Objective:To explore the core competency of doctors in tertiary public hospitals in regions of different income levels in China, and provide reference for promoting such competency and related policy formulation.Methods:Using multi-stage stratified cluster sampling method, 195 tertiary public hospitals in 16 provinces of China were selected from November 2021 to March 2022. 200 doctors were sampled from each hospital. A self-designed questionnaire was used to investigate the status of doctors′ core competencies, as well as the status of their postgraduate medical education and continuing medical education. According to the per capita gross regional product of each province in China Statistical Yearbook 2022, each province was divided into high, middle and low income regions, and the questionnaire data were descriptively analyzed, while χ2 test was used to compare the differences between groups. Results:A total of 32 673 valid questionnaires were collected. There were 12 135 doctors (37.14%) in China who had received comprehensive education and training of core competency in all dimensions. Among the dimensions of self-rated core competency of the surveyed doctors, there were 10 019 doctors (30.66%) with insufficient teaching ability and 438 (1.34%) with insufficient professional quality, and there was no significant difference between regions ( P>0.05). There were 2 385 (27.08%), 2 528 (27.55%) and 3 646 (24.82%) doctors in high-, middle- and low-income regions with insufficient lifelong learning ability, respectively. The proportion of doctors in middle- and high-income regions was higher than that in low-income ones ( P<0.05). There were 1 317 (15.57%), 1 290 (14.06%) and 2 719 (18.51%) doctors with insufficient knowledge and skills in high-, middle- and low-income areas, respectively. The proportion of doctors in low-income regions was higher than that in middle- and high-income regions ( P<0.05). The proportion of doctors who did not receive any kind of postgraduate medical education or continuing medical education in low-income regions was 7.33% (1 077 people), higher than that in high-income and middle- income ones ( P<0.05); 50.44% (4 442 people) of surveyed doctors in high-income regions believed that for standardized training of resident physicians (hereinafter referred to as residential training), the clinical teachers were " overworked to take this job", which was higher than that in middle- and low-income regions ( P<0.001); In middle-income regions, 46.16% (4 235 people) and 43.46% (3 987 people) believed that the salary residents and specialized physicians in standardized training (hereinafter referred to as specialized training) was too low, while 42.47% (3 897 people) and 30.44% (2 793 people) believed that the clinical practice opportunities of students were limited, both of which were higher than those in high-income and low-income regions ( P<0.001); 34.91% (5 128 people) of surveyed doctors in low-income regions believed that the investment was insufficient for training bases of residential training, 27.81% (4 085 people) of those held that training bases for specialized training were unevenly distributed, and 33.19% (4 876 people) of those held that continuing medical education was plagued by " insufficient promotion coverage, and insufficient opportunities for primary doctors", all of which being higher than those in high- and middle-income regions ( P<0.001). Conclusions:There is an obvious need to improve the core competence of doctors in the teaching ability dimension of tertiary public hospitals in China, especially in middle- and high-income regions for lifelong learning, and in low-income regions for knowledge and skills; There are differences between postgraduate medical education and continuing medical education systems in regions of different income levels in China. It is necessary to improve the competency oriented postgraduate medical education and continuing medical education systems.

Objective:To explore the predictive value of the serum C-reactive protein (CRP)/albumin (ALB) ratio (CAR) for organ damage in tsutsugamushi disease.Methods:The clinical data of 166 patients with tsutsugamushi disease admitted to the First Affiliated Hospital of Wenzhou Medical University from January 1, 2010 to December 31, 2020 were retrospectively analyzed. The patients were divided into the organ damage group (72 cases) and non-organ damage group (94 cases) according to the organ damage criteria. The general data and laboratory test results of the two groups of patients were compared. The significant indicators of univariate analysis were analyzed by multivariate logistic regression analysis. The receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to analyze the predictive value of CAR for organ damage in patients with tsutsugamushi disease.Results:There were no significant differences in age, sex, days of fever, and admission body temperature between the organ damage group and non-organ damage group ( P>0.05). However, the body mass index, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ), sequential organ failure assessment (SOFA), length of hospital stay, hospitalization expense, percentage of neutrophils (NEUT), lymphocyte count, procalcitonin, CRP, and CAR in the organ damage group were significantly higher than those in the non-organ damage group ( P<0.05), and ALB was significantly lower than that in the non-organ damage group ( P<0.05). Multivariate logistic regression analysis showed that APACHEⅡ( P=0.039), NEUT ( P=0.003), and CAR ( P=0.011) were independent risk factors for tsutsugamushi disease complicated by organ damage. The ROC curve showed that the AUCs of APACHEⅡ, NEUT, and CAR were 0.655, 0.716, and 0.727, respectively. When the cut-off value of CAR was 2.86, the sensitivity was 55.6%, and the specificity was 79.8%. Conclusions:Elevated CAR is an independent risk factor for tsutsugamushi disease complicated with organ damage and can be used as an important indicator to evaluate the presence or absence of organ damage in patients with tsutsugamushi disease.

BACKGROUND: Coronary artery disease (CAD) is the commonest cause of heart failure (HF), whereas pulmonary hypertension (PH) has not been established or reported in this patient population. Therefore, we assessed the prevalence, risk factors, and survival in CAD-associated HF (CAD-HF) complicated with PH. METHODS: Symptomatic CAD-HF patients were continuously enrolled in this prospective, multicenter registry study. Echocardiography, coronary arteriography, left and right heart catheterization (RHC), and other baseline clinical data were recorded. Patients were followed up and their survival was recorded. RESULTS: One hundred and eighty-two CAD-HF patients were enrolled, including 142 with HF with a preserved ejection fraction (heart failure with preserved ejection fraction [HFpEF]; left ventricular ejection fraction [LVEF] ≥50%) and 40 with a reduced ejection fraction (heart failure with reduced ejection fraction [HFrEF]; LVEF < 50%). PH was diagnosed with RHC in 77.5% of patients. Patients with PH showed worse hemodynamic parameters and higher mortality. HFrEF-PH patients had worse survival than HFpEF-PH patients. CAD-HF patients with an enlarged left ventricular end-diastolic diameter and reduced hemoglobin were at higher risk of PH. Nitrate treatment reduced the risk of PH. Elevated creatinine and mean pulmonary arterial pressure (mPAP), diastolic pressure gradient (DPG) ≥7 mmHg, and previous myocardial infarction (MI) entailed a higher risk of mortality in CAD-HF patients with PH. CONCLUSIONS: PH is common in CAD-HF and worsens the hemodynamics and survival in these patients. Left ventricle enlargement and anemia increase the risk of PH in CAD-HF. Patients may benefit from nitrate medications. Renal impairment, elevated mPAP, DPG ≥7 mmHg, and previous MI are strong predictors of mortality in CAD-HF-PH patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT02164526.
Coronary Artery Disease/epidemiology* ; Creatinine ; Heart Failure/complications* ; Humans ; Hypertension, Pulmonary/complications* ; Nitrates ; Prevalence ; Prognosis ; Prospective Studies ; Registries ; Risk Factors ; Stroke Volume ; Ventricular Function, Left

Objective:To study the curative effect of platelet-rich plasma (PRP) combined with internal fixation with hollow screws on femoral neck fractures.Methods:The clinical data of 160 patients with femoral neck fracture were retrospectively analyzed who had been treated by internal fixation with hollow screws at Orthopedic Department Ⅲ, The Second Affiliated Hospital to Luohe Medical College from May 2012 to May 2018. According to whether PRP was used or not to assist their internal fixation, they were divided into a PRP group ( n=80) and a control group ( n=80). In the PRP group, there were 46 males and 34 females with an age of 52.3 years±7.6 years, and one case of type Ⅰ, 5 cases of type Ⅱ, 57 cases of type Ⅲ and 17 cases of type Ⅳ by the Garden classification. In the control group, there were 41 males and 39 females with an age of 50.6 years ± 7.3 years, and 2 cases of type Ⅰ, 7 cases of type Ⅱ, 51 cases of type Ⅲ and 20 cases of type Ⅳ by the Garden classification. The 2 groups were compared in terms of fracture healing time, nonunion, femoral head necrosis and Harris hip scores. Results:The 2 groups were comparable because their preoperative general data showed no significant differences ( P>0.05). The 160 patients obtained follow-up for 12 to 36 months. The PRP group showed significantly shorter fracture healing time (4.3 months ± 1.0 months), significantly lower incidences of nonunion [0% (0/80)] and avascular necrosis of femoral head [3.8% (3/80)] than the control group [7.3 months ± 1.3 months, 7.5% (6/80) and 15.0% (12/80), respectively] (all P< 0.05). The Harris scores at 6 and 12 months after operation for the PRP group (88.7±5.3 and 94.2±4.8) were significantly higher than those for the control group (81.4±4.6 and 84.2±5.2) (both P<0.05). Conclusion:In the treatment of femoral neck fractures, compared with internal fixation with hollow screws alone, platelet rich plasma combined with internal fixation with hollow screws can significantly shorten fracture healing time, reduce incidence of avascular necrosis of the femoral head and improve functional recovery of the hip joint.

Objective: To analyze the clinical characteristics, treatment and prognosis of rhabdomyolysis (RM) caused by acute poisoning.Summarize the clinical characteristics and treatment experience, pay attention to the complications and improve the quality of rescue. Methods: We collecte and summarize the clinical data, treatment and prognosis of 22 cases of RM caused by acute poisoning. Results: We found that 21 patients (95.5%) had muscle damage, 13(59.1%) with coma, 8(36.4%) with brown, tea or even soy sauce urine, 6(27.3%) had acute renal injury (AKI), and 4(18.2%) had multiple organ dysfunction syndrome (MODS). After the treatment, 21 cases (95.5%) got better, and one case were discharged. All the patients with AKI were survived, three of them were treated by hemodialysis, and the other recovered gradually after massive fluid replacement. Conclusion Acute poisoning combined with RM is not uncommon in clinic. We should pay attention to examination of serum enzymes and other indicators, observe the clinical symptoms and make early diagnosis. The key to diagnosis and treatment is early fluid resuscitation, comprehensive treatment, blood purification and maintain the stability of water and electrolyte.

Objective: To explore the role of iTr35 cells in the pathogenesis of children with pulmonary artery hypertension (PAH) in children, and the percentage of iTr35 cells and serum interleukin(IL)-35 levels in peripheral blood of patients with PAH were investigated.Their inhibitory effects on the expression of vascular cell adhesion molecule-1 (VCAM-1) on vascular endothelial cells were also analyzed. Methods: After 3 mL peripheral blood of 30 congenital heart disease (CHD) patients with PAH, 22 CHD patients without PAH and 30 age or gender matched healthy controls (HC) were collected, the percentage of iTr35 cells were detected by flow cytometry and the concentrations of serum IL-35 were detected by Luminex, as well as soluble VCAM-1 (sVCAM-1). Human pulmonary artery endothelial cells (HPAECs) were cultured in vitro and divided into control group, tumor necrosis factor (TNF)-α group and IL-35+ TNF-α group.The expression of VCAM-1 and nuclear factor(NF)-κB P65 protein of each group were detected by flow cytometry and Western blot.The adhesion of peripheral blood mononuclear cells (PBMCs) to HPAECs was observed by fluorescence microscope. Results: Compared to CHD patients without PAH, the percentage of iTr35 cells[0.86(0.45-1.63)% vs.1.14(0.46-2.11)%](H=20.52, P<0.05) in peripheral blood and serum IL-35 levels[2.43(1.76-2.85) μg/L vs.3.17(2.92-5.66) μg/L](H=119.56, P<0.05) were significantly decreased in CHD patients with PAH.However, serum sVCAM-1 concentration[923.1(892.6-1 118.7) μg/L vs.776.1(743.5-932.3) μg/L ] in CHD patients with PAH were significant increased (H=65.65, P<0.05). In addition, the concentration of serum IL-35 were negatively correlated with sVCAM-1 in PAH patients (r=-0.374 P=0.042). In vitro, the positive rate of VCAM-1 on HPAECs was significant decreased in IL-35+ TNF-α group as compared to the TNF-α group [(2.07±0.82)% vs.(5.83±1.34)%, F=1 197.18, P<0.05]. In addition, the protein expression of NF-κB P65 in HPAECs was significantly decreased in TNF-α+ IL-35 group as compared to TNF-α group, as well as the adhesion of PBMCs to HPAECs (F=212.04, 2 533.51, all P<0.05). Conclusions The percentages of iTr35 and levels of IL-35 are reduced in the peripheral blood of patients with PAH.Through in vitro experiments, IL-35 is found to reduce PBMCs adhesion by inhibiting VCAM-1 expression in HPAECs.

Objective: To explore the risk factors influencing the prognosis of elderly patients with acute poisoning. Methods: We retrospected 177 elderly patients with Acute Poisoning who were treated in the emergency department of the first affiliated hospital of wenzhou medical university from July 2009 to May 2015. According to the outcome of patients, we distributed the patients to death group (31 cases) and survival group (146 cases) , compared the clinic data and using multivariate analysis with Logistic regression to prognosis factors. Results: There were 177 cases in total, with 146 survivors (82.5%) and 31 deaths (17.5%) . In which 102 cases (57.6%) had chronic underlying diseases. There were 28 cases of pesticide poisoning in the death group, and the fatality rate of pesticide poisoning was 23.5%. The mortality rate was 12.8% in the 60-69 years-old group (11/86) , 20% (13/65) in the 70-79 years-old group, 26.9% (7/26) in the 80-89 years-old group. The most common reason of poisoning was intentional ingestion, with 100 cases (56.5%) . The tract of the poisoning was mainly in digestive system, including 148 cases (83.6%) . The PSS score and APACHE-II score were 2.97±0.18 and 19.8±2.8 in the death group, 2.27±0.81 and 12.8±5.3 in the survival group. Compared with the survival group, poison (pesticides or non) 、poisoning route、cause of poisoning、PSS score、APACHEⅡ score have significant difference in death group (P<0.05) . Poison (pesticides or non) 、PSS score、APACHEⅡ, were the independent risk factors of poor prognosis. Conclusion Most of the elderly patients with acute poisoning have one or more chronic underlying diseases, the digestive tract ingestion and pesticide poisoning are more common. The fatality rate of the old patients is significantly higher than that of non elderly poisoning. Type of toxications, PSS score and APACHE-II score are the prognostic factors in elderly patients.

BACKGROUND:Previous clinical fol ow-up study showed that disc degeneration of adjacent segment after anterior cervical discectomy and fusion was faster than that of artificial cervical disc replacement. Compared with the anterior cervical discectomy and fusion, artificial cervical disc replacement can maintain a good range of motion of replacement segment. Further investigation should be taken to compare the difference between stress and fusion after replacement. OBJECTIVE:To compare the adjacent level discs loads between artificial cervical disc replacement and anterior cervical discectomy and fusion. METHODS:A healthy 30-year-old male volunteer was scanned with CT at the artificial cervical intervertebral disc and anterior cervical plate. Three-dimensional images were reconstructed with Mimics 10.01 and Geomagic Studio.v11 software. Above three-dimensional data were input into the Abaqus6.9 finite element analysis software for meshing, assignment, and stress analysis. Finite element method was used to simulate the stress changes of the adjacent segments after artificial cervical disc replacement and anterior cervical discectomy and fusion. RESULTS AND CONCLUSION:(1) Under the same preload, during anteflexion, posterior extension, and lateroflexion, the disc stress at adjacent segment was significantly larger after anterior cervical discectomy and fusion than normal disc. Compared with normal persons, no significant difference was detected in stress of adjacent segment at anteflexion, posterior extension, and lateroflexion after artificial cervical disc replacement. (2) Compared with artificial cervical disc replacement group, the stress of adjacent segment increased 10.3%-51.6%in the anterior cervical discectomy and fusion group. (3) Finite element analysis showed that the stress was larger in the anterior cervical discectomy and fusion group than in the artificial cervical disc replacement group. With prolonged fol ow-up, compared with the conventional anterior decompression and fusion, artificial cervical disc replacement can better play its protective effect on the adjacent intervertebral disc.

Objective To explore the clinical value of procalcitonin (PCT)in the disease severity and prognosis of patients with sepsis,and the relationship between PCT and acute physiology and chronic health evaluation Ⅱscore (APACHEⅡscore).Methods Clinical data (including the value of PCT,the count of the white blood cell WBC and the percent of neutrophils percentage Neut%,APACHEⅡ score,et al,within 24 hours after admission)of 109 sepsis patients admitted to the emergency department (including the general ward and emergency intensive care unit EICU)and infections department of our hospital from January 1st 2013 to December 31st 2014 were retrospectively analyzed.The patients were divided into several groups according to the patients condition (the sepsis group,the severe sepsis group and the septic shock group),the clinical outcomes (the survival group and the dead group ),and multiple organ dysfunction syndrome MODS (the MODS group and the non-MODS group),comparing the differences of all markers in each group;to analyze the correlation between PCT and APACHEⅡ score;to assess the value of PCT,APACHE Ⅱ score and APACHE Ⅱ score +PCT for prognosis and multiple organ dysfunction syndrome of patients with sepsis;to have a understanding of the independent effect of PCT on the prognosis andthe factors of prognosis in patients with sepsis.Results The value of PCT,APACHEⅡ score in sepsis group was lower than the severe sepsis group and the septic shock group,also the severe sepsis was lower than the septic shock group,and each group was significantly different (P <0.05).Compared with the septic shock group,the count of WBC of sepsis group was significantly lower (P <0.05).Also the dead group compared with the survival group,the APACHEⅡ score was significantly increased (P <0.01),but the values of PCT,WBC,Neut% were not significantly different.The values of APACHEⅡ score,WBC, Neut%,PCT in the non-MDOS group were significantly lower than those in the MODS group (all P <0.05).The relationship between the values of PCT and APACHEⅡ score was significantly correlated (rs=0.403,P <0.01 ).Using the receiver operating characteristic curve (ROC ) for evaluating the prognosis,the area under curve (AUC)of PCT,APACHE Ⅱ score and the PCT +APACHE Ⅱ score respectively were 0.617,0.899,0.917,and the last two were significantly better (all P <0.01),also the cut-off,sensitivity and specificity of PCT,APACHE Ⅱ score were respectively (3.40 ng/mL, 88.24%,38.04%),(20 scores,94.12%,81.52%).As the same to evaluating MODS,the AUC of PCT,APACHEⅡ score and APACHE Ⅱ score +PCT respectively were 0.824,0.796,0.871,the assessed value between PCT and APACHEⅡ score,between PCT and APACHEⅡ score +PCT were not significantly different;also the cut-off,sensitivity and specificity of PCT,APACHEⅡ score respectively were (7.26 ng/mL,88.24%,63.79%), (17 scores,64.71%,87.93%).The COR and AOR of PCT for the prognosis were respectively 1.008,1.014,and gender and APACHE Ⅱ score were the two independent risk factors for the prognosis in patients with sepsis.Conclusions The value of PCT and APACHEⅡ score could evaluate the severity of illness in sepsis patients,and the three were positive correlations.APACHEⅡ score,APACHEⅡ score +PCT had a significantly higher prognostic value than PCT,and PCT could not be a independent marker.But for assessing the MODS in patients with sepsis,the assessed value of PCT,APACHEⅡ score,APACHEⅡ score +PCT were medium.Gender and APACHEⅡ score were the two independent risk factors for the prognosis in patients with sepsis.

Objective To investigate the effect of resveratrol (Res) on paraquat (PQ)-induced acute lung injury (ALI) and mortality in mice and the mechanism of nuclear factor-κB (NF-κB) inflammatory pathway. Methods Sixty-eight healthy male ICR mice with grade SPF were enrolled, among them 20 mice were used for mortality observation (n = 10), and other 48 were used for determination of related parameters (n = 6). The mice were randomly divided into four group s: normal saline (NS) control group, Res control group, PQ group and PQ + Res group. The mice in the latter two groups were subdivided into 6, 24, 72 hours subgroups. The PQ poisoning model of mice was reproduced by one injection of 30 mg/kg PQ intraperitoneally. The mice in PQ + Res group were given 60 mg/kg Res intraperitoneally on the contralateral side after PQ injection. The mice were sacrificed at 6, 24, 72 hours after PQ poisoning, and lung tissue was harvested. The serum levels of tumor necrosis factor-α (TNF-α), interleukins (IL-6 and IL-1β) were determined by enzyme linked immunosorbent assay (ELISA). The pathological changes in lung tissue were observed with electron microscopy. Apoptosis cells in the lung were identified by terminal dexynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) for the estimation of apoptosis rate. The protein expression of NF-κB p65 was determined by Western Blot. Results Compared with PQ group, the death number of mice at 48, 72, 96 hours in PQ + Res group was slightly decreased (0 vs. 2, 2 vs. 5, 4 vs. 6) but without statistically significant difference (all P > 0.05). Under electron microscope, the lung injury in PQ group was severer than that in NS control group, and Res was found to be able to alleviate the lung injury. Compared with NS control group [(2.45±0.61)%], the apoptosis rate at 6 hours in PQ group was significantly increased [(8.42±1.48)%], and peaked at 72 hours [(21.23±3.47)%]. Res could decrease the apoptosis rate after PQ poisoning [6 hours: (5.56±1.31)% vs. (8.42±1.48)%, 24 hours: (11.14±2.07)% vs. (16.88±2.96)%, 72 hours: (13.28±2.32)% vs. (21.23±3.47)%, all P < 0.05]. The serum levels of TNF-α, IL-6, and IL-1β, and NF-κB p65 in lung tissue were all markedly increased after PQ poisoning, and they were significantly decreased after Res intervention as compared with those of PQ group [TNF-α (ng/L): 2.62±0.29 vs. 4.06±0.74 at 6 hours, 3.98±0.41 vs. 6.79±0.80 at 24 hours, 5.06±0.75 vs. 11.00±0.75 at 72 hours; IL-6 (ng/L): 14.19±1.54 vs. 16.55±1.24 at 6 hours, 13.21±1.37 vs. 19.73±0.85 at 24 hours, 13.72±0.56 vs. 22.45±0.72 at 72 hours; IL-1β (ng/L): 8.54±1.64 vs. 12.59±0.66 at 6 hours, 10.15±0.29 vs. 16.24±1.03 at 24 hours, 16.14±0.70 vs. 19.55±0.56 at 72 hours; 6-hour NF-κB p65: (1.34±0.07) folds vs. (1.86±0.11) folds when the expression in NS control group was represented as 1, all P < 0.05]. Conclusions Res cannot lower the mortality in mice with PQ poisoning, but it seems to be able to attenuate PQ-induced ALI and cell apoptosis. The mechanism responsible for the latter maybe the inhibitive effect of Res on NF-κB p65 translocation and cytokines production.