Objective To explore the effecr of problem-based leaming(PBL) in emergency clinic skill training.Methods Totally 65 students participating in emergency clinical skill training in The Ninth People's Hospital of Shanghai Jiao Tong University were enrolled.Thirty-three 2008 grade five-year clinic majors as control group were taught by traditional teaching method while Thirty-two 2009 grade five-year clinic majors as experimental group were taught by PBL.After the courses,final examinations (theoretical exam,case analysis and skill appraisal) and questionnaire smvey were used to evaluate the teaching effectiveness between the two groups.Data were managed by SPSS 13.0 software package.Quantitative data between two groups were compared by t-test.Enumeration data between two groups were compared by chi-square test.Results There was no difference in theoretical score between two groups(P=0.212).Scores of case analysis and skill appraisal in experimental group were higher than those in control group (P＜0.05).There were significant differences between experimental group and control group in arousing students' learning interest,promoting understanding of knowledge,cultivating clinical comprehensive ability,increasing communication skills,improving team cooperation ability and clinical operating ability(P＜0.05).Conclusions PBL mode is better than traditional teaching methods in emergency clinical skill training.PBL can improve students' clinical comprehensive ability and emergency operations can be perfectly applied in clinic typical cases.

Objective To analyze the possible prognostic factors of thoracic-esophageal cancer patients with lymph node (LN) metastasis after esophagectomy plus three-field lymphadenectomy.Methods 590 esophageal cancer patients with LN metastasis after esophagectomy plus three-field lymphadenectomy were recruited from Jan.1993 to Mar.2007,and the prognostic factors and causes of postoperative failure were analyzed.Results Five-year survival in the whole sample was 29.6％.While the 5-year survival in different subgroups with 1-2,3-6 or ＞ 7 metastatic LNs were 41.2％,22.2％ and 7.0％ (x2 =62.158,P ＜0.0001),respectively.Univariate analysis showed that tumor site,disease length,T stage,number of metastatic LN and the seventh edition of AJCC staging system were prognostic factors.Multivariate analysis indicated that tumor site and number of metastatic LN were two independent prognostic factors.Conclusion Tumor site and number of metastatic LN were independent prognostic factors influencing the outcome of esophageal cancer.

Objective To explore the expressions and distributions of glial cell line -derived neurotrophic factor (GDNF)and itstyrosine kinase receptor RET in the terminal rectums of fetal rats with congenital anorectal malfor-mations (ARM)at different gestationalage,and to explore their effects on the enteric nervous system in the terminal rectum of ARMfetal rats.Methods Thirty -five SD pregnancy rats were divided into a saline group (n =1 0)and an ethylenethiourea experiment group (n =25)by simple randomized study.The fetal rats were removed from the pregnant rats at the gestational 1 6 d,1 8 d and 20 d.The fetal rats were divided into the saline control group,the ethylenethiourea control group (fetal rats without ARM)and the ethylenethiourea malformation group (ARM fetal rats)by the naked eye and dissecting microscope.HE staining was used to observe the morphology and the intestinal ganglion cells in the terminal rectum were counted.The immunohistochemical staining and Western blot methods were used to observe the distributions of GDNF and RET in the rectum at the gestational 1 6 d,1 8 d and 20 d.The quantitative real -time poly-merase chain reaction (qRT -PCR)was used to detect the expression of GDNF mRNA in the fetal rats in the terminal rectum at the gestational 1 6 d,1 8 d and 20 d.Results HE staining:the development of anorectal terminal in 3 groups of fetal rats was unclear at the gestational 1 6 d.A small amount of scattered nerve plexuses were observed in the muscu-lar layer.The nuclei were small and sparse.The axons and cytoplasms were less.The serosal layer,muscular layer,sub-mucosa,mucosal layer and glands in the terminal rectum were gradually clear in the saline control group and the ethyle-nethiourea control group at the gestational 1 8 d and 20 d.The intermuscular submucosal nerve plexuses increased gra-dually (1 1 .400 ±3.1 34 and 1 1 .200 ±3.425 at the gestational 1 8 d;66.1 00 ±4.954 and 67.600 ±5.481 at the gesta-tional 20 d).While,the layer was unclear in the ethylenethiourea malformation group and the nerve plexus was less (7.800 ±1 .989 at the gestational 1 8 d,and 25.200 ±3.048 at the gestational 20 d),and the difference was statistical-ly significant compared with 2 control groups (F =7.591 ,271 .833,all P <0.05).Immunohistochemistry satning:the expressions of GDNF and RET in all layers of the intestinal wall in the 3 groups of fetal rats were unclear at the gesta-tional 1 6 d and only a few positive cells were observed.The GDNF and RET were expressed in the mucosal layer and submucosa of the terminal rectum as well as intermuscular nerve plexus in the saline control group and the ethylene-thioured control group at the gestational 1 8 d and 20 d.With the continuous development of the embryo,their expression intensities were gradually increased.The expressions of GDNF and RET positive cells were decreased gradually in the ethylenethiourea malformation group.The difference was significant statistically compared with 2 control groups (all P <0.05).qRT -PCR:the expressions of GDNF mRNA showed no statistical difference among 3 groups at the gestational 1 6 d (P >0.05);the expressions of GDNF and RET protein were 1 03.624 ±27.533 and 1 05.1 84 ±1 9.634 at the ges-tational 1 8 d;1 51 .496 ±33.622 and 1 50.738 ±21 .423 at the gestational 20 d in 2 control groups.Compared with the ethylenethiourea malformation group (79.1 69 ±1 1 .697 at the gestational 1 8 d;94.873 ±1 1 .309 at the gestational 20 d),and the difference were statistically significant (all P <0.05).Conclusions The expressions of GDNF and its tyrosine kinase receptor RET had a certain temporal correlation in the terminal rectum of normal fetal rats at different gestational ages and ARM.Moreover,the abnormal expressions of GDNF and its tyrosine kinase receptor RET in the dis-tal rectum of ARMfetal rats can affect the development of enteric nervous system.

Aim To investigate the effect of salvianolic acid B (Sal B)on c-Jun N-terminal kinase (JNK)ac-tivation and apoptosis of INS-1 cells induced by inter-mittent high glucose.Methods INS-1 cells were pre-incubated with Sal B for 24 h,followed by exposure to intermittent high glucose (IHG,11.1 mmol·L-1 12 h,33. 3 mmol·L-1 12 h)for 72 h.Cell viability was assessed by MTT assay and cell apoptosis was evalua-ted by flow cytometry.Glucose induced insulin secre-tion capacity and intracellular reactive oxygen species (ROS)contents were measured by enzyme linked im-munosorbent assay (ELISA)and a fluorescent probe DCFH-DA,respectively.Levels of JNK activation and PDX-1 protein expression were determined by Western blot analysis.Results Sal B significantly alleviated IHG-induced cell injury and apoptosis,with glucose induced insulin secretion capacity improved evidently (P<0.05 or P<0.01).Preincubation with Sal B no-tably decreased intracellular ROS and JNK activation in INS-1 cells,while the level of PDX-1 protein was in-creased markedly (P<0.05 or P<0.01 ).Conclu-sion Sal B is capable of ameliorating IHG-induced cell injury and apoptosis in INS-1 cells,which might be derived from suppression of JNK activation and up-regulation of PDX-1 protein expression.

Objective:To investigate the clinical features of Epstein-Barr virus associated lymphoproliferative disease in children and to improve the understanding of this disease.Methods:This study included the children with Epstein-Barr virus associated lymphoproliferative disease admitted to the First Affiliated Hospital of College of Medicine of Zhejiang University from January 2014 to December 2018.Data of these children were collected, including age, clinical manifestations, laboratory results, treatment and outcome.The clinical features and therapeutic effects were analyzed.Results:A total of 114 cases(mean age 6 years, 0~17 years)were enrolled in this study, including 53 males and 61 females.There were 107 cases(93.86%) in the mild group (38 cases of EBV infection and 69 cases of infectious mononucleosis) and 7 cases in the severe group (6.14%). Six cases of the severe group were T cell or NK cell proliferation.Compared with the mild group, the load of EBV-DNA was higher in the severe group, but there was no significant difference( χ2=0.957, P>0.05). The IgM in severe group was significantly lower( Z=-2.041, P<0.05). But the differences in the level of immune function including IgA, IgG, CD4 + cell and CD8 + cell between the severe group and the mild group were not significant.The cases in the mild group had improved after antiviral treatments.Among the severe group, 3 cases survived after treatment, another 1 case was diagnosed as hydroa vacciniforme-like EBV-related proliferative disease (HV-like LPD). After antiviral treatment, the effect was not good, then after high-dose IVIG treatment and Bortezomib combined with methylprednisolone treatment, the EBV-DNA load decreased and the condition improved.While 1 case lost to follow-up, there were 2 cases with EBV-associated hemophagocytic syndrome and 1 case with EBV-associated lymphoma died after chemotherapy or transplantation. Conclusion:EBV-associated lymphoproliferative disease may manifest as a condition similar to infectious mononucleosis.High IgE, low IgM or high DNA load may indicate poor prognosis.Immune function after EBV infection may have different effects on prognosis.When the infected lymphocyte types are NK or T cells, it may indicate poor prognosis.The efficacy of transplantation and chemotherapy in severe cases is still uncertain.

OBJECTIVETo evaluate the safety and efficacy of laparoscopy-assisted surgery for Siewert I adenocarcinoma of the esophagogastric junction (AEJ).

METHODSClinical data of 36 patients who underwent left transthoracic dissection of lower mediastinal lymph node followed by laparoscopy D2 lymph node dissection for Siewert I AEJ in the Fujian Provincial Cancer Hospital between March 2008 and March 2013 were analyzed retrospectively. A left thoracic-abdominal single incision was used without transection of costal arch. Celiac lymph nodes dissection was performed laparoscopically followed by left transthoracic dissection of lower mediastinal lymph node. Digestive tract reconstruction was carried out by esophagus-gastric posterior wall end-to-side anastomosis.

RESULTSLaparoscopy-assisted surgery was successfully achieved in all the 36 patients and there were no in-hospital deaths. The mean operation time, blood loss and number of harvested lymph node were (216.4±46.0) min, (252.1±41.1) ml and 30.7±3.2 respectively. All the procedures were R0 resections. The complication rate was 16.7% (6/36). All the complications were managed by conservative treatment, and there were no re-operations. The lymphatic metastasis rate was 50.0% (18/36), and the lymph node groups with high metastatic rate (all >10.0%) were groups 1, 2, 3, 7, 9, 110 and 111. The median follow-up was 25 months. The overall 3-year survival was 48.0%.

CONCLUSIONLaparoscopy-assisted surgery for Siewert I AEJ is safe and feasible.

Adenocarcinoma ; surgery ; Aged ; Esophageal Neoplasms ; surgery ; Esophagectomy ; methods ; Female ; Follow-Up Studies ; Gastrectomy ; methods ; Humans ; Laparoscopy ; methods ; Lymph Node Excision ; methods ; Male ; Middle Aged ; Retrospective Studies ; Stomach Neoplasms ; surgery ; Treatment Outcome

Biliary atresia (BA) is a common neonatal liver disease characterized by inflammation and fibrosis of the extrahepatic biliary ducts,leading to cholestasis and biliary cirrhosis.It is also a severe liver disease in infants.The pathogenesis of BA is associated with multiple genes and gene polymorphism,virus infections,epigenetic,immune abnormalities,and so on.With the development of genetic technology,it provides a new method to determine the susceptibility genes in BA.Now,more and more doctors pay attention to the change and regulation of genes in BA.

In order to improve the quality of medical records written by interns of clinical medicine in hematology department,we evaluated and analyzed 100 medical records written by the interns.The main reasons that affect the quality of medical record written by interns are the writing defects that are history of present illness,past history,personal history,the record of the clinical operation,blood transfusion and chemotherapy.There are other reasons for affecting the quality of medical records,such as students in clinical practice not paying attention to the writing of medical records,the relative lag of teaching management,the particularity of the diseases in the department of hematology and the weak legal consciousness.Therefore,we should strengthen the teaching management,improve the comprehensive quality of the clinical teaching teachers,carry out the pre job training of the medical records for the interns,train the interns' inquiries and the ability to communicate with the doctors and patients,and make use of the typical medical records of the Department of Hematology to combine the discussion and other ways,so as to strengthen the interns' clinical disease writing skills and legal consciousness as well as the quality of their writing medical records.

Objective To investigate association of the paired box 4 (PA X 4) gene rs3824004 (574C>A; R192S) and rs2233580 (575G>A; R192H) polymorphism with obesity and metabolic markers in children and adolescents. Methods A total of 103 obese children were randomly selected, and an average age was (10.82±2.57) years, and body mass index (BMI) was (26.82±4.57) kg/m2. At the same period, 100 normal weight children were selected as the control group, and an average age of (10.60±2.84) years, and BMI was (16.79±2.13) kg/m2. The blood pressure, physical measurements, and blood metabolic parameters were measured and compared. The oral glucose tolerance test (OGTT) and insulin release test were performed in the obesity group. The homeostasis model insulin resistance index (HOMA-IR) and the overall insulin sensitivity index (WBISI) were calculated. PA X 4 rs3824004 and rs2233580 polymorphism were detected by PCR.The differences of allele frequency and genotype frequency of polymorphic loci were analyzed, and the correlation between different genotypes and metabolic indexes was analyzed. Results The height, weight, BMI, systolic blood pressure, diastolic blood pressure, waist circumference, hip circumference, waist to height ratio (WHtR), fasting blood glucose (FPG), total cholesterol (TC), low density lipoprotein (LDL), triacylglycerol (TG), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) in the obesity group were significantly higher than those in the control group, and the high density lipoprotein (HDL) was significantly lower than that in the control group (all P<0.05). The frequency of gene distribution was in accordance with the Hard-Weinberg balance. The frequencies of A allele of rs3824004 in obesity and control groups were 4.9% and 5.0%, respectively, and the frequencies of CA genotype were 9.7% and 10.0%, respectively, and there was no significant difference between two groups (P>0.05). The frequency of GA allele of rs2233580 in obesity group was 25.2%, which was significantly higher than that in control group (P<0.05). The BMI and waist in rs2233580 GA genotype were significantly higher than those in GG genotype (all P <0.05). However,logistic regression analysis showed that there was no correlation between PA X 4 rs2233580 genotype and metabolic markers (all P>0.05).There were no significantly differences in HOMA-IR and WBISI among different genotypes of PA X 4 rs2233580 in obesity group(all P>0.05).Conclusions PA X 4 rs2233580 affects children's BMI and waist circumference and may be involved in the development of childhood obesity, but it is not an independent risk factor for obesity in children and adolescents.

Background/Aims: Acute-on-chronic liver failure (ACLF) is a catastrophic illness. Few studies investigated the prognostic value of vitamin D-binding protein (VDBP) for hepatitis B virus (HBV)-related ACLF (HBV-ACLF) resulted in conflicting results. Methods: Two prospective HBV-ACLF cohorts (n=287 and n=119) were enrolled to assess and validate the prognostic performance of VDBP. Results: VDBP levels in the non-survivors were significantly lower than in the survivors (P<0.001). Multivariate Cox regression demonstrated that VDBP was an independent prognostic factor for HBV-ACLF. The VDBP level at admission gradually decreased as the number of failed organs increased (P<0.001), and it was closely related to coagulation failure. The areas under the receiver operating characteristic curve (AUCs) of the Child-Pugh-VDBP and chronic liver failuresequential organ failure assessment (CLIF–SOFA)-VDBP scores were significantly higher than those of Child-Pugh (P<0.001) and CLIF-SOFA (P=0.0013). The AUCs of model for end-stage liver disease (MELD)-VDBP were significantly higher than those of MELD (P= 0.0384) only in the case of cirrhotic HBV-ACLF patients. Similar results were validated using an external multicenter HBV-ACLF cohort. By longitudinal observation, the VDBP levels gradually increased in survivors (P=0.026) and gradually decreased in non-survivors (P<0.001). Additionally, the VDBP levels were found to be significantly decreased in the deterioration group (P=0.012) and tended to be decreased in the fluctuation group (P=0.055). In contrast, they showed a significant increase in the improvement group (P=0.036). Conclusions The VDBP was a promising prognostic biomarker for HBV-ACLF. Sequential measurement of circulating VDBP shows value for the monitoring of ACLF progression.