Emergency practice is an important part of clinical study.At present,the emergency teaching content of general practice is so wide that the teaching time is not enough,We do not pay enough attention to the cultivation of clinical thinking,pre-hospital care,two-way referral,and first aid skills training and so on.In this paper,the development of community emergency oriented teaching content,cultivation of de-escalation clinical thinking,and the pre-hospital emergency training and other aspects are studied for the students' teaching in emergency practice in order to improve the clinical practice teaching level of general medicine sttdents.

Objective To investigate the correlation between serum procalcitonin (PCT) and acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score and prognosis in acute exacerbation of chronic obstructive pulmonary disease (AECOPD).Methods A total of 88 patients with AECOPD admitted to emergency department of Peking university third hospital were prospectively studied,and were divided into three groups,namely high score group,median score group and low score group according to APACHE Ⅱ score.Serum PCT,hypersensitive C-reactive protein (hs-CRP),WBC and lactate were assayed within the first 24 hours after admission,the differences in those indicators between three groups were analyzed; and the correlation between PCT and APACHE Ⅱscore,hs-CRP,WBC,lactate were investigated.The patients were divided into survival group and death group according to prognosis,and the differences in those indicators between the two groups were analyzed.Results The serum levels of PCT was higher in high score group (0.60±0.32) ng/ml than that in median score group (0.36 ±0.23) ng/ml and that in low score group (0.24 ±0.19) ng/ml,differences between groups were statistically significant (P ＜0.01).The hs-CRP was higher in high score group M (P25,P75) 36.88 (10.14,47.16) mg/L than that in median score group 15.00 (3.64,30.33) mg/L and that in low score group 14.77 (4.35,15.80) mg/L (P =0.046).The PCT significantly correlated with APACHE Ⅱ and hs-CRP (P ＜0.01).The serum levels of PCT,APACHE Ⅱ score,hs-CRP and lactate were significantly higher in death group than those in survival group (P ＜ 0.05).Conclusions There is a good correlation between PCT and APACHE Ⅱ score in patients of AECOPD,suggesting PCT to be a sensitive predictor of prognosis.

Objective To investigate the clinical characteristic and treatment of dieulafoy lesion in order to improve the early diagnosis and treatment.Methods A retrospective review of clinical records of 15 cases of dieulafoy lesion admitted to our emergency department from October 2005 to August 2012 was carried out.Results The male patients were more vulnerable to this disease than female patients,thereby the ratio of male to female patients was 6.5∶ 1,and the mean age was 48.3 years.The precipitating factors were often obscure,and some possible factors were related with certain amount of wine (1/15),using nonsteroidal anti-inflammatory drugs (2/15),and eating irritant food (2/15),and a few patients had a past history of hypertension (3/15) or diabetes mellitus (5/15) and no patient had past history of peptic lesion and cirrhosis of liver.The Dieulafoy' s lesion occurred suddenly without premonitory symptoms such as pain or upset of stomach,presented with the episodes of hematemesis or hemafecia,and the patients were in a stage of shock and moderate to severe anemia because of massive blood loss.The majority of lesions located at the posterior wall of the stomach (9/15) or adjacent to the lesser curvature (10/15).Endoscopy was of prime importance for confirming the diagnosis of Dieulafoy's lesions.Endoscopic treatments included hemostasis with clipping combined with epinephrine submucosa injection and successfully excising the lesion in 14 patients (14./15).Surgical treatment was done in 1 patient after failure of endoscopic treatments.Conclusions Dieulafoy lesion is characterized by sudden massive hemorrhage of the alimentary tract,it most commonly locates in the pars posterior of stomach adjacent to the lesser curvature in the middle-aged and the elderly males.Endoscopy is the most simple and essential method to confirm the diagnosis,and emergency endoscopic hemostasis with clipping for treating Dieulafoy lesion is an effective therapeutic strategy.

Objective To analyze the clinical characteristics, diagnosis, therapy and prognosis of acute pulmonary embolism (APE) following surgery so as to advise clinicians to pay more attention to and prevent postoperative APE. Method Thirty-one APE patients following surgery treated in the recent 8 years were analyzed retrospectively. The clinical features, diagnosis, therapy and prognosis of patients were analyzed. Results (1) Post-operative APE patients accounted for 21.9% of all APR patients during that period. The mortality of patients after surgical operation was 3.2%. (2) APE following surgery often occurred in patients after operations of spine, abdomen, gynecological surgery and point replacement as well as in patients with malignant tumor. The APE following surgery often occurred in the first week after surgery. The APE after surgery for malignant tumor occurred sooner. (3) Among many clinical manifestations, dyspnea (90.3%) was the commonest one. Other manifestations included chest pain, palpitation and syncope. The typical triad of dyspnea, hemoptysis and cheat pain was rarely seen. (4) The venous thrombolysis was a absolute contra-indication for massive PE after surgery. Catheter embolectomy and fragmentation, and surgical embolectomy were the alternative treatment. Conclusions Surgery is the essential risk factor of APE. When patients present dyspnea, chest pain or syncope, clinicians should pay attention to APE. Anticoagulation and embolectomy can improve the prognosais of the patients.

Objective To investigate the regularity of variation in number of emergency patients visiting doctors within each 24 h during holidays and festival days,so as to provide a scientific basis for hospital administration and the rational allocation of human resources.Methods Based on the hospital's statistical data of emergency patients visiting doctors during winters from December 2010 to February 2014,a retrospective analysis was carried out for the number and the visiting time of emergency patients on holidays (weekends,the minor long holiday of 3 days for New Year and the major long holiday of 7 days for spring festival) and on general working days (Monday to Friday),respectively.The variation in number of patients and peak time of visiting doctors were analyzed by using circular distribution method,and compared the differences in the number of emergency patients visiting doctors and peak time period between holidays and working days.Results Most of emergency patient visitors were 50-79 years old males; the number of emergency patients on holidays was significantly higher than that on general working days,especially during the seven-day spring festival (P ＜ 0.01),while the number on New Year' s day was similar to that on weekends; peak time for emergency patients' visiting doctors was from 13:05 to 0:28 during general working days.On the contrary,the peak time occurred earlier at 10:05 until 21:05 during the holidays if the hospital offers half-day outpatient service,and in the absence of outpatient service,the peak time emerged further earlier at 9:16 until 21:26 during holidays.Conclusions The ages,number and the peak time of emergency patients visiting doctors on holidays are different from those on the general working days,so medical staff on duty should be arranged reasonably to follow this regularity.

Objective To evaluate the early diagnostic value of human heart-type fatty acid- binding protein (H-FABP) of acute coronary syndrome (ACS) and compare the diagnostic accuracy of different combination regimens of cardiac markers. Methods A total of 103 consecutive patients with chest pain (within 6 h after admission to Peking University Third Hospital,emergency department) suggestive of ACS were recruited for the analysis from April,2010 to June,2011.The blood levels of H-FABP,cardiac troponin-T (cTnT) and creatine kinase-myocardial band (CK-MB) were obtained at admission. The sensitivity,specificity,positive predictive value and negative predictive value together with the sensitivity and specificity in different phases of illness at admission were analyzed and compared among H-FABP,cTnT,CK-MB and different combinations by using SPSS version 17.0 software.Results Within 6 h of onset of symptom,the overall sensitivities of H-FABP,cTnT and CK-MB were 62.5％,30.6％ and 33.3％ respectively for patients with ACS.The sensitivity of H-FABP was significantly higher than that of cTnT and CK-MB (P ＜0.01 ).There were no differences in specificity and positive predictive value.The combination of H-FABP with cTnT had the greatest negative predictive value (53.8％ ).The sensitivity of H-FABP was higher during 3 - 6 h (77.8％ ) than during 0 - 3 h (53.3 ％ ) after chest pain onset (P =0.038).Within 0 - 3 h of onset of AMI,the overall sensitivities of the combination of H-FABP with cTnT and H-FABP with CK-MB (55.6％) were significantly higher than the combinaton of cTnT with CK-MB ( 24.4％ ) ( P =0.003 ).The sensitivity of the combination of H-FABP with cTnT was higher than that of single H-FABP during 0- 3 h and 3 -6 h after onset of AMI with increment in 3.3％ and 7.4％ respectively.The combination of H-FABP with cTnT had the greatest sensitivity ( 85.2％ ) during 3 - 6 h after onset.Conclusions H-FABP is the most sensitive cardiac marker in diagnosing of ACS in the early phase within 6 h,especially during 3 -6 h after onset.The sensitivity of the combination of H-FABP with cTnT is higher than that of H-FABP alone.The combination of H-FABP with cTnT has the best diagnostic value during 3 -6 h after onset of ACS.

Objective To evaluate the status of implementation of the chain of survival and the gap between the guideline's recommendations and clinical practice as well as to analyze the factors influencing the prognosis of cardiac arrest (CA) patients.Methods A retrospective analysis of CA in adult patients admitted to Emergency Department of Peking University Third Hospital from January 2012 to December 2013 was carried out.The epidemiology,clinical features,implementations of the chain of survival and outcome were compared between out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) patients,with regard to the analysis of the predictors for survival and neurological outcome.Results A total of 414 patients with 69.8％ male and average age of (61.7 ± 18.0) years were divided into two groups,OHCA group (n =190) and IHCA group (n =224).Cardiogenic cause was found in 30％ of CA patients.There were 27.5％ patients with restoration of spontaneous circulation (ROSC),8.2％ patients discharged in survival and 3.1％ patients with good neurologic outcome (CPC =1 and 2).There were higher proportion of medical responders arriving to CA patients within 5 minutes after onset (99.1％ vs.10.5％,P ＜0.01),bystander carrying out cardiopulmonary resuscitation (100％ vs.15.3％,P ＜0.01),CPR initiated in 5 minutes (98.7％ vs.11.1％,P ＜ 0.01),defibrillation performed in 5 minutes (87.5％ vs.12.5％,P ＜ 0.01) in IHCA group compared with OHCA.There were no statistical differences in epinephrine administration and epinephrine dose,and targeted temperature management between two groups.There were higher proportion of ROSC (37.1％ vs.16.3％,P ＜ 0.05),higher percentage of survivals discharged (31.0％ vs.22.6％,P =0.002) and good neurologic outcome with CPC =1 or 2 (48.1％ vs.0.0％,P =0.029) in IHCA group compared with OHCA.Location of CA occurred and initial arrhythmia rectifiable with defibrillation treatment after ROSC were the favorable predictors for assessing the percentages of ROSC and survivals discharged.In contrast,male and age over 65 years were the unfavorable predictors of ROSC.Conclusions Improvement in outcome of victims with CA is required in every link of the chain of survival,especially in prehospital rescue act,bystander carrying out CPR,defibrillation,and therapeutic hypothermia in unconscious patients after resuscitation.The effective implementation of chain of survival concept can improve the prognosis of CA patients.

Objective To investigate the correlation between platelet-related parameters and the severity as well as prognosis of septic patients.Methods A total of 91 patients with sepsis were included in this study, and the platelet-related parameters were detected in all patients within 24 hours and 72 hours after admission to hospital, respectively.Clinical information of each patient was recorded including age, gender and underlying diseases, APACHE Ⅱ score at admission and the incidence of the consequent multiple organ dysfunction syndrome (MODS) and 28-day mortality.The differences in platelet-related parameters between non-severe sepsis group and severe sepsis group were compared, the correlation between plateletrelated parameters and the prognosis was studied by using rank method and the reliability of platelet-related parameters to predict the prognosis was estimated by using receiver operating characteristic curve (ROC).Results The differences in results of platelet-related parameters between non-severe sepsis group and severe sepsis group within 24 hours and 72 hours after admission were as follows : platelet count : (166.34 ± 58.27) ×109L-1vs.(198.57±65.82) ×109L-1, P=0.02and (138.85 ± 53.31) ×109L-1vs.(173.79 ± 67.48) × 109 L-1, P =0.00;the platelet distribution width (PDW) : (13.84 ± 2.46) ％ vs.(12.73±1.72)％, P=0.01 and (16.07 ±2.87)％ vs.(13.86 ±2.31)％, P=0.00;mean platelet volume (MPV) : (10.17 ±1.82) fl (femto-liter) vs.(9.32 ±1.34) fl, P=0.01 and (11.49 ± 1.53)fl vs.(10.37 ± 1.24) fl, P =0.00, respectively.The value of the PDW showed positive correlation with the prognosis (dead) (r=0.51, P＜0.05), and the MPV did likewise (r=0.53, P＜0.05, while the platelet count negatively correlated (r =-0.61, P ＜ 0.05), These characteristics were more obvious at 72 hours after admission (rPDW =0.68, rPv =0.67, rPLT =-0.71, P ＜0.01).The areas under the ROC curve 72 hours after admission as follows: PLT count0.95, PDW0.93 and MPV0.93, respectively, which were higher than those of PLT count (0.88), PDW (0.82) and MPV (0.83) within 24 hours after admission.The sensitivity and specificity of platelet count 72 hours after admission predicting the prognosis of death were 91.24％ and 80.35％, respectively.Conclusions The changes of platelet-related parameters in septic patients are related to the severity of the disease, and platelet count at 72 hours after admission may play an important role in prognosis of disease.

Objective To explore the relationship between content of fine particulate matter (PM2.5) in atmospheric and the number of emergency room (ER) visits with acute coronary syndrome (ACS).Methods Daily data of ER visits to Peking University Third Hospital for ACS was collected from December 1st,2013 to November 30th,2014.All patients were resident population of Haidian District,Beijing.The daily meteorological data and contents of air pollutants in Beijing were also collected in the same time period.Generalized Additive Model (GAM) was fitted to estimate the association between the ambient PM2.5 and the ER visits for ACS,under controlling for time trends,holiday effect,day of week effect and weather conditions.Results The annual average amount of PM2.5 was 85.44 μg/m3 over the study period.There were 619 cases with ACS as ER visits.PM2.5 was positive related with PM10,NO2 and SO2.The corresponding correlation coefficients were 0.87,0.48 and 0.67,respectively (P ＜ 0.05).But PM2.5 was negative related with mean temperature (r =-0.04,P ＜ 0.05).In the polluted model,there was positive association between PM2.5 and ER visits with ACS.When each increament in PM2.2 with 10 μg/m3,the relative risk strength of ER visits with ACS was 1.019 (95％ CI:1.000-1.038).PM2.5 concentrations had a delayed effect on the onset of ACS occurred on the next day.This lagged 1 day phenomenon showed the most significant influence of PM2.5 on ER visits for ACS.Conclusions The ambient concentrations of PM2.5 are positively associated with ER visits for ACS.And there is a lag effect.

Objective To study the relationship between red blood cell distribution width (RDW) and the malignant arrhythmia event of patients with chronic heart failure (CHF) during hospitalization. Methods A retrospective study was conducted. The clinical data of patients with CHF admitted to Department of Emergency and Cardiology of Peking University Third Hospital from January 2014 to February 2016 were reviewed. The patients with New York Heart Association (NYHA) Class Ⅱ, Ⅲ, Ⅳ at hospital admission and courses lasted at least six months were enrolled. The patients were divided into two groups according to malignant arrhythmia events (ventricular tachycardia, ventricular flutter or ventricular fibrillation) during hospitalization, i.e. malignant arrhythmia group and non-malignant arrhythmia group. The value of RDW and left ventricular ejection fraction (LVEF) were compared between two groups, and correlation of RDW, LVEF and malignant arrhythmia events by Spearman rank correlation analysis were studied, and the predictive value of RDW and LVEF for malignant arrhythmia events in patients with CHF was analyzed with receiver operating characteristic (ROC) curve. Results A total of 226 CHF patients were enrolled with 148 male and 78 female, the average age was (61.52±13.27) years old (range: 26-91 years old), the average hospitalization days were (14.5±3.5) days (range: 14-21 days), and malignant arrhythmia occurred in 102 patients (45.13%) during hospitalization. There were no statistically differences in gender, age, past history, etiology of heart disease, the usage of angiotensin receptor converting enzyme inhibitors (ACEI) or angiotensin Ⅱ receptor inhibitors (ARB) and beta blockers, serum potassium levels and so on between two groups. Compared with non-malignant arrhythmia group, the value of the RDW was significantly increased in malignant arrhythmia group [(13.28±1.07)% vs. (12.87±1.32)%, t = 2.531, P = 0.012], but the levels of LVEF was significantly reduced (0.425±0.116 vs. 0.458±0.104, t = 2.249, P = 0.026), the proportion of patients with NYHA Class Ⅱ was significantly lower (4.90% vs. 19.35%, χ2= 10.451, P = 0.000) and that of NYHA Class Ⅳ was just the opposite (57.84% vs. 41.13%, χ2 = 6.264, P = 0.011). The value of the RDW showed positively correlation with the malignant arrhythmia events (r = 0.758, P = 0.023), while LVEF was negatively correlated (r = -0.719, P = 0.019). The area under the ROC curve (AUC) for predicting the malignant arrhythmia events of RDW and LVEF was 0.882 [95% confidence interval (95%CI) = 0.839-0.925), 0.903 (95%CI = 0.866-0.941), respectively. The sensitivity and specificity for RDW in predicting in-hospital malignant arrhythmia event respectively were 82.0% and 79.0% with the optimal cut-off of 14.20%, and those for LVEF were 78.0% and 85.0% with the optimal cut-off of 0.375. Conclusion RDW can be used to predict the occurrence of malignant arrhythmia in patients with CHF during hospitalization.