Difficult cases are frequently found at the department of internal medicine of large hospitals.Better quality of ward-rounds by these department heads is key to medical safety,to better operations,and to reducing medical disputes incurred by malpractice.Focusing on standardizing wardround behavior and medical records,the People's Liberation Army General Hospital established and applied the Quality Standards of Ward-rounds on difficulty cases,which scored expected outcomes of better quality of care and better patient satisfaction.

Objective To analyze the miss rates of colorectal adenomas during colonoscopy as well as risk factors influencing the adenoma miss rates and to take corresponding measures. Methods A total of 432 patients who underwent index and follow-up colonoscopy in 18 months were randomized and investigated. The results of two colonoscopies were compared and the missed adenomas were defined as the adenomas de-tected only during the second colonoscopy. Miss rates were calculated according to patient-based methods. Chi-square test was used to analyze the relative factors influencing the adenoma miss rate of per-patient. Then the meaningful factors were chosen into the logistic regression model for multiple factors analysis. Results Of 432 patients,116(26. 9%)had missed adenomas on first colonoscopy. Single factor analysis found that the size of adenoma( χ2 = 89. 686,P = 0. 000),the shape of adenoma( χ2 = 68. 488,P = 0. 000),the location of adenoma(χ2 = 77. 055,P = 0. 000)and adenoma tissue types(χ2 = 417. 000,P = 0. 000)were the risk factors for miss rates of colorectal adenomas. Number of polyps(χ2 = 8. 450,P= 0. 038),the organi-zation type of polyp(χ2 = 10. 718,P= 0. 013)and proficiency of colonoscopists(χ2 = 56. 069,P= 0. 000), the quality of bowel preparation(χ2 = 39. 195,P = 0. 000),insertion time(χ2 = 13. 133,P = 0. 001)were also the risk factors for miss rates of colorectal adenomas. Logistic regression analysis showed that the bigger the adenoma size,the less missed adenomas(OR= 0. 341,95%CI:0. 173-0. 671). Also,the longer insertion time took,the lower the adenoma miss rate(OR = 0. 987,95% CI:0. 981-0. 994). Per-patient miss rates were lower for high-risk adenomas compared with low-risk adenomas(OR = 0. 324,95%CI:0. 154-0. 680). Adenomas happening in multiple parts of bowel easily leads to missing(OR= 3. 791,95%CI:1. 505-9. 546). Conclusion The missed diagnosis of adenomas is not only significantly associated with features of missed adenomas,but also with skills of colonoscopists,insertion time,and bowel preparation. The key is high-quality index colonoscopy to avoid adenomas missing.

Objective: To explore the antagonistic effect of quercetin on fine particulate matter (PM2.5)-induced embryonic developmental toxicity in vitro.Methods: PM2.5 was collected on glass fiber filters by PM2.5 samplers during the heating period of Dec.2015 to Mar.2016 in an area of Haidian District, Beijing City.The sampled filters were cut into 1 cm×3 cm pieces followed by sonication.The PM2.5 suspension was filtered into a 10 cm glass dish through 8 layers of sterile carbasus and stored at-80 ℃ until freeze drying.Frozen PM2.5 suspension was dried by vacuum freeze-drying.In vitro post-implantation whole embryo culture was used in this study.Pregnant rats with 9.5 gestation days (GD) were killed by cervical dislocation and the uteri were removed into sterile Hank's solution.The embryos with intact yolk sacs and ecto placental cones were induced by PM2.5, and then subjected to intervention of quercetin at the doses of 0.1 μmol/L, 0.5 μmol/L, 1.0 μmol/L and 5.0 μmol/L, respectively.At the end of the 48 h culture period, the cultures were terminated, and all embryos were removed from the culture bottles and placed in prewarmed Hank's solution for evaluation.Morphological evaluation of the embryos was conducted under a stereomicroscope using the morphologic scoring system by Brown and Fabro.The mitochondrial reactive oxygen species (ROS) level was detected by FACSCalibur flow cyto-metry using MitoSOXTM Red staining.Results: An obvious antagonistic effect was achieved through querce-tin at the dose of 1.0 μmol/L, which could result in an increase of visceral yolk sac (VYS) diameter, crown-rump length and head length, somite number, and the differentiation of visceral yolk sac vascular vessels.The scores of allantois, flexion, heart, hind brain, midbrain, forebrain, auditory system, visual system, olfactory system, branchialarch, maxillary process, forelimb bud and hindlimb bud also revealed a significant increase and the relative mitochondrial ROS level of embryonic cells was significantly decreased when compared with PM2.5 group.Although quercetin at the doses of 0.1 μmol/L, 0.5 μmol/L, 5.0 μmol/L also exhibited protective effects against PM2.5-induced embryonic developmental toxicity, the protective effect was weaker when compared with the dose of 1.0 μmol/L.Conclusion: Quercetin at proper dose may be of great benefit for the development of embryos exposed to PM2.5 in the uterus of the rats.Quercetin provides an effective strategy for the prevention of PM2.5-induced embryonic developmental toxicity.Clearance of mitochondrial ROS may be one of its mechanisms.

Objective:To evaluate the immunomodulating effect of oyster peptide on immunosup-pressed mice.Methods:ICR mice injected with cyclophosphamide (CTX)were adopted as the module group,with mice without treatment as the control group,and different dosages of oyster peptide (0.5 g/kg,1 .0 g/kg,and 2.0 g/kg)were given to the low,middle,and high groups for 1 5 days.The body weight,spleen,and thymus weight of the mice,structures under the microscope of the immune organs, numbers of white blood cells,ratios of T lymphocyte subsets,immune cytokines and numbers of nuclear cells,and DNA content in bone marrow were all assessed.Results:Compared with the control group, the structures of thymus and spleen of the mice in the CTX group appeared obscure and shrunk when ob-served under microscope,the number of their white blood cells declined (P =0.04),the proportion of their CD3 +T cells in peripheral blood declined (P =0.003),the proportion of their CD8 +T cells in pe-ripheral blood declined (P =0.002),the concentration of their IL-5 in peripheral blood significantly in-creased (P <0.01 ),the concentration of their nucleated cells and DNA density in bone marrow de-creased (P =0.04,P <0.01 ).Oyster could improve the structures of thymus and spleen of the immuno-suppressed mice.Compared with the CTX group,the number of white blood cells in 2.0 g/kg group in-creased (P =0.003),the proportion of CD3 +T cells in peripheral blood in 1 .0 g/kg group (P =0.04) and 2.0 g/kg group (P =0.02)increased,the proportion of CD8 +T cells in peripheral blood in 2.0 g/kg group increased (P =0.002),the concentration of IL-5 in peripheral blood in all the oyster treated groups increased (P <0.01 in 0.5 g/kg,1 .0 g/kg,and 2.0 g/kg groups),the concentration of IL-1 7 in peripheral blood in 2.0 g/kg group decreased (P =0.03),the concentration of nucleated cells in bone marrow of all the oyster treated groups increased (0.5 g/kg vs.CTX,P =0.04;1 .0 g/kg vs. CTX,P =0.02;2.0 g/kg vs.CTX P =0.01 ),the DNA content in bone marrow of all the oyster treated groups increased (P <0.01 in the 0.5 g/kg,1 .0 g/kg,and 2.0 g/kg groups).Conclusion:Oyster peptide could improve the structures of immune organs of the CTX-induced immunosuppressed mice,re-cover the imbalances of T lymphocyte subsets,improve the immune cytokines and increase numbers of nucleated cells and DNA content in bone marrow,thus improving the immunologic function.

Objective:To systematically review the qualitative researches on patients′ lived experiences of being mechanically ventilated in intensive care unit.Methods:The Cochrane Library, PubMed, Web of Science, Ovid, CNKI, VIP and Wanfang database were searched to collect qualitative studies on patients′ lived experiences of being mechanically ventilated in intensive care unit, from October 2009 to October 2019. Two reviewers independently screened the literature against the pre-determined inclusion and exclusion criteria, extracting the data, and evaluated the included studies according to JBI Critical Appraisal Tool for qualitative studies in Australia.Results:A total of fourteen studies were included. Thirty-eight complete results were grouped according to their similarities to form seven categories. These categories led to three synthesized findings: results 1: patients suffered from both physical and mental distress; results 2: they were eager for supports; results 3: patients achieved personal growth through self-adjustment and reflection.Conclusion:Discomfort experience during mechanical ventilation reduces patients′ comfort, and to a certain extent, has negative impacts on their physical or mental health and clinical outcome. As the main caregiver of patients with mechanical ventilation, not only should nurses alleviate patients′ physical distress by strengthening communication but also give them adequate psychological support. Eventually, promote the physical and mental recovery of patients.

Gut microbiota provide enzymes and additional biochemical metabolic pathways for the host, which together with the host genome and the external environment, influence the body function. The composition of gut microbiota in infant is closely related to health in later life. However, it is influenced by many factors, including delivery mode, feeding pattern, prenatal diet, pregnancy psychology and antepartum antibiotic treatment. Vaginal delivery and breastfeeding is beneficial for shaping gut microbiota, while cesarean section and formula feeding would reduce the amount of gut dominant bacteria. In addition, inappropriate diet during pregnancy, prenatal stress and antepartum antibiotic treatment alters bacterial colonization of the gut in infant.

‍ ObjectiveTo investigate the serum level of HBV RNA in untreated or treatment-experienced patients with chronic hepatitis B （CHB） and the correlation between serum HBV RNA level and the duration of antiviral therapy with nucleos（t）ide analogues （NAs）. MethodsA total of 300 patients with CHB who attended Department of Infectious Diseases in The First Affiliated Hospital of Shihezi University School of Medicine from February to July， 2022， were enrolled as subjects. Related clinical data were collected， and according to the duration of antiviral therapy， they were divided into untreated group with 73 patients， treatment duration ≤1 year group with 91 patients， and treatment duration >1 year group with 136 patients. Serum HBV RNA load， HBV DNA load， and HBsAg concentration were measured for all patients. The Mann-Whitney U test was used for comparison of continuous data between two groups， and the Kruskal-Wallis H test was used for comparison between multiple groups， further pairwise comparison using Bonferroni method； the chi-square test was used for comparison of categorical data； a Spearman correlation analysis was used to investigate the degree of correlation between various indicators. ResultsThe positive rate of HBeAg was 18.3%， and among the patients with negative HBV DNA， the patients with positive HBV RNA accounted for 44.1% （86/195）. There was a significant difference in the distribution of the serum levels of HBV RNA， HBV DNA， and HBsAg between the positive HBeAg group and the negative HBeAg group （Z=10.740， 6.300， and 7.280， all P<0.05）. There was a significant difference in the distribution of DNA level between the untreated group and the treatment duration ≤1 year group （P<0.05）； there was a significant difference in the distribution of HBV RNA and HBV DNA levels between the untreated group and the treatment duration >1 year group （P<0.05）； there was a significant difference in the distribution of HBV RNA， HBV DNA， and HBsAg levels between the treatment duration ≤1 year group and the treatment duration >1 year group （P<0.05）. The correlation analysis between the duration of antiviral therapy and the levels of HBV RNA， HBV DNA， and HBsAg showed that the duration of antiviral therapy had an extremely weak negative correlation with the levels of HBV RNA and HBsAg （r=-0.247 and -0.138， both P<0.05） and a strong negative correlation with the level of HBV DNA （r=-0.771， P<0.001）. There was a low degree of correlation between the serum level of HBV RNA and the serum levels of HBV DNA and HBsAg （r=0.360 and 0.442， both P<0.001）. Further stratified analysis showed that in the untreated group， there was a strong positive correlation between HBV RNA and HBV DNA （r=0.752， P<0.001） and a moderate positive correlation between HBV RNA and HBsAg （r=0.559， P<0.001）； in the treatment duration ≤1 year group， there was a low degree of positive correlation between HBV RNA and HBV DNA/HBsAg （r=0.396 and r=0.388， both P<0.001）； in the treatment duration >1 year group， there was a low degree of positive correlation between HBV RNA and HBsAg （r=0.352， P<0.001）. ConclusionSerum HBV RNA is negatively correlated with the duration of treatment with NAs， and the correlation of HBV RNA with HBV DNA and HBsAg gradually decreases with the increase in the duration of treatment. Therefore， it can be used as a supplementary indicator for monitoring the level of virologic response in CHB patients to a certain extent， with a relatively high accuracy in reflecting the level of viral replication in untreated patients.