Objective To improve the diagnosis and treatment of Q fever endocarditis.Methods From 2008 to 2013,four cases of Q fever endocarditis were diagnosed in Peking Union Medical College Hospital.Clinical features,laboratory test,management and prognosis were analyzed with literature review.Result All four cases had long period of fever and heart murmur.Two patients represented with respiratory symptom and one with non-specific rash.General laboratory tests including complete blood cell count,ESR,C-reactive protein(CRP),liver function and radiology of lung did not show specific abnormalities.Signs of endocarditis were shown by ultrasound and important for diagnosis.Repeated blood culture was negative.All of the diagnoses were confirmed by serum antibody detection and the patients recovered well with treatment based on doxycycline or minocycline.Conclusions Endocarditis is the most common form of chronic Q fever,which is easily misdiagnosed because its blood culture is negative and may accompanied with varied manifestation such as pneumonia and liver injury.For the patients with chronic fever and blood culture negative endocarditis,chronic Q fever should be considered as differential diagnosis.The confirmatory method for diagnosis is serum antibody detection.Early and sufficient treatment may improve the prognosis.

Objective To improve the diagnosis and treatment of infective endocarditis(IE)by exploring its causes,pathogenic microorganism and clinicsI characteristics.Methods The clinical data of 120 IE patients treated in Peking Union Medical College Hospital from October 1997 to September 2007 were analyzed retrospectively.Results Of the 120 consecutive cascs diagnosed as IE according to the Duke's new criteria,79 were male and 41 female with a average age of(43.2±16.7)years old.Twelve cases were prosthetic valve endocarditis(PVE)and 108 cases native valve endocarditis(NVE)and there were no previously known heart diseases in 29 of the cases.Seventy-nine of the 108(73.1%)NVE patients had basic cardiac abnormalifies before IE diagnosis,such as congenital cardiovascular disease(30 cases),idiopathic mitral valve prolapse(23 cases)and rheumatic heart disease(11 cases).Fever(100.0%),anemia(54.2%)and embolism(48.3%)were the most common clinical manifestations in the IE development.Of the 83 patients who had a positive blood culture result,Streptococcus vividaus(51.8%)was the most common isolated microorganism.Conclusions Congenital cardiovascular diseases and idiopathic mitral valve prolapse are the two most commonly heart diseases in IE.Blood culture and echocardiogram should always be done to exclude IE,especially presenting with fever of unknown reasons.

Objective To evaluate the clinical diagnostic contribution of 18 F-FDG PET/CT in giant cell arteritis with initial presentation as fever of unknown origin (FUO).Methods Eight cases with initial presentation as FUO diagnosed with the contribution of PET/CT were retrospectively studied in Peking Union Medical College Hospital.The radiologic manifestations of PET/CT were analyzed.Results Eight patients (4 men and 4 women) with average (63 ± 7) years (range from 55-75 years) were included in our study based on the criteria.Non-specific clinical symptoms were common in these patients,including fatigue,night sweat and weight loss.They all suffered from anemia of chronic disease.Not surprisingly,the inflammatory parameters were elevated significantly in all patients.The medical history,physical examination and routine lab and radiologic examinations couldn't reveal the causes of fever.PET/CT was performed in all of them,which demonstrated intense 18F-FDG uptake in the area of aorta and its major branches with maximal standard uptake value (SUVmax) 2.1-4.6 (3.6 ± 0.9).Immunosuppressive agents were effective to control the inflammation activity.The SUV decreased significantly after treatment in the follow-up PET/CT.Conclusions PET/CT has demonstrated high yield of diagnostic contribution in giant cell arteritis with initial presentation as fever of unknown origin.As to elderly FUO patients presenting with prominent inflammatory reaction,PET/CT may provide potential value to differentiate diagnosis from maligancies.

Objective To evaluate effects of acitretin on HaCaT cells cultured in hypoxic condition,and to preliminarily explore the possible therapeutic mechanisms of acitretin in psoriasis.Methods HaCaT cells were divided into several groups to be cultured in hypoxic condition with the presence of acitretin at concentrations of 10-5,10-6,10-7 and 10 8 mol/L respectively,with cells treated with dimethyl sulfoxide (DMSO) as DMSO control group and those receiving no treatment as blank control group.Cellular proliferative activity was evaluated by CCK-8 assay after 12-,24-and 36-hour hypoxic culture in vitro.The mRNA and protein expressions of hypoxia-inducible factor-1α (HIF-1α) and vascular endothelial growth factor (VEGF) were determined by reverse transcription (RT)-PCR and Western-blot analysis,respectively,after 24-hour hypoxic culture.Results After 24-hour hypoxic culture,the cellular proliferation rate was inhibited by 13.31％ ± 1.15％,21.86％ ± 5.31％,32.05％ ± 2.99％ and 37.28％ ± 3.21％ in the 10 8-,10-7-,10-6-and 10-5-mol/L acitretin groups respectively.With the increase of culture duration and acitretin concentrations,the degree of inhibition on cellular proliferation increased gradually.Compared with the blank control group,the 10-5-mol/L acitretin group showed significantly decreased protein expression of HIF-1α (0.319 ± 0.180 vs.1.196 ± 0.088,P ＜0.05),as well as decreased mRNA and protein expressions of VEGF (mRNA:0.442 ± 0.090 vs.1.108 ± 0.073;protein:0.216 ± 0.066 vs.1.174 ± 0.186;both P ＜ 0.05).However,no significant difference was found in the mRNA expression of HIF-lα between the 10-5-mol/L acitretin group and blank control group.Conclusion Acitretin can suppress the in vitro proliferation of HaCaT cells cultured in hypoxic condition,and down-regulate the expressions of HIF-1α and VEGF proteins as well as VEGF mRNA.

Objective To construct the evaluation index system of clinical nursing competence for higher vocational nursing skills contest. Methods A total of 31 nursing experts participated in the three-round consultation by Delphi technique, and empirically tested the final result. Results The response rates of questionnaire investigation for the three-round were 93.6%(29/31),100.0%(29/29) and 100.0%(29/29) respectively. The specialist authority coefficient was 0.861,and the coordination coefficients for each round were 0.207,0.291 and 0.371, respectively, P<0.01.The overall reliability coefficient was 0.921, evaluators reliability correlation coefficient was 0.942. There were significant correlation between each item and total score, P<0.05. The overall degree of differentiation was 0.523. Finally, the clinical nursing competence assessment system for higher vocational nursing skills contest was constructed,including 3 first-level indexes,10 second-level indexes and 39 third-level items. Conclusions The results of three-round expert consultation are reliable, the reliability, validity and differentiation are high. To evaluate clinical nursing ability higher vocational nursing students provide scientific basis.

Objective To evaluate the PDCA cycle on the rehabilitation of postoperative patients with anal fistula, aiming at improving the recovery of patients and preventing recurrence. Methods 144 postoperative patients of anal fistula were randomly divided into the observation group and the control group with 72 cases in each group. The observation group received intervention based upon the PDCA cy-cle, and the control group was given the traditional oral propaganda. The recovery time, recurrence rate, mastering of education content and self-control ability were compared in the two groups using t test and χ2 test. Results The mastering level of education content and the self-management skills in the observation group were superior to those of the control group. After 3 to 24 months of follow-up, the observation group showed shorter recovery time and less recurrence rate than that of the control group. Conclusions Nurs-ing intervention based upon PDCA cycle can strengthen the patients' mastering of related knowledge, pro-mote the recovery, reduce recurrence rate and improve the patients' quality of life.

Objective To report the clinical characteristics of prosthetic valve endocarditis (PVE).Methods All 25 cases of definite PVE (Duke criteria) diagnosed at our hospital between January 1992 to December 2008 were retrospectively analyzed. Among them, 7 cases were pathologically confirmed and the others were clinically confirmed with either 2 major criteria or 1 major and ≥3 minor criteria. Their clinical characteristics, underlying heart diseases, previous heart operations, presenting manifestations, causative microbes, echocardiographic findings and prognosis, were studied. Results (1) Although most cases underwent valve transplantations for underlying heart diseases of rheumatic heart diseases and congenital heart diseases, 10 patients were complicated with infectious endocarditis (IE) prior to the operations, 4 of them were PVE. (2) Eleven of them developed PVE within 2 months postoperatively. Fever (100%),major vessel embolism (48%), and anemia (36%) were the most frequently manifestations. Fourteen cases (56%) had positive culture results with 15 causative pathogens, including 5 coagulase-negative Staphylococcus (CNS, 3 were methicillin-resistant coagulase-negative Staphylococcus, MRSCoN), 4 fungi, 2Enterococcus faecalis, 2 Burkholderia cepacia, 1 Stenotrophomonasmal-tophilia, and 1 Streptococcus.(3)Prosthetic valve vegetations, periannular leakage, regurgitation, were the main echocardiographic findings.Transesophageal echocardiography (TEE) revealed 13 PVE who had no positive findings on previous transthoracic echocardiography (TTE). (4) Eighteen PVE (72%) developed peri-annular complications (12 leakage, 3 dehiscence, 2 abscesses, 1 fistula), major vessel embolism, congestive heart failure (16%) were frequently observed, 9 of the 17 patients died in hospital, in spite of intensive managements.Conclusions PVE has a high mortality and is a severe complication for patients who underwent heart surgery. Its causative pathogen spectrum is quite different from that of native valve endocarditis. TTE is not sensitive for some PVE cases.

Objective: To review the clinical characteristics of a pedigree with inherited hemorrhagic disease to explore its molecular pathogenesis. Methods: The clinical data of the pedigree with inherited hemorrhagic disease were collected. After extracting DNA, next generation sequencing was utilized to detect the potential gene mutation. The changes of RASGRP2 transcript of this proband and his parents were detected using RT-PCR to compare with normal control. Results: The phenotype of the proband in this pedigree with inherited platelet dysfunction and bleeding disorder was similar to variant Glanzmann’s thrombasthenia, the maximum aggregations of platelet in response to the physiological agonists including ADP, epinephrine and arachidonic acid were significantly lower, leading to severe spontaneous mucosal bleeding. Integrin αIIbβ3 gene mutation was not detected, but another gene mutation RASGRP2 IVS3-1 stood out. The mutation was homozygous in the proband and heterozygosis in both of his parents. Two transcript types were detected in the proband, without transcripts coding functional RASGRP2 protein, however, his parents had functional transcripts and abnormal transcripts, with the normal transcripts in the majority. Conclusions The RASGRP2 IVS3-1 gene mutation was responsible for the inherited hemorrhagic disease. The RASGRP2 IVS3-1 gene mutation led to abnormal alternative splicing, without formation of functional RASGRP2 protein. The RASGRP2 protein is at the nexus of calcium-dependent platelet activation and hemostasis after damage of blood vessels. Spontaneous mucosal bleeding was a result of the lack of the functional RASGRP2 protein. This was the first report of RASGRP2 gene mutation resulting in bleeding disorder in China, and also the first report of the mutation type of RASGRP2 IVS3-1.

Objective To investigate the diagnostic value of ultrasound scan at 16 to 18 gestational weeks in euploid fetuses with increased nuchal translucency (NT).Methods From January 2015 to June 2017,214 fetuses diagnosed with increased NT thickness (NT ≥ 3.0 mm) during early pregnancy in Guangzhou Panyu Central Hospital were enrolled.Fetal chromosome karyotype analysis was carried out prenatally.Those cases with normal karyotype underwent ultrasound scan at 16-18 and 20-24 gestational weeks and their outcomes were followed up via telephone.Descriptive statistics was used for statistical analysis.Results There were 198 out of the 214 cases undergoing chromosome karyotype analysis and among them,78 (39％) pregnancies were terminated due to chromosomal abnormalities.Out of the 107 cases with normal karyotype and successful followups,35％(37/107) had structural malformations.There were 19,11 and 6 cases of fetal structural malformations diagnosed at 11-13+6,16-18 and 20-24 weeks of gestational age,respectively,and the rest one was at 28 weeks.Structural deformities detected at 16-18 weeks included cleft lip and palate (n=2),cardiac malformations (n=2),spinal deformities (n=2),body deformities (n=2),diaphragmatic hernia (n=1),encephalocele (n=1) and left multicystic dysplastic kidney (n=1).About 91％ (70/77) of the fetuses with normal karyotype but without abnormal ultrasound findings at 16-18 weeks were free of structural malformations and achieved good pregnant outcomes.Conclusions Ultrasound screening at 16 to 18 weeks of pregnancy can be used to detect multiple structural malformations in fetuses with increased NT and normal karyotype,which may contribute to early detection of fetal structural malformations and help gravidas and their families make timely decisions.

Objective:Through the investigation of the injured persons in explosion accidents, the impact of wearing the ear protectors device (anti-noise earplugs) on the auditory organs and hearing loss of the injured person was understood, which could provide reference for the clinical diagnosis, treatment and prevention of the explosive hearing impairment.Methods:A retrospective survey was conducted on 39 directly injured persons who were injured in 23 explosion accidents involving a steel plant from 1990 to 2016 as the explosive hearing loss, taking the time of the patient＇s injury and 3-6 months after the injury as the time of investigation and evidence collection, and according to whether to wear the ear protectors device for group comparison and statistical analysis.Results:There was no significant difference between the two groups in hearing loss, tinnitus, earache, headache, some patients with dizziness and craniocerebral injury, regardless of whether the injured person wore anti-noise earplugs or not ( P=0.444-1) , the shock (coma) patients in the non-protected group were more common (34.8%, 8/23) , and the difference was statistically significant ( P=0.012) ; Although auricle injury was detected in both groups and there was no significant difference between the two groups ( P=1) , but the external ear canal injury, tympanic membrane perforation were more common in the non-protected group, and there was no external ear canal and tympanic membrane perforation in the wearing earplug group, and the difference between the two groups was significant ( P=0.000) . After 3-6 months, the rehabilitation of auditory system and other symptoms in patients showed that the hearing loss, tinnitus, earache, headache, dizziness and other symptoms all disappeared in patients wearing earplugs, while the above symptoms in the non-protected group were improved but more persisted, and the difference between the two groups was statistically significant ( P=0.000-0.012) , and there was no significant difference in rehabilitation conditions such as craniocerebral injury between the two groups ( P=1) ; There were patients with unhealed auricle injury in both groups in 3-6 months after the injury, and there was no significant difference between the two groups ( P=1) , however, in the non-protected group, 69.57% (16/23) of the patients with external auditory canal injury were still unhealed and none of the patients with tympanic membrane perforation recovered, and the difference between the two groups was obvious ( P=0.000~0.001) ; Pure tone air conduction examination showed that the hearing of the earplugs wearers was well recovered at the time of the explosion, while irreversible hearing impairment was common in the non-protective group, the difference was statistically significant ( P=0.000) . Conclusion:Ear protector plays an important role in protecting the auditory organs and hearing of workers in explosion accident, and it is an effective protective measure to prevent and reduce the damage of external ear canal, perforation of tympanic membrane and explosive hearing loss caused by explosion accidents.