Objective To learn the suitability and validity of readmission service at counties and townships in rural China.Methods Seven pilot counties were randomly selected from the eastern,middle and western areas of China,and five diseases of the respiratory infection and cerebral system were set as the targets,while 600 target inpatient readmitted who had any of the five target diseases from 2012 to 2013 in such counties were selected from the NRCMS database.With expert consultation and empirical evaluation,the fitness of the days of stay at township hospital and necessity of hospitalization at county hospitals were evaluated for such target inpatients.Results 64.7％ of the target inpatients were found with unfit days of stay at township hospitals,mostly too short;59.0％ of the target inpatients' hospitalization at county hospitals were found with serious risk factors during their hospitalization;18.5％ of the inpatients were found with unnecessary hospitalization.Conclusions Hierarchical medical system can enhance the efficiency of the heahhcare system,but the current validity of readmission is poor,so is the fitness of days of stay at township hospitals,and the quality of the referral pattern.These problems mostly result from poor medical competence at township hospitals and high autonomy of patients in seeking medical service anywhere in the country.

Objective:To explore the application of self-teaching model based on PBL teaching combined with flipped classroom in standardized residency training of orthopedics.Methods:There were 102 cases of residents who received standardized residency training from March 2017 to February 2018 in orthopedics department of Yueyang Hospital of Traditional Chinese and Western Medicine, among whom 55 were randomized into the observation group and 47 were divided into the control group. Traditional teaching was applied in the control group and self-teaching model was applied additionally in the observation group. At the end of the month, the teaching effect was evaluated by the department graduation examinations and questionnaire survey. SPSS 19.0 was used for t test. Results:The ability of history inquiry, diagnosis and physical examination of the residents in the observation group were higher than those in the control group. The self-study and data access ability, confidence in presenting, and satisfaction with teaching in the observation group were better than those in the control group.Conclusion:The self-teaching mode can arouse the learning initiative of residents, and increase residents' literature retrieval ability and their learning satisfaction.

ObjectiveTo explore the characteristics of the fetal pulmonary venous Doppler spectrum in medium-term and terminal pregnancy and to evaluate its application in the cardiac function assessment and lung maturation.Methods The study group consisted of 86 normal fetuses aged from 23rd to 41st week's gestation.The Doppler echocardiography was used to record the pulmonary venous spectra.The peak diastolic velocity (D),deceleration time of D wave,deceleration of D wave (Ddec),the peak systolic velocity (S),acceleration time of S wave,and acceleration of S wave of the right superior pulmonary vein (Sac.c) were measured.Sacc/Ddec was calculated.The Tei index of the left ventricle was calculated.ResultsThe D and deceleration time of D wave and Ddec increased with gestational age (P ＜ 0.05).S,the acceleration time of S wave and Sacc showed no significant correlation with gestational age.Sacc/Ddec ratio was more likely smaller than 1 with the gestational age less than 28 weeks and larger than 1 with the gestational age longer than 28 weeks ( P ＜0.05).ConclusionsD wave flow velocity,deceleration time of D wave and the Ddec of the right superior pulmonary vein had a good correlation with the global left ventricular function.The Sac/Ddec ratio might be new index for assessing cardiac function and lung maturation.

Objective To investigate the clinical value of blood vessel diameter tracking and X-strain technology in evaluating the carotid elasticity in patients with diabetes.Methods Thirty-eight patients who were confirmed as diabetes without complications were enrolled in this study as the patient group and thirtyseven healthy volunteers matched with the patient group with sex,ages were typed as controls.The parameters reflecting common carotid elasticity:pulse wave velocity ( PWV),compliance coefficient (CC),stiffness index ( β),endovascular circumferential strain,strain rate,strain time ( EN _ CS,EN _ CS_ T,EN_CSR,EN_CSR_T),adventitial circumferential strain,strain rate,strain time (EP_CS,EP_CS_T,EP_CSR,EP_ CSR_ T),radial strain ( RS),radial strain rate (RSR) and radial strain time (RST) were measured using blood vessel diameter tracking technique and X-strain technique.Significant difference between the two groups and correlations among these variables were evaluated.Results In patient group,PWV and β were significantly higher than those of the control group,while variables like CC,EN_CS,EN_CSR,EP_CS,EP_CSR,RS and RSR were lower with P ＜0.05.All strain time prolonged in patient group ( P ＜0.05).No significant differences were observed in longitudinal strain index.Furthermore,CC was inversely related with PWV( r =- 0.872,P ＜0.001 ),and age,systolic pressure,β were positively related with PWV ( r =0.322,P =0.005; r =0.384,P =0.001; r =0.927,P ＜0.001) in patients group.Conclusions The stiffness and compliance indexes measured by blood vessel diameter tracking technique and the circumferential and radial strain index obtained by X-strain technique can reflect vessel elasticity change of patient with diabetes objectively.

ObjectiveTo test the reproducibility of wave intensity (WI)analysis derived measurements of pulse wave velocity (PWV),and to compare it with the traditional method-applanation tonometry.MethodsOne hundred and ten outpatient volunteers were enrolled in the study.The R-W1 of right brachial artery and right posterior tibial artery were measured through WI in diagnostic ultrasound equipment (Aloka α10),and were used to calculate the right brachial artery PWV which were also measured by tonometry (VP-1000) simutaneously;thus 30 of these volunteers were randomly selected to repeat the above examinations in the same session.Differences between the two methods were investigated by means of a paired t-test,and their linear correlations were also analyzed.Bland-Altman method was used to analyze the agreement between the two methods and their intraobserver intrasession variabilities.ResultsMean baPWVs determined by WI and tonometry were (13.03 ± 1.93) m/s and ( 12.05 ± 2.02) m/s,respectively (P ＜0.001),and the mean of their difference was (0.98 ± 1.1)m/s giving 95 ％ limits of agreement of ( - 1.18 m/s,3.14 m/s).Values of PWV obtained by the two systems were highly correlated( r =0.85,P＜ 0.001 ),with their intraobserver intrasession variabilities being 8.2％ and 7.0％,respectively.ConclusionsWI provides a new noninvasive and convenient method to measure PWV with good agreement and similar reproducibility to the standard tonometry system.

Objective To explore changes of left ventricular filling during the strain phase of Valsalva maneuver (VM) and its mechanism. Methods Thirty healthy volunteers were recruited to perform VM with a load of 40 mmHg. Left ventricular filling parameters (E, A, E/A ratio, e and E/e ratio) were determined by echocardiography at baseline,at the first beat and at the second beat during the strain phase of VM,respectively. Results Compared to those at baseline, E, E/A ratio and E/e ratio increased ( P ＜0.05) while A and e did not change ( P＞0.05) at the first beat during the strain phase. Compared to those at the first beat during the strain phase,E, E/A ratio and E/e ratio decreased ( P ＜0.05) while A and e did not change ( P ＞0. 05) at the second beat during the strain phase. Conclusions Left ventricular filling decreased at the second beat during the strain phase of VM, which is different from the present knowledge that left ventricular filling would begin to decrease 4-5 beats later during the strain phase of VM. Positive intrathoracic pressure decreases left-side heart and pulmonary vessel' transmural pressure while increases the blood resistance, which may be the reason that E, E/A ratio and E/e ratio decreased at the second beat during the strain phase of VM.

Objective To compare inter-hospital transport and clinical outcome in severe acute respiratory distress syndrome(ARDS)patients whom were transported either on extracorporeal membrane oxygenation(ECMO) or on conventional ventilation,and to investigate the optimal means of inter-hospital transport. Methods Eleven patients with severe ARDS who were invalid under conventional ventilation and were transported from other hospitals to Tianjin Third Central Hospital from November 2009 to January 2014 were analyzed. Five patients were transported on ECMO(observation group)and 6 on conventional ventilation(control group). The clinical characteristics,outcomes, transportation,vital signs before and after transportation,respiratory parameters,and Murray score between two groups were compared. Results Patients in observation group were significantly older than those in control group〔years:73(46,77)vs. 34(23,46),Z=-2.293,P=0.022〕. There was no significant difference between observation group and control group in acute pathologic and chronic health evaluationⅡ(APACHEⅡ)score,Murray score,oxygenation index(PaO2/FiO2)before transportation,transit time,and transit distance〔APACHEⅡscore:36(33,39)vs. 27(23,35),Z=-1.830,P=0.067;Murray score:3.5±0.3 vs. 3.4±0.2,t=0.667,P=0.524;PaO2/FiO2(mmHg, 1 mmHg=0.133 kPa):61±14 vs. 63±14,t=-0.249,P=0.809;transit time(minutes):24(18,74)vs. 79(41, 86),Z=-1.654,P=0.098;transit distance(km):12.9(8.3,71.8)vs. 72.4(39.5,86.8),Z=-1.651,P=0.099〕. There was no significant difference between two groups in vital signs and respiratory parameters before transportation. When arrived in ECMO centre,heart rate,respiratory rate,fractional inspired oxygen,inspiratory pressure and Murray score in observation group were significantly lower than those in control group〔heart rate(beat/min):102±16 vs. 136±8, t=-4.374, P=0.002;respiratory rate(beat/min):23±3 vs. 37±2,t=-7.967,P=0.000;fractional inspired oxygen:0.40±0.05 vs. 0.96±0.09,t=-12.152,P=0.000;inspiratory pressure(cmH2O, 1 cmH2O=0.098 kPa):21±1 vs. 34±4,t=-6.887,P=0.000;Murray score:2.7±0.2 vs. 3.8±0.2,t=-8.573, P=0.000〕,but PaO2/FiO2 was higher than that of control group(mmHg:278±65 vs. 41±5 ,t=8.075,P=0.001). Four patients were survived in observation group,and one died from the shortage of oxygen induced lung injury deterioration during transportation. Three patients died in control group,which was directly associated with lung injury deterioration. Conclusion For patients with severe ARDS who need the support of ECMO,ECMO-assisted transfer is safer than conventional ventilation,but transfer should be implemented by experienced team.

Objective To investigate the clinical value of circumferential strain and strain rate in estimating the carotid elasticity. Methods Thirty-five consecutive patients of hypertension were enrolled in this study as the patient group and 36 healthy volunteers whose ages were matched with the patient group were included as controls. The intima-media thickness(IMT) of common carotid arteries of both the patients and controls were measured using RF-Data technique of ultrasound vascular measurement and the following traditional parameters reflecting common carotid elasticity were obtained: pulse wave velocity (PWV),arterial compliance (AC). While the new parameters reflecting vascular strain including endovascular longitudinal strain(EN-LS), endovascular circumferential strain(EN-CS), endovascular longitudinal strain rate(EN-LSR) ,endovascular circumferential strain rate(EN-CSR), adventitial longitudinal strain(EP-LS),adventitial circumferential strain ( EP-CS ), adventitial longitudinal strain rate ( EP-LSR ), adventitial circumferential strain rate(EP-CSR) were collected using the technique of X-strain. All the corresponding parameters were compared between hypertensive group and controls. The correlations between elasticity and hemodynamic parameters were analyzed. Results In the hypertension patients,PWV was higher while AC,EN-CS,EN-CSR,EP-CS and EP-CSR were lower than that of the control group( P ＜0.05). No significant differences were detected in the longitudinal strain and strain rate. In the hypertension group,AC correlated positively with PWV, while EN-CS, EN-CSR, EP-CS and EP-CSR correlated negatively with PWV and positively with AC. Conclusions Circumferential strain and strain rate conform well to the mechanical principle and the characteristic anatomic and histological structure of the vessels and may be used to reflect the early changes of the vascular elasticity.

Objective:In this study, the feasibility of this method was evaluated in children with large distance femoral lengthening cases, and the acute correction and staging surgeries were compared at healing speed. At the same time the key points of surgical techniques would be summarized, so as to clarify the application value of this technology in children patients.Methods:Since July 7 of 2014 to January 16 of 2018, a total of 10 cases of Lengthening Over Retrograde Nail (LORN) surgery have been formulated and carried out, including 9 males and 1 females.The average age of the operation was 13.10±2.18 y. In all cases, the osteotomy point was located in the metaphysis of the distal femur, and the records from the first meeting to the end of follow-up included gender, date of birth, reason of discrepancy and treatment history, age at surgery, lengthing distance, the length of duration with frame, healing time, ROM of the knee joint, complications, et al. To compare the healing time of acute correction and staging surgery. Statistical analysis was made by SPSS 22.0 software, and then reasonable treatment strategies were proposed.Results:The average lengthing distance of 7.07±1.01 cm. The median time of the duration with frame was 8.5 (4,16) months, and the median follow-up time was 39 (34, 54) months. All cases obtained good clinical and imaging healing (1.70±1.10 month/cm vs. 1.16±0.54 month/cm), and all regained to normal walking function (136.67°±20.82° vs. 125.71°±26.37°), without the occurrence of fracture after therapy. There were no statistically significant differences in the speed of healing, range of joint motion or complication rate between acute correction and staging treatment. Conclusion:It is feasible for femoral lengthening surgery assisted by retrograde intramedullary nail in the treatment of femoral shortening deformityin children. The correction of mild angular deformity and lengthening surgery can be performed simultaneously. The osteotomy site was proposed at distal metaphysealof the femur for better quality of osteogenesis and shorter duration for fixator. It is safe to osteotomy and lengthening in the area of enchondroma.

Objective:To compare the efficacy between arthroscopy-assisted reduction and internal fixation (ARIF) versus open reduction and internal fixation (ORIF) in the treatment of tibial plateau fractures.Methods:A retrospective analysis was done of the 75 patients with tibial plateau fracture who had been treated by ARIF or ORIF at Department of Orthopaedics, Union Hospital Affiliated to Tongji Medical Collage from January 2016 to August 2018. They were 58 men and 17 women, aged from 20 to 54 years (average, 47 years). The left side was affected in 42 cases and the right side in 33. By the Schatzker classification, there were 23 cases of type Ⅰ, 49 cases of type Ⅱ and 3 cases of type Ⅲ. Of them, 40 were treated by ARIF and 35 by ORIF. The 2 groups were compared in terms of operation time, incision length, intraoperative blood loss, hospital stay, postoperative complications and the Hospital for Special Surgery (HSS) scores 12 months after operation.Results:There was no statistically significant difference between the 2 groups in the preoperative general data, showing the 2 groups were comparable ( P>0.05). The patients were followed up for 12 to 15 months (average, 13.5 months) after operation. The wounds in the 75 patients healed at one stage with no complications like neurovascular lesions. All the fractures healed within 6 months after operation. Compared with the ORIF group, the ARIF group had significantly longer operation time (58.3 min ± 4.2 min versus 48.4 min ± 5.2 min), a significantly shorter incision (4.3 cm ± 0.9 cm versus 6.2 cm ± 0.8 cm), and significantly less intraoperative blood loss (60.8 mL ± 4.5 mL versus 72.8 mL ± 6.5 mL) ( P<0.05). There was no significant difference between the 2 groups in hospital stay (5.1 d ± 0.6 d versus 5.5 d ± 1.6 d) ( P>0.05). Fifteen patients in the ARIF group and 5 in the ORIF group were complicated with soft tissue injury, showing a statistically significant difference ( P<0.05). The excellent and good rate by HSS scores was 100% (40/40) for the ARIF group and 85% (34/40) for the ORIF group, showing no significant difference ( P>0.05). Conclusions:In the treatment of tibial plateau fractures of Schatzker types Ⅰ-Ⅲ, both ARIF and ORIF may result in good efficacy. However, ARIF can evaluate and treat the complicated soft tissue injuries to the knee joint more precisely, showing advantages of shorter operation time, a smaller incision and less blood loss.