Currently, there are practical and technical difficulties in the construction of clinical questions in the development of clinical practice guidelines. Clinicians or guideline developers seldom construct clinical questions based the actual case scenario, leading to some information loss between structured and actual clinical connotation. To overcome this challenge, we proposed a case-guided questions construction approach, and carried out case research and verification in the formulation of the guideline. We found that this method could more efficiently and scientifically assist the formulation of clinical questions, and provide reference for clinicians or guideline developers.

The incidence of augmented renal clearance (ARC) in intensive care patients (ICU) is exceptionally high, and these patients are often co-morbid with infection. The occurrence of ARC will significantly increase the clearance rate of antibiotics, making it difficult for conventional doses to reach effective therapeutic concentrations and affect the patient's anti-infective treatment effect and prognosis. It can be seen that it is crucial to formulate a reasonable dosing regimen for ICU patients with ARC. Regrettably, few reports in China about the adjustment strategy of antibiotic dosing regimens for ARC patients. Therefore, this article reviews the domestic and foreign literature for reference to provide evidence for medical personnel to adjust the dose of antibacterial drugs for such patients.

Objective:To determine the clinical features of papillary thyroid microcarcinoma (PTMC) and the risk factors for central compartment lymph node (CCLN) metastasis in PTMC. Methods:Data of 1 401 patients with PTMC who were treated in Tianjin Medi-cal University Cancer Institute and Hospital between January 2014 and December 2014 were retrospectively analyzed. Chi-square test and multivariate Logistic regression analysis were used to study the risk factors. Results:With regard to clinicopathological features, the sex ratio is 1:3.4 in patients with PTMC. CCLN metastasis affected 427 (30.5%) of the total 1 401 patients. Age (χ2=14.587, P<0.01), sex (χ2=21.636, P<0.01), tumor multifocality (χ2=35.505, P<0.01), tumor size (χ2=58.868, P<0.01), tumor site (χ2=8.385, P<0.05), and extracapsular/extraglandular invasions (χ2=26.481, P<0.01) were significantly correlated with CCLN metastasis. For patients with a soli-tary primary tumor, tumor location in the lower third of the thyroid lobe was associated with a higher risk of CCLN metastasis (48.1%). The male gender, age<45 years, tumor size>6 mm, extracapsular spread, and tumor bilaterality were independently correlated with CCLN metastasis. Conclusion:A prophylactic neck dissection of the central compartment must be considered particularly in male PT-MC patients with age<45 years, tumor size>6 mm, extracapsular spread, and tumor bilaterality.

Objective To study the effects of percutaneous liver tumor injection combined with the clinical efficacy of transcatheter hepatic artery chemoembolization in the treatment of advanced liver cancer,and to provide ref-erence for clinical treatment.Methods 22 patients using percutaneous liver tumor injection combined with transcath-eter arterial chemoembolization for treatment were selected,with which 1 month follow-up after discharge.Situation of patients with percutaneous liver tumor injection and transcatheter hepatic artery chemoembolization was analyzed,and the changes of the patients in the following -up of survival time,tumor volume and clinical symptoms were also ana-lyzed.Results Among the patients of postoperative recheck after 6 weeks,6 cases were complete remission,there were partial remission in 8 cases,6 cases of stable,2 cases of progress.Follow up to 2013 December,the patients'sur-vival time was 17-82 months,the average survival time was (55.71 ±13.47)months.After treatment,4 cases of patients'tumor diameter reduced 1 -3cm,18 cases of tumor diameter reduced 3 -5cm,19 cases of liver area pain symptoms for more than half a year of remission,3 cases of liver area pain relief time less than half a year.During the follow -up period,12 patients died of multiple organ failure.Conclusion The development of percutaneous liver tumor injection combined with transcatheter hepatic arterial chemoembolization therapy can delay the development of the disease in patients with advanced HCC,and prolong the survival time.

Objective To evaluate the middle and short-term effects of integrative cognitive training on mild cognitive impairments(MCI).Methods All the participants with MCI aged over 70 years were selected from one sub-district of Putuo District,Shanghai and divided into cognitive intervention group (n=46) and control group (n=35).The integrative cognitive training was conducted in 24 sessions for 12 weeks.All subjects were assessed by Neuropsychological Test Battery for Elderly (NTBE) and by a questionnaire of Shanghai Health Survey for the Elderly (VER2006)at baseline,follow-up and one-year follow up phases.Results At baseline phase,semantic relations test in NTBE was better (t=2.13,P=0.037),verbal fluency test (vegetables) in NTBE was worse(t =-2.25,P=0.038) in intervention group than in control group,while there were no significant differences in scores of other neuropsychological tests between intervention group and control group(all P＞0.05).At follow up phase,16 subscales in reasoning test of NTBE were improved (t=-2.70,P=0.010)and 2 subscales were declined in cognitive intervention group(all P＜0.05).9 subscales in semantic relations test of NTBE (t=-2.27,P=0.013) were improved and 5 subscales were declined in control group (all P＜ 0.05).Comparison between groups at one year follow-up showed that 5 subscales in reasoning test of NTBE (F=16.80,P=0.000) were better in intervention group than in control group(all P＜0.05).General linear model (GLM) with repeated measures at three time points showed that 4 subscales in reasoning test of NTBE had a time-by group interaction (F=5.16,P=0.01).Conclusions Integrative cognitive training can improve cognitive function in patients with mild cognitive impairments,and the validity of reasoning ability can sustain one year.

Objective To evaluate the capability of multilocus variable-number tandem-repeat ( VNTR) analysis ( MLVA) and pulsed-field gel electrophoresis ( PFGE) for genotyping Salmonella enterica serovar Typhi (S.Typhi) isolates.Methods Five polymorphic VNTRs (SAL02,SAL11,SAL16,SAL20, and TR4699 ) that were observed in S.Typhi strains from previous studies were selected to establish MLVA . Twenty-one epidemiologically unrelated S.Typhi strains that were isolated from Shenzhen ,China from 2002 to 2007 were genotyped by the established MLVA , and the results were compared with those by PFGE . Results The Simpson′s index of diversity ( D value ) for all five different VNTRs ranged from 0.838 to 0.943 .A total of 19 MLVA profiles and 19 PFGE profiles were found , respectively .The D value for both MLVA and PFGE were 0.99 and the test results from two analyses were identical .Conclusion The five polymorphic VNTRs analysis could be used as an alternative typing scheme for epidemiologic investigation of S.Typhi infection .

Objective To investigate the prevalence and molecular characteristics of the extended -spectrum β-lactamase ( ESBL) and AmpC enzyme-producing Proteus mirabilis ( P.mirabilis) strains isola-ted in Shenzhen People′s Hospital.Methods The production of ESBLs and AmpC enzymes by P.mirabilis isolates were detected by a screening and confirmatory test for ESBLs and AmpC disk test , respectively .The PCR assays followed by DNA sequencing of the products were employed to analyze the multiple genes inclu -ding the ESBLs genes, AmpC genes, insertion sequences (ISs) upstream of the ESBLs or AmpC genes, plasmid -mediated quinolone resistance ( PMQR ) determinants , quinolone resistance-determining region (QRDR) genes , the integrase genes, and class1 integron cassette.The epidemiological analysis of the iso-lates was performed by pulsed field gel electrophoresis .Results There were 130 P.mirabilis clinical iso-lates collected from Shenzhen People′s Hospital in China during the year 2004 to 2010.Among them, 13 isolates (10%) produced ESBLs, that accounted for 0%-9.1%in the year 2004-2009 and up to 29.4%in 2010, and 3 isolates (2.3%) produced AmpC enzymes.The predominant genotype of ESBLs -producing isolateswas b al CTX-M-14(n=7), followed by blaCTX-M-65(n=3), blaCTX-M-55(n=1), blaCTX-M-24(n=1) and blaPER-1 (n =1).The clinical isolate of PER-1-producing P.mirabilis was reported for the first time in China.Twoisolates carried an AmpC β-lactamase gene of blaCMY-2 and one isolate carried an unidentified AmpC gene .ISEcp1 located upstream of blaCTX-M and blaCMY-2 were detected in 91.7% (11/12) of CTX-M-producing isolatesand one CMY-2-producing isolate, respectively.ISPa12 was present upstream of blaPER-1 in one studiedisolate.Approximately 66.7% (10/15) of ESBL and /or AmpC-producing isolates harbored PMQR genes including2 carrying qnrD, 5 carrying aac-Ib-cr and 3 carrying both qnrD and aac-Ib-cr.Twelve ESBL and /orAmpC-producers with high level of resistance to ciprofloxacin carried the similar mutation profiles of S 83I inGyrA, S80I or S80R in ParC and among them, six strains showed E466D mutation in GyrB.Approximately86.7% (13/15) of ESBL and/or AmpC-producing isolates carried class 1 integron.Fourteen PFGE typeswere observed among 15 ESBL and/or AmpC-producers.Conclusion The prevalence of CTX-M β-lactamasesin P.mirabilis isolates contributed to the increased resistance to extended -spectrum cephalosporins.The qnrD and/or aac-Ib-cr genes were detected among the most of ESBL and /or AmpC-producing P.mirabilis clinical isolates.

Objective To evaluate clinical effects of integrated traditional Chinese and western medicine therapy for epilepsy after stroke. Methods Literatures about the treatment of epilepsy after stroke with the combination of traditional Chinese medicine and western medicine which come from the database such as CNKI, VIP, WanFang and Pubmed, were studied and all the randomized controlled trials on comparing therapeutic effects of treating epilepsy between combined treatment of TCM and western medicine and western medicine were enrolled. The Cochrane Collaboration's software RevMan 5 was used for meta-analysis. Results 7 articles were included in the study, there is homogeneity among these articles(P>0.05), The fixed effect model was used for the meta analysis. the combined results were OR=5.17, 95%CI(3.02, 8.82), the overall effect of test Z=6.01, P<0.01, the difference between the treatment group and the control groups was significant, that means the overall effect of the combination of traditional Chinese medicine and Western medicine treatment was better than western medicine treatment; Funnel plot graphic displayed asymmetrically, which indicated the literatures publication bias. Conclusion The current data indicate that the curative effect of TCM and west medicine combined treatment is better than pure western medicine therapy for epilepsy after stroke, but as the literature publication bias, clinical studies need more high quality large samples to prove this conclusion.

ObjectiveTo investigate the feasibility and efficacy of using the hepatoduodenal ligament tension-reduced operation (tension-reduced operation in short) for iatrogenic bile duct injury where the bile duct was severely defective. MethodsBetween March 2006 and May 2009, the authors treated 6 patients with iatrogenic bile duct injury (Bismuth type Ⅱ : 5 patients and type Ⅲ : 1 patient). A no. 7 black silk thread was used to hold the hilar plate tissues and the seromuscular layer of the bulbous part of the duodenum closer together and knots were tied. This method brought the porta hepatis and the duodenal bulb closer together and the hepatoduodenal ligament was shortened. An end to end anastomosis could then be made between the two broken ends of the defective bile duct without tension. ResultsSix patients suffered from bile duct injury and they recovered fully after the tensionreduced operation. There was no complication on follow-up. ConclusionsThe tension-reduced operation was efficacious in the treatment of iatrogenic bile duct injury. This technique should be popularized and more widely used.