Based on the Miller Pyramid for assessing clinical competence, this article analyzed the existing problems in the practice of teaching physical examination and provided suggestions for possible reforms.

ObjectiveTo investigate the clinical features and risk factors of patient with Wegener's granulomatosis complicated with pulmonary infection.Methods Patients with Wegener's granulomatosis admitted to our hospital in the past 11 years were retrospectively analyzed.Comparisons between groups were performed by t tests or Fisher test.ResultsPulmonary infection occurred in 27 cases with an incidence rate of 29％.Twenty-six percent of pulmonary infections occurred at the initial diagnosis,and 44％ occurred within 6 months,while 30％ occurred later than 6 months.The clinical manifestations of pulmonary infection were productive cough (89％),hemoptysis (63％),fever and fatigue (56％),chest pain and pactoralgia (33％).The most common causative pathogen were bacteria(59％ ),fungi(37％ ),and tubercle bacillus(37％ ).Sinus infection(P=0.01),hypoproteinemia(P=0.03),hypoimmunoglobulinemia (P=0.007),and methylprednisolone pulse therapy(P=0.002) were the risk factors for pulmonary infection.ConclusionThe occurrence of Wegener's granulomatosis complicated with pulmonary infection is high within 6 months.The most common clinical manifestation is productive cough.The most common causative pathogens are bacteria,tubercle bacillus and fungi.Sinus infection,hypoproteinemia,hypoimmunoglobulinemia,and methylprednisolone pulse therapy are risk factors of pulmonary infection.

Objective To analyze the result of treatment for acute-on-chronic liver failure patients with fast high efficiency Nucleoside and to explore the relations among inhibition to virus replication , liver failure development and immune rejection .Methods Sixty-two cases of acute-on-chronic liver failure pa-tients with HBV DNA(+) were divided into study group (treated with a kind of fast and nucleoside , n =30) and control group( n =32).HBV DNA,CD4 +T,CD8 +T, C3,C4 TBIL,PTA were observed at treat-ment 0w,2w and 4w.Results All of the study and control group patients , serum HBV DNA were positive before treated.And the levels of CD4+,CD8 +,C3,C 4,TBIL,PTA of study group were not significantly compared with control group .At treatment 2w , the rate of HBV DNA diverted negative in study group 90.0%(27/30), was significantly more then control group (9.4%, 3/32)(χ2=37.14 , P <0.01).But the CD4 +,CD8 +,C3,C4,TBIL,PTA levels were not significantly however between study and control group . At treatment 4w ,the rate of HBV DNA diverted negative in study group (96.7%, 29/30), was significant-ly more then control group(12.5%,4/32) (χ2 =40.74, P <0.01).CD4 +, CD8 +,C3,C4,TBIL,PTA levels of the study group were significantly more compared with the control group .The CD4 +level of study group (495.33 ±89.91)cells/ml, was higher significantly then control group (270.34 ±97.74)cells/ml( t=9.42, P <0.01),the CD8 +level (571.03 ±120.15 ) cells/ml, was higher significantly then control group(224.88 ±79.68)cells/ml( t =13.45, P <0.01).The C3 level of the study group (0.28 ±0.11) g/L, was lower significantly then control group ( 0.68 ±0.13 ) g/L ( t =13.13 , P <0.01 ) , the C4 level (0.12 ±0.06)g/L, was lower significantly then control group (0.23 ±0.10)g/L( t =4.92, P <0.01). The TBIL level of study group ( 653.93 ±131.02 )μmol/L, was higher significantly then control group (285.63 ±154.63)μmol/L( t =10.09, P <0.01),the PTA level (17.13 ±7.07)%, was lower signifi-cantly then control group(50.94 ±13.68)%( t =12.10, P <0.01).The death rate of the study group( 57.9%) was higher significantly compared with the control group (28.1%)(χ2 =6.39, P <0.05).Con-clusion Treatment of chronic severe hepatitis with fast and high efficiency nucleoside may arise the T cell subset level and make the immune rejection strength , as a result the liver failure maybe far away from cure .

Objective To explore the features of patients with acute leukemia (AL) in Hematology Department of Shenzhen Hospital affliated to Beijing University during the past six years. Methods The data of the 1056 acute leukemia dignosed in our department between 2002-2007 were collected and analyzed retrospectively. Results The male patients was predominant (male/female ratio was 1.78). The number of patients with acute myeloid leukemia(AML) was higher than that of patients with acute lymphoblastic leukemia (ALL) (AML/ALL ratio was 1.85). Most of the AML patients were young adult (65 %) and elderly ALL patients were very rare(1.33 %). AL cases were tended to increase gradually by year. The ratio of treatment-related AL in Shenzhen was lower than that reported literature in other countries. The major cause of the treatment-related AL were chemotherapy/radiotherapy and psoriasis treated with bimolane. Conclusion Some of the features of AL patients in China were further confirmed and some new features were also found in this study. These changes should be demonstrated by the next national epidemiology survey of leukemia.

OBJECTIVETFo compare the efficacy and complications rate of intramedullary (IM) nailing or K-wire versus plating fixation for clavicular fractures.

METHODSPubmed, Embase, Cochrane Library databases, CNKI, VIP and Wangfang databases were searched to find all randomized or quasi-randomized controlled trials of clavicle fractures using plating versus IM nailing or K-wire. The methodologic quality of the studies was assessed. After independent study selection by 2 authors ,data were collected and extracted independently. Outcomes of postoperative shoulder functional measurement, the efficacy and information of the operation and complications rate were meta-analyzed using RevMan 5 software.

RESULTSNine hundreds and seventy-six patients in 10 randomized controlled trials (RCTs) and 3 quasi-RCTs were involved in the meta-analysis,of which 5 studies compared the K-wire and the plating fixations and 8 studies compared the IM nailing and the plating fixations. The overall odds ratio(OR) (with 95% CI) of the operation efficacy for K-wire versus the plating was 3.79 (1.93, 7.46). The overall weighted mean difference (with 95% CI) of Constant Shoulder score for plating versus IM fixation was -1.39 (-3.43, 0.65) in 6 studies. The overall OR of the plating versus IM nailing was 9.34(2.70, 32.32) for the overall major complications in 5 studies and 5.04 (1.52,16.77) for the revision rate in 5 studies.

CONCLUSIONThe current limited evidences suggested that the IM fixation could reduce the incidences of the overall major complications and the revision surgery, while the post-operative efficacy of the plating was superior to the K-wire. More high quality RCTs are still needed in the future.

Bone Nails ; Bone Wires ; Clavicle ; injuries ; surgery ; Fracture Fixation, Intramedullary ; instrumentation ; methods ; Fractures, Bone ; surgery ; Humans ; Randomized Controlled Trials as Topic

Objective To investigate the management and control of hypertension in patients with chronic kidney disease(CKD) and its associated factors.Methods Data of 726in-patients with CKD and hypertension who hospitalized in our hospital from March 2009 to April 2010 were studied.Results 91.74％ of patients was treated with antihypertensive medications,and 21.21％, 22.59％, 19.56％, 28.37％ of patients received 1, 2, 3, ≥4 antihypertensive drugs,respectively.42.4％ of patients with CKD and hypertension could be controlled up to the standard,and the mean blood pressure was(137.86±20.75)/(76.30±11.35) mm Hg.There was significant difference among stage 1 plus 2, 3, 4 plus 5 (non-dialysis), 5 (dialysis) kidney diseases, with the hypertension control rate being 50.8％, 46.7％, 42.0％, 33.5％, respectively.The hypertension control rate of non-dialysis patients was significantly higher than that of dialysis (44.9％ vs 33.5％,P＜0.05).There was no significant difference between blood dialysis group and peritoneal dialysis group(32.3％ vs 38.7％, P＞0.05).Multivariate Logistic regression analysis showed that female (OR=1.787, 95％CI 1.045-3.056)and ACEI application (OR=4.378, 95％CI1.830-10.472) were positively associated with hypertension control.Whereas, diabetes (OR=0.415, 95％CI 0.188-0.919)and pulse pressure (OR =0.847, 95％ CI 0.811-0.885) were associated with inadequate blood pressure control.ConclusionsDespite almost universal hypertension treatment is used in patients with CKD and high blood pressure, the hypertension control rate is still suboptimal.Female and ACEI are positively associated with adequate hypertension control, whereas diabetes and pulse pressure are negatively associated with the standard.

Objective To compare the curative effects ofziprasidone and aripiprazole at acute stage on patients with drug-naive schizophrenia and their effects on metabolism of these patients.Methods Forty-six patients with drug-naive schizophrenia,admitted to our hospital from February 2010 to February 2011,were divided into ziprasidone treatment group (n=24,[165±13.51] mg/d) and aripiprazole treatment group (n=22,[28.86±3.06] mg/d); these patients were given the above treatment for 6 week.The scores of positive and negative syndrome scale (PANSS),body mass index (BMI),insulin resistance index (IRI),and levels of fasting blood glucose (FBG),insulin (INS),C-Peptide (CP),total cholesterol (TC),high density lipoprotein cholesterol (HDL-C),low density lipoprotein cholesterol (LDL-C),triglyceride (TG),apolipoprotein-a (APOA) and apolipoprotein-b (APOB) were obtained before and at the end of treatment.Results At the end of treatment,2 patients (9.1％) were cured,7 (31.8％)achieved obvious improvement,9 (40.9％) achieved improvement,and only 4 (18.2％) did not achieve any improvement in the aripiprazole treatment group.However,at the end of treatment,no patient (0％)was cured,7 (29.2％) achieved obvious improvement,12 (50％) achieved improvement,and 5 (20.8％)did not achieve any improvement in the ziprasidone treatment group.The total scores of PANSS after the treatment in both groups decreased significantly as compared with those before treatment (P＜0.05).The BMI ([20.14±2.63] kg/m2) in the ziprasidone treatment group at the end of treatment was obviously increased as compared with that ([19.68±2.76] kg/m2) before treatment (P＜0.05).The FBG ([4.38±0.59]mmmol/L) at the end of treatment decreased significantly as compared with those before treatment ([4.79±0.59] mmmol/L),and the BMI ([19.65±2.15] kg/m2) was obviously increased as compared with that before treatment ([19.19±2.28] kg/m2) in the aripiprazole treatment group (P＜0.05).The metabolic index in the 2 groups was not significantly different at the end of the treatment (P＞0.05).Conclusion Both ziprasidone and olanzapine are effective in the treatment of patients with drug-naive schizophrenia;both of them have mild effects on weight of patients with drug-naive schizophrenia,but no obvious effects on other metabolic indices.

Objective:To observe the effect of smoking on inhaled corticosteroids and long‐acting beta‐2 agonists (ICS/LABA) therapy for patients with moderate to severe chronic obstructive pulmonary disease (COPD) .Methods:Elderly patients with moderate to severe COPD in stable stage ,who consulted doctors at Department of Geriatric Respiratory Disease in our hospital or were admitted to our hospital during January 2013 and December 2013 ,were selected and allocated to smoking group (n=98) or ex‐smoker group(n=98) .All subjects were treated with inhaled formoterol and budesonide ,and the treatment lasted for 6 months .Before treatment and at the 3rd and 6th month of treatment ,pulmonary function (FEV1 pred% ,FEV1/FVC % ) , concentration of interleukin‐8(IL‐8) and tumor necrosis factor‐α(TNF‐α) in the blood ,and glucocorticoid receptor (GR)‐αand GR‐βpositive peripheral blood mononuclear cells (PBMC) were determined ,and meanwhile dyspnea score was evaluated . Results:In both smoking group and ex‐smoker group ,compared with that before treatment ,at the 3rd and 6th month of treatment ,the FEV1% and FEV1/FVC% gradually increased (P< 0 .05) ,dyspnea score decreased (P< 0 .05) .Blood concentrations of TNF‐α and IL‐8 decreased gradually after treatment (P< 0 .05) .The percentage of GR‐α positive PBMC didn’t change significantly (P>0 .05) ,while the percentage of GR‐βpositive PBMC decreased significantly at the 6th month of treatment in ex‐smoker group (P<0 .05) .Compared with that in smoking group ,FEV1% and FEV1/FVC% in ex‐smoker group increased more at the 3rd and 6th month of treatment ,while dyspnea score declined more (P< 0 .05) ,as well as the TNF‐αand IL‐8 (P< 0 .05) .At the 3rd and 6th month of treatment ,GR‐α positive PBMCs increased more in ex‐smoker group ,while GR‐βpositive PBMCs decreased more (P<0 .05) .Conclusions :For both smokers and ex‐smokers with CODP , ICS/LABA can improve pulmonary function , relieve respiratory symptoms , reduce inflammatory reaction , and regulate glucocorticoid receptor .Smoking has negative effect on ICS/LABA treatment .

ObjectiveTo measure the iodine content of normal thyroid and the sternocleidomastoid muscle with gemstone spectral imaging (GSI),in order to offer diagnostic reference for iodine excess or iodine deficiency disorders.MethodsA total of 226 cases of patients with suspected neck or cervical disease underwent GSI of the neck,the thyroid and the sternocleidomastoid muscle.One hundred and nineteen cases were male and 107 female,aged 18 to 77 years,average age(46 ± 17) years.Data were transmitted to AW 4.4 workstation and processed using GSI Viewer software to obtain the best contrast-to-noise ratio(CNR) of thyroid to sternocleidomastoid muscle and corresponding singe-energy images.Iodine content of left and right thyroid lobes and both sides of sternocleidomastoid muscle as well as iodine content ratio of thyroid to sternocleidomastoid muscle were calculated in the iodine-based images.ResultsTotal iodine content of the left and the right lobes of the thyroid was (1.5233 ±0.4318)mg/cm3,of the left lobe was (1.5230 ± 0.4271 )mg/cm3,of the right lobe was (1.5236 ± 0.4365 )mg/cm3,there was no significant difference statistically between the two(t =0.0084,P ＞ 0.05).The iodine content of the male was (1.6395 ± 0.4105)mg/cm3,and of the female was (1.4238 ± 0.3832)mg/cm3,there was statistically a significant difference between the two(t =3.4743,P ＜ 0.01 ).Iodine content ratio of thyroid to sternocleidomastoid muscle was 96.6271 ± 33.2442,the ratio in male was 94.6250 ± 37.3621 and in female was 98.0000 ± 29.0737,there was no statistical difference between the two(t =0.3817,P ＞ 0.05).The iodine content of thyroid decreased gradually with age,the difference between groups was statistically significant(F =9.66,P ＜ 0.01 ).The iodine content in ＜ 40 age group[(1.7256 ± 0.4631)mg/cm3] was higher than that in 40 - 60 age group[(1.4517 ±0.3643)mg/cm3] and ＞ 60 age group [(1.4368 ± 0.3465)mg/cm3; q =5.6195,5.4158,all P ＜ 0.01).Conclusions It is easy to calculate thyroid iodine content with gemstone spectral imaging,which can reflect the iodine level of our body,and is helpful for the diagnosis of iodine excess or iodine deficiency disorders.

Objective To explore the association of mild cognitive impairment (MCI) with obesity level in middle and elderly population. Methods A total of 19181 subjects aged 50-85 years were collected in this study from the first and second recruitment phase of the Guangzhou Biobank Cohort Study. The subjects received face-to-face interviews to collect the detailed information on their sociodemographic background, occupational exposures, living environment, lifestyle, family and personal disease histories, and had physical examinations and tests including 12-lead ECG, chest radiograph, and pulmonary function testing. Each subject was screened for a range of fasting biochemical parameters. The cognitive ability was tested with 10-words delayed memory test. The associations between cognition function and anthropometric indices of obesity, including body mass index, waist-to-hip ratio (WHR) and waistline, were evaluated. Results Apart from fast glucose and hypertension in subjects with normal cognition function and abnormal cognition function, some lifestyle and such physiological and biochemical factors as age, education, smoking status, and drinking status were significantly different in both gender (P＜0.05). WHR was the independent risk factor of MCI in both gender (P＜0.05). Logistic regression indicated that high WHR was a risk of MCI in both gender; the greater the WHR, the poorer memory the middle and elderly population; the OR and 95％ CI was 1.57 (1.42-1.72) in female and 1.22(1.05-1.41) in male. Conclusion Centripetal obesity is associated with MCI. WHR is a sensitive indicator influencing the cognitive function in women.