During the process of teaching in clinical practice, there objectively exist the contradiction between the obligation of teaching and the invasion of the right to informed consent, and the contradiction between the growth of medical students and the invasion of patients' right to privacy. Health reforms, such as the regulation of "patient selecting doctor", bring some side effects to the teaching in clinical practice. In order to maintain the right to informed consent and privacy, to benefit the teaching in clinical practice, to develop the doctor-patient relationship, and to decrease medical disputes, the art to deal with the doctor-patient relationship must be explored. The laws and regulations of the teaching in clinical practice and of the right of doctors and patients must be developed too.

Objective To compare the efficacy of sevoflurane combined anesthesia and propofol combined anesthesia in elderly patients undergoing abdominal surgery.Methods Sixty patients aged 65-80 yr scheduled for elective abdominal surgery under general anesthesia were randomly divided into 2 groups (n = 30 each): sevoflurane group (group S) and propofol group (group P).Anesthesia was induced with TCI of sufentanil and propofol.The initial target effect-site concentration (Ce) of sufentanil was set at 0.25 ng/ml and initial target plasma concentration (Cp) of propofol set at 2.0 μg/ml,and then both concentrations were increased in 0.5 μg/ml increment when they reached the balance until loss of consciousness.Tracheal intubation was facilitated with rocuromitm 0.6 mg/kg and the patients were mechanically ventilated.Anesthesia was maintained with inhalation of sevoflurane (end-tidal concentration set at 1.0%-2.0%) in group S,TCI of prepofol (Cp set at 2-4 μg/ml) in groups P, and sufentanil by TCI ( Ce set at 0.15 ng/ml) and iv infusion of vecurenium 0.15 mg·g-1·h-1 in both groups. .BIS value was maintained at 40-60,and changes of MAP and HR were less than 30% of the baseline value in both groups.The use of vasoactive drugs during perioperative peried,time of awakening,extubation and consciousness were recorded and compared between the 2 groups.Results The usage rate of urapidil was significantly decreased,and the awakening time,extubation time and consciousness time shortened in group S compared with group P.Conclusion Sevoflurane-sufentanil combined anesthesia provides better hemodynamic stability and faster recovery than propofol-sufentanil combined anesthesia in elderly patients.

Objective To investigate the efficacy of anesthesia with propofol-remifentanil given by targetcontrolled infusion (TCI) for thymectomy in patients with myasthenia gravis ( MG). Methods Forty-five ASA Ⅰ or Ⅱ MG patients aged 16-64 yr weighing 45-95 kg undergoing thymectomy were studied. Anesthesia was induced with TCI of propofol (target plasma concentration 4 μg/ml) and remifentanil (target effect-site concentration 4 ng/ml). Thracheal intubation was performed after topical anesthesia with 2% lidocaine 2-3 ml and then the patients were mechanically ventilated. Anesthesia was maintained with TCI of propofol ( target plasma concentration 3-5 μg/ml) and remifentail (target effect-site concentration 3-6 ng/ml). Sufentanil 0.15 μg/kg was injected intravenously for analgesia 30 min before operation. The success rate of intubationat at first attempt, body movement in response to skin incision, recovery time, extubation time, extubation condition at the end of operation and cardiovascular events were recorded. Results Thracheal intubation was performed successfully in all patients. The success rate of intubation at first attempt was 100%. No body movement occurred during skin incision in the patients.Recovery time was 1.0-3.2 min and extubation time 2.6-7.0 min. All patients were successfully extubated at the end of operation. Bradycardia developed in 3 patients and hypotension in 4 patients during induction, but they all returned to normal after symptomatic treatment. Bradycardia developed in 3 patients during operation, but returned to normal after symptomatic treatment. Conclusion Anesthesia with TCI of propofol and remifentanil can be used safely and effectively in MG patients undergoing thymectomy.

Objectives To observe the effectiveness of bronchoscope guided microwave heating coagutation therapy(HCT)combined with systematic chemotherapy in treating advanced lung cancer.Methods 44 patien with advanced bronchogenic carcinoma were divided into the test group(22 patients)and the control group(22 patients)randomly.Test group received HCT through needle mono pole microwave antenna guided by bronchoscope combined with the routine Carboplatin and etoposide (CE)regimen.While the control group was treated only by chemotherapy with the routine CE regimen.Results in the 22 patients,8 were completely cured and 12 showed partial recovery,the other 2 without any change.The 91% effective rate was significantly higher than 55% of the control group (P

1. 50 heart specimens (30 ABS cast and 20 dissected specimens) were used to study the origin, course and diameter of the branches of the atrial artery. And some measurements were made. 2. Most of the S-A node artery are the first or second anterior atrial branch. In 26 cases (52%), it arises from the right coronary artery, with a diameter of 1.2～ 2.2mm; and in 24 cases (48%)from the left coronary artery, with a diameter of 1.1～ 2.0mm. Their courses are closely related with the anterior interatrial sulcus and the interatrial muscular bundle. Most of the right and left S-A node arteries take a counter-clockwise course and end at the orifice of the superior vena cava. During their course around the orifice of the superior vena cava, a descending loop is present in the posterior interatrial sulcus, only in two cases which is different from McAlpine's observation. Only in 6 cases the origin of the S-A node artery is at the other site, i. e. 4 from left circumflex atrial artery, and 2 from the extension of the terminal branch of the right coronary artery. 3. Kugel's artery usually arises from these branches of the promixal part of the right or left coronary artery, i. e. from the left or right S-A node artery, or from the left or right anterior atrial artery. It usually penetrates into the septum at the anterior interatrial sulcus, with a diameter of 0.1～1.2mm, during penetration. In the septum it has a constant course around the inferior border of the fossa ovalis and may be anastomosed with the branches of the right and left coronary artery at the posterior wall of the atrium. This is an important collteral circulation of the coronary artery. 4. A-V node artery usually arises from the right coronary artery, 94%; and only a small portion, 6%, from the left coronary artery. Its diameter is around 0.4～1.9 mm. Usually only one A-V node artery is present. Double A-V node artery is observedonly in 2 cases both of them are arising from the right coronary artery. In 2 cases, A-V node artery arises from the posterior ventricular branches, penetrates into the posterior wall of the left ventricule, runs between the right and left atrioventricular foramin and reaches the A-V node. In 44.23% of the 50 specimens, A-V node artery take its origin from the top of the "U" turn of the coronary artery at the crux. In 36.5% of the specimen the artery originates from the plain straight type of coronary artery; in the other 19.24% though the "U-turn" is present, but the artery does not originate from the top of the turn. The course of the artery is generally along the midline between the right and left atrio-ventricular foramina, and rarely along the borders of the left or right afrioventricular foramina. 5. The clinical importances of the topographical characteristics are discussed.

1.There were 80 heart specimens(age:17～95,with no marked pathological chauges) used to observe the origin,course and the site of anastomosis of the atrial arteries. 2.Within the 80 specimens there are 34 hearts with anastomoses,and the frequen- cies of the anastomoses are 53,including one case of anastomosis between an artery of extracorary origin and the atrial artery. 3.The commonest site of the anastomosis is the posterior wall of the left atrium, there are 23 cases(43.40%)within the 53.The other sites are the base of interatrial septum,13 cases(24.53%);anterior wall of the atrium,13 cases(24.53%);the lateral wall of the right atrium and the orifice the superior vena cava being 2 cases respecti- vely(3.77%). 4.The diameters of the anastomosis are as follows:In the A.B.S.casts:We have measured the anastomotic diameter in 38 cases.Most of them are within the range of 100～200?m in 20 cases(52.6%),200～300?m in 9 cases(23.6%). In dissecting specimens:Within the measured 19 cases,50～100?m in 8 cases (42.1%),100～200?m in 5 cases(26.3%),200～300?m in 3 cases(15.8%),300～ 500?m in 3 cases(15.8%).Among the adult hearts,it seems that the diameter of the anastomosis and the site of the anastomosis are not increased by advancement of the age. 5.The origin of the anastomotic branch of the A-V node artery is near the A-V node.This is very important for the blood supply of A-V node,when there is patholo- gical changes of the coronary artery. 6.Since there is a great range of variation in the diameter of the anastomosis and the formation of the anastomosis,such as two-branches-form,three-branches-form, four-branches-form,or network-like anastomosis,perhaps,the morphological charact- eristics of the anastomosis is closely related with the pathogensis of coronary artery. 7.In this set of specimen,we have observed three cases in which the ventricular branches of the coronary artery joined the anastomosis on the wall of the atrium.

Objective To investigate the management status of loaner surgical instruments,and evaluate the effect of plan-do-check-act cycle (PDCA)quality control on loaner surgical instrument management.Methods From July 2011 to June 2012,8 965 pieces of loaner surgical instruments before adopting PDCA quality control management was as control group;from July 2012 to June 2013,8 564 pieces of loaner surgical instruments adopting PDCA quality control was as ob-servation group.The defects of loaner surgical instruments during application process and effect of PDCA quality control on loaner surgical instrument management were analyzed.Results There were many problems in checking-tracking,cleaning quality and company personnel of loaner surgical instruments.The qualified rate of observation group was higher than that of control group(99.36% vs 96.27%)(χ2 =194.74,P <0.01).The main causes for unqualification of observation group were unqualified cleaning (n=21 ,38.18%)and incomplete function of instruments(n=8,14.55%);while the main causes for unqualification of control group were the loss of instruments(n=81,24.25%),lack of monitor and record (n=71, 21.26%),unqualified cleaning(n=55,16.47%)and the soaking of package(n=54,16.17%).Conclusion PDCA quality control is an effective method for loaner surgical instruments management,it is helpful for building long-term effective quali-ty control system for loaner surgical instruments,and make loaner surgical instrument management more scientific,system-atic,and standard.

Objective To summarize the experience of laparoscopic massive splenectomy combined with selective pericardial devascularization using endoligature technique. Methods By using silk ligature and hamonic scapel or the LigaSure, 6 patients with portal hypertension and esophagogastric varices underwent laparoscopic massive splenectomy and selective pericardial devascularization. Results All the operations were completed successfully under laparoscope. The intraoperative blood loss was 80~200 ml (mean, 130 ml). None of the patients required blood transfusion or conversion to open procedure. The operation time was 150~210 min (mean, 190 min). There were no surgical complications. All the patients resumed to normal activities 5 days after operation. Follow-up observations for 3~10 months (mean, 8 months) revealed no recurrent variceal hemorrhage. Conclusions Laparoscopic massive splenectomy combined with selective pericardial devascularization using endoligature technique is a feasible, effective, safe, little hemorrhagic, and minimally invasive procedure for portal hypertension with esophagogastric varices.

It is an essential component of medical exams to evaluate the clinical competency of medical students. After introducing Standardized Patients and non-Standardized Patients examinations into the final comprehensive examination, China Medical University continued to undertake the construction of computer-based case simulations examination system, a project of National Medical Examination Center. The article introduced the design and some crucial points in constructing the examination system.

Objective　To study the change of the serum lipoprotein(a)〔Lp(a)〕 and other lipid levels in the childhood simple obesity.Methods　The levels of serum Lp(a),cholesterol(TC),triglyceride(TG),high density lipoprotein cholesterol(HDL-ch),low density lipoprotein cholesterol(HDL-ch),apoA-I and apoB were investigated in 42 simple obesity children and 30 control subjects.Results　The levels of serum Lp(a),TC,TG,HDL-ch，LDL-ch of obesity children were markedly higher than those of normal.Conclusion　Simple obesity children are at increased risk of the development of cardiovascular disease.