Nurses often face ethical dilemmas in clinical practice,originating from nurses themselves,nursing measures,and nursing management as well.Only by correctly recognizing and analyzing the causes of ethical dilemmas in nursing care,can help nurses get out of the ethical dilemmas and make reasonable ethical decisions in nursing care.

Background The fibrosis of filtering area caused by proliferation of human Tenon fibroblasts (HTFs) is one of failure causes following glaucoma surgery.Researches revealed that hydroxycamptothecin can induce the apoptosis of HTFs,but its influence on autophagy of HTFs is unclear.Objective This study attempted to investigate whether hydroxycamptothecin can cause an alteration of autophagic activity in HTFs.Methods Human Tenon capsular tissue was obtained from 3 patients during strabismus correction surgery under the informed consent of patients and their parents for the primary culture and passaged of HTFs in DMEM containing 10％ fetal bovine serum.The generation 3 to 6 cells then were incubated with 0.0,0.5,1.0,4.0,10.0 mg/L hydroxycamptothecin for 24 hours,respectively.A cell counting kit-8 (CCK-8) was used to detect the cell viability in different treated groups.The autophagic activity of HTFs was evaluated by a Cyto-ID autophagy detection kit,and then the autophagic flux was evaluated by counting the Cyto-ID positive cells under a fluorescence microscope,and the green fluorescence intensity was determined by flow cytometry.Quantitative reverse transcriptase PCR (qRT-PCR) and Western blot analysis were employed to assay the relative expressions of autophagic-associated genes and their proteins in HTFs,including Beclin-1,autophagy related gene 5 (ATG-5) and light chain 3 (LC-3).Results The cell viability of HTFs in the 0.0,0.5,1.0,4.0 and 10.0 mg/L hydroxycamptothecin groups were (100.00 ± 6.44) ％,(91.70 ± 6.36) ％,(81.47 ± 6.00) ％,(68.43 ± 6.69) ％ and (59.97 ± 6.98) ％ respectively,showing a gradually declining trend with the increase of hydroxycamptothecin doses,with a significant difference among them (F=19.040,P＜0.001),and the viability of HTFs in the 1.0,4.0 and 10.0 mg/L hydroxycamptothecin groups were significantly decreased than the control group (P＜0.05,P＜0.01,P＜0.01).qRT-PCR analysis revealed that the relative expression levels of Beclin-1 mRNA,ATG-5 mRNA and LC-3 mRNA in 4.0 mg/L hydroxycamptothecin group were (3.225 ±0.346),(2.839 ±0.418) and (3.761±0.224) folds higher than those of the control group.The expressions of Beclin-1 and ATG-5 proteins were significantly increased in the 4.0 mg/L hydroxycamptothecin group in comparison with the control group,and the expression intensity ratio of LC-3-Ⅱ/Ⅰ was 0.965±0.159 in the hydroxycamptothecin group,which was significantly higher than 0.275 ±0.860 of the control group (P =0.003).Cyto-ID staining showed that the percentage of autophagic cells increased dramatically from (11.333±4.010) ％ to (55.000±9.013) ％ upon the exposure of HTFs to 4.0 mg/L hydroxycamptothecin (P=0.002).Flow cytometry analysis showed that the green fluorescence intensity in the 4.0 mg/L hydroxycamptothecin group was (3.037 ±0.513) fold relative to that in the control group,showing a significant difference between the two groups (P =0.003).Conclusions Hydroxycamptothecin can induce autophagy in HTFs in vitro.

Object To estabish a method for the quantitative analysis of osthol in LOTIO FRUCTUS CNIDII COMPOSITA by RP HPLC Methods Megestrol acetate was used as the internal standard Results Chromatographic separation of osthol and megestrol acetate was accomplished within 12 min on Hypersil ODS 2(200 mm? 4 0 mm, 5 ?m) column and acetonitrile 0 01 mol/L sodium dihydrogen phosphate (48∶52) as mobile phase The flow rate was 1 2 mL/min and the detection wavelength was 320 nm A good linearity was obtained in the range of 0 123 8～2 970 ?g/mL (r=0 999 6) for osthol and the average method recovery was (98 4?0 90) % with RSD=0 91% Conclusion The method was simple, rapid, accurate, reliable, and suitable for the quality control of LOTIO FRUCTUS CNIDII COMPOSITA

Objective Retrospectively investigate the application of anterolateral thigh flow-through flap in reconstruction of the extremities,to estimate its role and characteriscts.Methods From March,2010 to January,2016,anterolateral thigh flow-through flap was performed for reconstruction of the extremities in 87 patients (56 males,and 31 females).Patient ages ranged from 13 to 68 years,average of 34.4 years.Of all cases,there were 37 legs,21 ankles or foots,1 arm,19 forearms,and 9 hands.The role and result of anterolateral thigh flow-through flap was analyzed retrospectively.Results The result showed that when anterolateral thigh flow-through flap was transferred,which simutaneously played various roles as follows:①rebuilding main vascular defect,to revascularise the distal limb.② preserving recipient vessels,to prevent flow impaired.③rebulding recepient vessel defect.④ protecting vascular anastomosis and preserving recipient flow simultaneously.⑤avoiding the dilemma of end-to-side anastomosis when recipient vessels is deep.⑥ balancing blood flow,the blood supply of the flap was more stable.⑦ linking another tissue in a series fashion,to achieve complex reconstruction.Vascular compromise occurred in 3 cases after surgery,total necrosis occurred in 1 case and partial necrosis in 1 case after reexploration.One case presented deep infection and secondary with renal failure,and received amputation.Local infection presented in 3 cases,wound dehiscence in 2 cases.All the other flaps survivled uneventfully,and its texture and color was normal.In donor site,local infection occurred in 1 case,wound dehiscence in 2 cases.Conclusion Anterolateral thigh flow-through flap has function of many sided reconstruction,which is able to play a vital role in reconstruction of the extremities.

Objective. To understand drug susceptibilities to common antibacterials, resistance mechanism to β-lactams and quinolones and the clonal spread of resistant stains of Haemophilus influenzae (H. influenzae) and Haernophilus parainfluenzae (H. parainfluenzae) isolated from some hospitals in Shanghai. Methods The in vitro antimicrobial susceptibilities to 13 antibacterials, such as ampicillin, of 156 Haemophilus strains collected from 5 hospitals of Shanghai in 2006 were tested by agar dilution method. The β-lactamase production was determined by chromogenic cephalosporin test. TEM and ROB type of β-lactamase genes and quinolone resistance determining regions (QRDR) of ciprofloxacin-resistant strains were detected by polymerase chain reaction (PCR) amplification. The homology of H. influenzae strains were analyzed by enterobacterial repetitive intergenic consensus (ERIC)-PCR. Results The susceptible rate of 109 strains H. influenzae to ampicillin was 74.3%, while those to ampicillin-sulbactam, cephatosporins and fluoroquinolones were all 100.0%. The β-lactamases-producing rates of 109 strains H. influenzae and 47 strains H. parainfluenzae were 25.7% and 19.1% (χ2=0.776,P=0.378), respectively. TEM gene was detected in all β-lactamases-producing strains. Of 109 H. influenzae isolates, only one was resistant to ciprofloxacin, and Ser84Leu mutation was detected in gyrA gene and Gly206Arg mutation in parC gene. The results of ERIC-PCR showed that 106 H. influenzae strains were clustered into 73 groups with similarity level of 85%. Conclusions Clinical isolates of H. influenzae from hospitals in Shanghai remain highly susceptible to common antimicrobial agents except ampicillin. TEM type of β-lactamase production is the main ampicillin-resistant mechanism of the tested stains. The clonal spread of H. influenzae, including ampicillin-resistant strains, is not prevalent.

Objective To investigate the efficacy of combined intravenous rt-PA and free-radical scavengen (edaravone) on Chinese patients with acute ischemic stroke. Methods Eighty-nine subjects with ultra-acute ischemic stroke were assigned to the group treated with intravenous rt-PA and another group treated with a combination of intravenous rt-PA and edaravone. The NIH Stroke Scale (NIHSS) and Barthel Index (BI) in 30 days and 90 days after thrombolysis were compared between two groups. Results There were statistically significant differences between the group of rt-PA thrombolysis and the group of combined with rt-PA and edaravon in the ratio of NIHSS 0-1 of 30 days after therapy (25.0% vs35.6%, χ2=8.259,P=0.041) and 90 days (27.3%vs 40.0%, χ2=9.158,P=0.027),as well as in the proportion of BI 95-100 of the same time points(30 days:20.5%vs33.3%,χ2=8.833,P=0.032;90 days:25.O%vs37.8%,χ2=8.221,P=0.042).The rates of hemorrhagic conversion and mortality in two groups were similar. Conclusion rt-PA combined with free radical scavenger edaravone safely and effectively decreases the loss of neurofunctions and reserves more self-dependence capability in patients with acute ischemic stroke 30 days and 90 days after treatments.

Objective:To study the clinicopathological features and differential diagnosis of metaneph-ric adenoma (MA).Methods:The clinicopathological data of 16 cases with MA diagnosed and treated in Peking University First Hospital from 2004 to 2016 were retrospectively analyzed,and the clinical characteristics,pathologic parameters,differential diagnosis,treatment options and prognosis of MA were analyzed with literature review.Results:The patients included 10 females and 6 males.The age of pa-tients ranged from 14 to 83 years (mean =33.7 years).The partial nephrectomy was carried out for most patients.All cases were located in renal codex with 3 growing into the renal sinus.Histologically,the tumor was composed of tubules,papillary or glomeruloid structures and psammoma bodies were focally seen.Immunohistochemical study showed that all the cases expressed vimentin,and 94% cases ex-pressed CD57,63% WT1,75% AE1 /AE3,19% cytokeratin 7 (CK7 )and 13%α-methylacyl-CoA racemase (AMACR),and negative expressions for MA included CD10,neuron-specific enolase (NSE) and CD56.Follow-up information from 1 to 125 months was available in all the patients;and none of the patients showed any evidence of recurrence and metastasis.Conclusion:The benign tumor characteris-tics of MA are not obvious for preoperative imaging diagnosis,and the diagnosis of MA should be based on the unique pathological features.Positive immunostain of CD57 is a useful indicator for MA diagnosis and differential diagnosis.The partial nephrectomy surgical treatment can achieve good clinical cure with good prognosis.

Objective To investigate the safety of intraoperative electron radiation therapy (IOERT) for stage Ⅰ hepatocellular carcinoma (HCC) by a cohort study.Methods From November 2010 to May 2012,16 patients who were pathologically diagnosed with stage Ⅰ HCC underwent IOERT after radical resection.With a cohort study,87 patients with stage Ⅰ HCC who underwent radical resection alone during the same period were qualified,and according to tumor size (＞ 5 cm and ≤ 5 cm) and resection margin (close margin and negative margin),32 of 87 patients made up the control group.The intraoperative and postoperative adverse events,liver function parameters,coagulogram,and routine blood parameters,as well as IOERT-related adverse reactions,were evaluated.Independent-samples t test was used for analyzing the differences between groups.Results Compared with the control group,the IOERT group had a significantly longer operative time ((275.4 ± 71.55) min vs.(184.7 ± 64.74) min,P =0.000),a slightly higher incidence of intraoperative adverse events (18.75％ vs.6.25％,P=1.000),a slightly lower incidence of operative complications (12.50％ vs.28.12％,P =0.460),and a lower perioperative mortality (0 vs.6％,P =0.440).Liver function parameters showed no significant differences between the two groups (P ＞ 0.05).There were no significant differences between the two groups in postoperative time to grade 1 or normal liver function parameters,median length of postoperative hospital stay,length of hospital stay in the surgical department,time to incision healing,and level of incision healing (P ＞ 0.05).During follow-up,no radiation hepatitis was found in the IOERT group.Conclusions As an adjuvant therapy after radical resection for early HCC,IOERT has no significant side effects on postoperative recovery and liver function,and an intraoperative dose of 15-16 Gy is safe.

Objective To evaluate the value of CTA in assessing congenital heart disease and related heterotaxy syndrome.Methods A total of 20 patients with congenital heart disease and heterotexy syndrome underwent CTA and 3-dimensional reconstructions.And intracardiac and extracardiac abnormalities were assessed.Results Three cases were left isomerism,two of which were bi-lobed left lungs and trilobed right lungs,and another one was bi-lobed lungs.The most common associated cardiovascular anomalies included single ventricle (n=2),atrial septal defect (n=2),ventricular septal defect (n=1),transposition of the great arteries (n=2),pulmonary artery stenosis (n=2),atresia (n=1),persistent left superior vena (n=1),no hepatic segment of inferior vena cava (n=1).The rest 17 cases were right isomerism.All of them were trilobed lungs.Associated cardiovascular anomalies included single ventricle (n=9),double outlet of right ventricle (n=2),endocardial cushion defect (n=6),atrial septal defect (n=10),patent foramen ovale (n=1),ventricular septal defect (n =8),transposition of the great arteries (n =14),pulmonary artery stenosis (n =16),atresia (n =1),pulmonary venous drainage (n=6),persistent left superior vena (n=7),no hepatic segment of inferior vena cava (n=2).Conclusion CTA can clearly show the structure of heart,great vessels,chest and abdomen which is a useful tool to accurately assess congenital heart disease and related heterotaxy syndrome for medical or surgical management.