Physical diagnosis is an important part of training in diagnosis clinical skills.We can explore effective teaching methods by adopting student-oriented teaching method,applying the electronic standardized patients and reasonable application of standardized patients.

Objective To investigate the effect of insulin glaring(IG)and neutral protamine hagedorn(NPH)on metabolic control and islet cell function in type 2 diabetic patients who secondly failed to sulfonylureas(SU)treatment.Methods Fifty-two diabetic patients with second SU failure were studied in our hospital during May,2004 to Nov,2004,and they were divided into two groups:twenty treated with glipizide extended release tablets(GERT)plus IG injection,while thirty-two with GERT plus NPH.Fasting and postprandial blood glucose,HbA_1c,fasting and postprandial C-peptide were determined in all patients at different following points.Results Blood glucose decreased obviously and similarly in two groups;however,hypoglycemia occurred less in IG group.Interestingly,fasting and postprandial C-peptide significantly increased in IG group,but didn't change in NPH group.Conclusion Combination treatment with IG or NPH has good effect on metabolic control in second SU failure patients;and moreover,IG improves B-cell function.

Diabetic patients with secondary sulfonylureas failure were shifted to glipizide plus glargine ( n = 20) or neutral protamine hagedorn (n =32). Sixteen weeks later, blood glucose and HbAIC were decreased and serum C peptide level increased in both groups. Hypoglycemia occurred less frequently and?-cell function was improved in glargine group.

Objective To investigate the prevalence of thyroid disorders and positive thyroid autoantibodies,and evaluate the necessity for universal thyroid screening during the second and third trimesters of pregnancy.Methods The pregnant women during the second and third trimesters who visited Shanghai Jiaotong University Affiliated First People's Hospital between June 2006 and February 2008 were chosen for thyroid screening by determining serum free triiodothyronine,free thyroxine,thyrotropin,thyroid peroxidase antibody (TPOAb),and thyrotropin receptor antibody.A personal and family history of thyroid disease and other autoimmune diseases was investigated by questionnaire.The pregnant women were divided into high risk or low risk groups for thyroid disease based on their personal or family histories.Results A total of 2 101 pregnant women were screened,712 ( 33.89％ ) of them were identified to suffer from thyroid disorders or with positive thyroid autoantibody.The prevalence of thyroid dysfunction was increased in high risk group.While in low risk group( n =1 983 ),the prevalence of clinical hypothyroidism was 2.27％ ( n =45 ),subclinical hypothyroidism 11.60％ ( n =230 ),clinical hyperthyroidism 0.20％ ( n =4 ),subclinical hyperthyroidism 1.06％ ( n =21 ),hypothyroxinemia 6.45％ ( n =128 ),and euthyroid with positive TPOAb 10.74％ ( n =213 ) in our study.Pregnant women with positive TPOAb were susceptible to thyroid dysfunction.It was shown that 79.74％ of pregnant women with thyroid disorders were diagnosed by universal thyroid screening.Conclusions 33.89％ of pregnant women in the second and third trimesters were identified to suffer from thyroid disorders or positive thyroid autoantibody by universal thyroid screening.Increased prevalence of thyroid dysfunction was found in pregnant women with positive TPOAb.79.74％ of pregnant women with thyroid disorders might be missed if screening was made only in the high risk cases.

Objective To investigate bone strength in adults,and explore its influencing factors. Methods One hundred and ninety-one adults undergoing health examinations were selected.The questionnaires about milk intake and exercise conditions were performed,the body weight,fat mass,body mass index(BMI)and calcaneal bone strength were measured,and the relationship between each parameter and bone strength was analysed. Results Bone suength decreased with age increase,and was higher in males than that in females.Bone strength of overweight to obese adults was higher than that with normal body weight(P<0.05).Bone strength of adults with high milk intake was higher than that of those with low milk intake(P<0.05).Multivariate analysis revealed that age was negatively related to bone strength,females were more susceptible to bone strength decrease,and BMI and milk intake were positively related to bone strength. Conclusion Gender,age,BMI and milk intake are main influencing factors for bone strength.Bone strength decreases with age increase,and increase of BMI and milk intake will benefit bone strength,especially for females.

Objective To provide references for anatomical reduction and correct implantation in treatment of distal fibular fracture by analyzing morphological characteristics of distal fibula on three-dimensional (3D) modes.Methods 16-row spiral CT scans of 126 normal ankle structures from May 2009 to June 2014 were collected.Surface shaded display technique was used to reconstruct 3-D images of bones around the ankle.The distal fibula was extracted using 3D segmentation technique.The parameters of distal fibula were measured by selecting points,lines and surfaces on the 3D models.Results The morphological characteristics of distal fibula were complicated.Significant differences were observed between males and females in most parameters (P ＜ 0.05),but not in the length between the plane of the most lateral point of the tibial anterior node and the most distal point of the fibula,the length between the midpoint of lateral border of the fibula and its opposite cortex on the plane of the most proximal border of the fibular fossa or the mean angle of posterior crest of the fibula (P ＞ 0.05).The intra and interclass correlation coefficients (ICC) were excellent.Conclusions When a lateral plate is used for internal fixation of distal fibula,the plate should be placed as proximally as possible.When a posterior-lateral plate is used,the screws to be inserted on the plane proximal to the initial point of anterior node of the tibia can be fixed bi-cortically.When a posterior plate is used,pre-contour of the plate before insertion is required.

Objective To discuss the curative effect of computer assisted pre-operation plan (CAPP) in treating the geriatric intertrochanteric femoral fracture.Methods The data of intertrochanteric fractures treated with PFNA-Ⅱ between March 2012 and June 2015 were retrospectively analyzed.They were divided into two groups by preoperative design.One group was the CAPP group consisting of 53 patients with a mean age of 75.3 years (range,60-92 years).According to the Evans Classification,there were 12 Evans type Ⅰb,9 Evans type Ⅰc,15 Evans type Ⅰd and 17 Evans type Ⅱ fractures.The other group was the non-CAPP group consisting of 74 patients with a mean age of 76.6 years (range,62-95 years).There were 18 Evans type Ⅰb,15 Evans type Ⅰc,20 Evans type Ⅰd and 21 Evans type Ⅱ fractures.Operation time,intraoperative blood loss,times of fluoroscopy during operation and days of hospital stay were compared.The hip joint function was evaluated by Harris score at the final follow-up.Results The CAPP meanly cost 24.7 min.The consistency of the surgery and CAPP was up to 100％.In the CAPP group,the average operation time was 46.8±6.5 min;the average times of fluoroscopy during operation were 12.0±2.3 times;and the average blood loss was 154.4±27.6 ml.In the non-CAPP group,the average operation time was 57.8±10.3 min;the average times of fluoroscopy during operation was 20.9±3.2;and the average blood loss was 235.0±65.8 ml.All above data in the CAPP group were significantly lower than those in the non-CAPP group.The mean days of hospital stay were 13.9±1.3 days in the CAPP group and 14.3±1.4 days in non-CAPP group.The days of hospital stay had no significant difference between the two groups.Forty-five patients with an average follow-up period of 18.3 months were reviewed in the CAPP group.Fifty patients were followed up with an average period of 19.2 months in the non-CAPP group.At the final follow-up,the average Harris score was 88.6±2.8 points (range,84-96 points) in the CAPP group and 87.5±3.2 points (range,80-95 points) in the non-CAPP group.Conclusion CAPP system is convenient and efficient.It can facilitate the treatment of intertrochanteric fracture effectively.

Objective To explore the early diagnosis and risk factors for judging prognosis of acute respiratory distress syndrome (ARDS),and to provide references for clinical intervention.Methods Using the method for prospective cohort study,clinical data were collected from 64 ARDS and 66 high-risk ARDS patients in Department of Respiratory Diseases of Xinqiao Hospital from January 2013 to March 2016.They included patients' demographic data,Acute Physiology and Chronic Health Evaluation system Ⅱ (APACHE Ⅱ) score,oxygenation index,blood routine test,coagulation function and inflammatory markers (procalcitonin,C-reaction protein,tumor necrosis factor and interleukin-6) within 24h and the state of survival or death of the 24th day.Risk factors for predicting progression of the high-risk ARDS patients into ARDS patients and influencing the prognosis of the ARDS patients were analyzed by using logistic regression.Results Univariate logistic regression analysis found that the independent risk factors for progression of ARDS were APACHE Ⅱ score (OR=6.764,P=0.001),hypoproteinemia (OR=10.54,P=0.002),white blood cell count (OR=3.912,P=0.012),fibrinogen (OR=9.953,P=0.064),and D-dimer (OR=4.239,P=0.029).The mortality rate was 43.75％ (36/64) in ARDS group,and the oxygenation index (OR=6.573,P=0.014),platelet count (OR=9.376,P=0.003),hypoproteinemia (OR=10.738,P=0.056) were the independent risk factors of death in ARDS patients.Multivariate logistic regression showed that combination of multiple indicators for predicting ARDS improved the specificity,but reduce the sensitivity.APACHE Ⅱ and hypoproteinemia (sensitivity 62.50％,specificity 92.42％) and APACHE Ⅱ and D dimmer (sensitivity 62.07％,specificity 93.33％) had better specificity and sensitivity.The specificity and sensitivity of combining hypoproteinemia and platelet count to predict the risk of death in these patients were 77.78％ and 60.71％.Conclusions In high-risk ARDS patients,combining hypoproteinemia or APACHE Ⅱ score with D-dimer to judge the development of ARDS has good specificity but poor sensitivity.For ARDS patients,low oxygenation index,thrombocytopenia and hypoproteinemia indicate a poor prognosis.

ObjetiveTo investigate the obstetrical and neonatal outcomes of pregnant women with hypothyroidism or subclinical hypothyroidism.MethodsOne hundred and sixty-eight pregnant women with clinical or subclinical hypothyroidism during pregnancy,including 9 controlled hypothyroidism,29 uncontrolled hypothyroidism and 130 subclinical hypothyroidism,were enrolled in this study.The general clinical information,obstetrical complications and neonatal outcomes of these pregnant women were compared with that of 180 healthy pregnant women who delivered during the same period.ResultsCompared with control group,there were no significant differences in the levels of serum free triiodothyronine( FT3 ),free thyroxine ( FT4 ),thyrotropin-stimulating hormone (TSH) in the controlled hypothyroidism group in the third trimester [(3.68 ±1.11 ) pmol/L vs (3.19 ±0.33) pmol/L,(15.48 ±4.14) pmoL/L vs (13.95 ± 1.68) pmol/L,1.87 mU/L vs 1.76 mU/L,P ＞0.05].However,in the second and third trimester,the levels of FT3,FT4 in the uncontrolled hypothyroidism group were lower,while the levels of TSH were higher than in control group [(2.71 ±0.80) pmol/L vs (3.14 ± 0.34) pmoL/L,(10.94 ± 2.68) pmol/L vs (14.25 ±2.01) pmol/L,5.62 mU/L vs 2.28 mU/L,( 2.34 ± 0.70 ) pmol/L vs ( 3.19 ± 0.33 ) pmol/L,( 10.16 ± 1.65 ) pmol/L vs (13.95 ± 1.68) pmoL/L,7.13 mU/L vs 1.76 mU/L,t =2.754～9.15,P ＜0.01],the levels of TSH in the subclinical hypothyroidism were higher than in control group ( t =18.28,18.57,P ＜0.01 ).There was no adverse perinatal outcome of neonate happened in controlled hypothyroidism group.In contrast,the incidences of adverse perinatal outcomes and complications in the uncontrolled hypothyroidism group were higher than that in the control group ( 17.2％ vs 2.8％,37.9％ vs 5.6％,x2 =11.47,28.97,P ＜0.01 ).Compared with that of control group,the incidences of adverse obstetrical outcomes in pregnant women with subclinical hypothyroidism were increased (40.0％ vs 5.6％,x2 =52.97,P ＜ 0.01 ).ConclusionsThe rate of adverse obstetrical outcomes and complications is increased in women with clinical or subclinical hypothyroidism.But the incidence of adverse outcomes would decrease if hypothyroidism is controlled by treatment.

Objective To investigate the three-dimensional morphological characteristics of tibial plateau based on CT image post-processing technique and analyze its significance in preoperative planning of tibial plateau fractures.Methods Multi-slice spiral CT data of 98 humans (56 males and 42 females) with normal tibial plateau and 30 patients (15 males and 15 females) with tibial plateau fractures were extracted.Morphological measurements of the tibial plateau were achieved by means of a three-dimensional measurement method based on points,lines and surfaces.Differences in threedimensional parameters between genders in normal tibial plateau and differences between normal tibial plateau and tibial plateau fractures were analyzed.Results Differences of males and females were significant in width of tibial plateau [(73.2 ± 3.7) mm,(65.5 ± 3.7) mm],anteroposterior dimension of medial tibial plateau [(39.8 ± 3.5) mm,(34.8 ± 2.6) mm] and anteroposterior dimension of lateral tibial plateau [(34.0 ± 3.3) mm,(29.8 ± 3 5) mm] (P ＜ 0.05),but not in varus inclination of tibial plateau [(3.19 ± 1.98) °,(3.16 ± 1.89) °],medial plateau posterior slope [(7.31 ± 3.04) °,(8.16 ± 2.46)°] and lateral plateau posterior slope [(5.23 ±2.35)°,(5.60 ±2.55)°] (P ＞0.05).Above parameters in three-dimensional morphological measurements of tibibial plateau fractures varied compared to the normal reference value (P ＜ 0.05).Intraclass correlation coefficient (ICC) for intra-observe and inter-observer agreement in normal tibial plateau measurement was excellent.Conclusions Present research provides a series of scientific and objective data for preoperative planning of tibial plateau fractures.Measurements of tibial plateau can assist the evaluation of reduction of tibial plateau fractures.