16 patients had involvement of tricuspid valve, 1 mitral valve associated with ventrieular septal defect. Preoperative blood culture was positive in 8 patients. The operations included tricuspid valve repair (6 cases),tricuspid valve replacement(8 cases), mitral valve replacement and VSD closure(1 cases). Results All patients were alive and discharges. After follow-up of 6 months to 6 years, 1 case had severd tricuspid alve regurgitation, 1 had haemoptysis because of incorrect anticoagulation. Conclusions This study indicated surgical intervention is effective treatment of venous drug-induced infective endocarditis.

Objective To explore the clinical features and possible carcinogenesis mechanism of the ulcerative colitis (UC)-associated colorectal cancer. Methods From 1984 to 2008, 6 clinical cases of UC-associated colorectal cancer were collected at Peking Union Medical College Hospital. The characters of morbidity, clinical features, pathology type, treatment and prognosis were analyzed.Immunohistochemistry(IHC) was performed to study the protein expression of adenomatous polyposis coli protein(APC), β-catenin, P53 and Wnt-1 in the specimens. Results The canceration of UC was 1.1 %, higher in female cases (5/6), the average duration was 14.3 years. All cases presented typical UC manifestation, most involved total colon (5/6) and none of them complicated with primary sclerosing cholangitis (PSC). There were 4 rectal cancers and 2 descending colon caners the UC cases collected. The major pathology type was adenocarcinoma with poor prognosis. The positive protein expression ratio of APC, β-catenin, P53 and Wnt-1 were 6/6, 6/6, 5/6 and 6/6 respectively.Conclusion The rectal cancer should be monitored and prevented in UC patients with total colon involved and long disease duration. Multi-pathway may possibly be involved in the carcinogenesis.