A survey of resident physicians' perceptions of competency-based education in standardized resident training in China: a preliminary study.

BACKGROUND: Understanding resident physicians' perceptions of competency-based medical education(CBME) may help improve approaches for implementing such education in standardized resident training (SRT). We conducted surveys of residents in China to identify their perceptions of CBME and determine the degree to which such education impacts their career plans. METHODS: Questionnaire contained a total of 24 questions, which were answered using multiple choice or yes/no, was distributed to residents who were undergoing SRT, regardless of specialty, at 7 accredited training bases located across six provinces of China. The survey aimed to investigate residents' reasons for participating in SRT, perceptions of CBME, interest in receiving CBME-associated courses, and attitudes towards CBME. RESULTS: Overall, 441 residents completed the questionnaire.17.7% (78/441) responded "no clear objective" before the participated in SRT. Only 3.9% (17/441) fully understood the objectives, training contents, and assessment system of the current "competency-based" standardized training program for residents in China. Residents ranked clinical skills and patient care, interpersonal communication, and professionalism, as the three most important competencies. Most were interested in the CBME residency programs. 90.7% felt that implementing CBME could help them clarify their professional direction and improve their career planning. CONCLUSION: Residents had positive perceptions of the incorporation of CBME into SRT. Administrators, educational leaders, and clinical faculty should seek to further publicize and increase the popularity of CBME.

Oral sulfate solution benefits polyp and adenoma detection during colonoscopy: Meta-analysis of randomized controlled trials.

OBJECTIVES: Although oral sulfate solution (OSS) has been revealed to be not only safe and efficacious but also noninferior to polyethylene glycol with ascorbic acid (PEG + ASC), it is unclear whether OSS can ultimately increase the polyp detection rate (PDR) and adenoma detection rate (ADR). We performed this meta-analysis to estimate the effect of OSS on PDR and ADR during colonoscopy. METHODS: We searched PubMed, EMBASE, and the Cochrane Library to identify relevant randomized controlled trials (RCTs) investigating the comparative effect of OSS versus PEG + ASC on the PDR and ADR during colonoscopy. Cecal intubation time (CIT), cecal intubation rate (CIR), and bowel preparation score were also evaluated. Review Manager (RevMan) version 5.3.0 was used to perform statistical analysis. RESULTS: Eight RCTs involving 2059 patients fulfilled the selection criteria. Meta-analysis suggested that OSS significantly increased the PDR (47.34% vs. 40.14%, risk ratio [RR] 1.13, 95% confidence interval [CI] 1.03-1.24, P = 0.01) and ADR (44.60% vs. 38.14%, RR 1.17, 95% CI 1.03-1.33, P = 0.01) during colonoscopy. Subgroup analysis showed that the beneficial effects of OSS on PDR and ADR were consistent among patients with mean age >55 years and with body mass index <25 kg/m2 receiving outpatient colonoscopy, morning colonoscopy, and the 2-L bowel preparation protocol. Meanwhile, patients receiving OSS had a beneficial bowel preparation score. CONCLUSION: Compared with polyethylene glycol-based regimens, the OSS bowel preparation regimen significantly increased the PDR and ADR in patients undergoing colonoscopy.

Transplantation of autologous esophageal mucosa to prevent stricture after circumferential endoscopic submucosal dissection of early esophageal cancer (with video).

BACKGROUND AND AIMS: Esophageal stricture is a common adverse event after endoscopic submucosal dissection (ESD) when it involves the entire circumference of the esophagus. We aimed to assess the effectiveness and safety of endoscopic transplantation of autologous esophageal mucosa in preventing stricture formation after circumferential ESD. METHODS: Nine patients who underwent circumferential ESD for early esophageal cancer were enrolled. After the patients underwent ESD, autologous esophageal mucosal patches were attached to the ulcer surface by using hemoclips and were then fixed with a covered metal mesh stent. The stent was removed 7 days after the procedure. The patients were followed up with endoscopy at scheduled times. RESULTS: Epithelialization occurred within a median of 7.1 days, with a graft survival rate of 96.5%. Strictures occurred at a mean of 24.7 days (range 18-34 days) after the procedure. The median number of endoscopic balloon dilatation sessions was 2.7 (range 0-6). CONCLUSIONS: Transplantation of autologous esophageal mucosa could be a safe way of relieving the severity of esophageal stricture after circumferential ESD.

A novel two-stage approach for epistasis detection in genome-wide case-control studies.

A significant challenge in epistasis detection is the huge amount of data, which leads to combinatorial explosion. This study focuses on a two-stage approach for detecting epistasis only among single nucleotide polymorphisms (SNPs) that show some marginal effect. We present this two-stage approach based on the fusion of two criteria (TwoFC) to detect epistatic interactions. We fuse the G (2) test and absolute probability difference function as a scoring function to measure the strength of association between SNPs and disease status. The fused scoring function is an excellent measure of the strength of such an association. The two-stage strategy greatly reduces the computation load on epistasis detection. We use both simulated data sets and a real disease data set to evaluate our method. The results of an experiment on the simulated data sets show that TwoFC exhibits high power and sample efficiency. The results of an experiment on the real disease data set show that our method performs well even with large-scale data sets.

Administration of modified Gegen Qinlian decoction for hemorrhagic chronic radiation proctitis: A case report and review of literature.

BACKGROUND: Hemorrhagic chronic radiation proctitis (CRP) is a common late complication of irradiation of the pelvis and seriously impairs life quality. There is no standard treatment for hemorrhagic CRP. Medical treatment, interventional treatment, and surgery are available, but they are limited in their applications due to nondefinite efficacy or side effects. Chinese herbal medicine (CHM), as a complementary or alternative therapy, may provide another option for hemorrhagic CRP treatment. CASE SUMMARY: A 51-year-old woman with cervical cancer received intensity-modulated radiation therapy and brachytherapy with a total dose of 93 Gy fifteen days after hysterectomy and bilateral adnexectomy. She received six additional cycles of chemotherapy with carboplatin and paclitaxel. Nine months after radiotherapy treatment, she mainly complained of 5-6 times diarrhea daily and bloody purulent stools for over 10 d. After colonoscopy examinations, she was diagnosed with hemorrhagic CRP with a giant ulcer. After assessment, she received CHM treatment. The specific regimen was 150 mL of modified Gegen Qinlian decoction (GQD) used as a retention enema for 1 mo, followed by replacement with oral administration of 150 mL of modified GQD three times per day for 5 mo. After the whole treatment, her diarrhea reduced to 1-2 times a day. Her rectal tenesmus and mild pain in lower abdomen disappeared. Both colonoscopy and magnetic resonance imaging confirmed its significant improvement. During treatment, there were no side effects, such as liver and renal function damage. CONCLUSION: Modified GQD may be another effective and safe option for hemorrhagic CRP patients with giant ulcers.

Efficacy and mechanisms of 4-week MBSR on psychological distress in lung cancer patients: A single-center, single-blind, longitudinal, randomized controlled trial.

Objective: This study aimed to evaluate the efficacy of a 4-week mindfulness-based stress reduction (MBSR) program on psychological distress in patients with lung cancer and elucidate its mechanisms. Methods: This single-center, single-blinded, longitudinal, randomized controlled trial was conducted on 175 patients with lung cancer randomly allocated to a 4-week MBSR or a waiting-list group. The efficacy and mechanisms of the 4-week MBSR program were evaluated by outcome measures at preintervention (T0), the immediate postintervention (T1), 1 month (T2), and 3 months (T3). We analyzed the collected data using the per-protocol set principle, independent sample t-test, repeated measure analysis of variance, and structural equation modeling. Results: The 4-week MBSR program significantly alleviated psychological distress (F â€‹= â€‹15.05, P â€‹< â€‹0.001), decreased perceived stigma (F â€‹= â€‹8.260, P â€‹= â€‹0.005), improved social support (F â€‹= â€‹16.465, P â€‹< â€‹0.001), and enhanced mindfulness (F â€‹= â€‹17.207, P â€‹< â€‹0.001) compared with usual care at T1, T2, and T3. All variables significantly changed over time except for copying style (P â€‹= â€‹0.250). The changes in social support, mindfulness, and perceived stigma mediated the efficacy of the 4-week MBSR program on psychological distress (ߠ​= â€‹-0.292, P â€‹= â€‹0.005; ߠ​= â€‹-0.358, P â€‹= â€‹0.005). Conclusions: This study shows the benefits of the MBSR program for psychological distress, social support, mindfulness, and perceived stigma in patients with lung cancer. Also, it elucidates the mechanisms by which the MBSR program alleviates psychological distress by improving social support, enhancing mindfulness, and decreasing perceived stigma. The findings provide insights into applying the MBSR program to reduce psychological distress among patients with lung cancer.

Antitumor effect of new multiple antigen peptide based on HLA-A0201-restricted CTL epitopes of human telomerase reverse transcriptase (hTERT).

The development of peptide vaccines aimed at enhancing immune responses against tumor cells is becoming a promising area of research. Human telomerase reverse transcriptase (hTERT) is an ideal universal target for novel immunotherapies against cancers. The aim of this work was to verify whether the multiple antigen peptides (MAP) based on HLA-A0201-restricted CTL epitopes of hTERT could trigger a better and more sustained CTL response and kill multiple types of hTERT-positive tumor cells in vitro and ex vivo. Dendritic cells (DC) pulsed with MAP based on HLA-A0201-restricted CTL epitopes of hTERT (hTERT-540, hTERT-865 and hTERT-572Y) were used to evaluate immune responses against various tumors and were compared to the immune responses resulting from the use of corresponding linear epitopes and a recombinant adenovirus-hTERT vector. A 4-h standard (51) Cr-release assay and an ELISPOT assay were used for both in vitro and ex vivo analyses. Results demonstrated that targeting hTERT with an adenovector was the most effective way to stimulate a CD8(+) T cell response. When compared with linear hTERT epitopes, MAP could trigger stronger hTERT-specific CTL responses against tumor cells expressing hTERT and HLA-A0201. In contrast, the activated CTL could neither kill the hTERT-negative tumor cells, such as U2OS cells, nor kill HLA-A0201 negative cells, such as HepG2 cells. We also found that these peptide-specific CTL could not kill autologous lymphocytes and DC with low telomerase activity. Our results indicate that MAP from hTERT can be exploited for cancer immunotherapy.

Neutrophil-to-Lymphocyte Ratio as an Indicator of Opioid-Induced Immunosuppression After Thoracoscopic Surgery: A Randomized Controlled Trial.

Purpose: The neutrophil-to-lymphocyte ratio (NLR) is a useful prognostic marker for various diseases and surgery-induced immunosuppression. While opioids are important in general anesthesia, the association between immediate perioperative immune monitoring and opioid consumption for postoperative analgesia after video-assisted thoracoscopic surgery (VATS) is unknown. We aimed to investigate the effect of analgesic techniques on opioid-induced immune perturbation, and the feasibility of NLR as an indicator of opioid-induced immune changes. Patients and Methods: Patients were randomly assigned to two groups: Group P (n=40) or Group C (n=40). Patients in group P received ultrasound-guided paravertebral block (PVB) before surgery, and followed by sufentanil patient-controlled intravenous analgesia (PCIA) after surgery, and group C received sufentanil PCIA only. The total and differential white blood cell counts, including CD4+ T lymphocyte counts, CD8+ T lymphocyte were recorded before surgery and at 24 and 72 hours after surgery. NLR was determined using the frequencies of lymphocyte subpopulations. The cumulative dose of sufentanil were recorded at 24 and 24h after surgery while the 40-item quality of recovery questionnaire (QoR-40) score were assessed at 48h after the surgery. Results: At 24 and 48 hours after surgery, a lower sufentanil consumption, and higher QoR-40 recovery scores were found in group P than in group C (P<0.05). In biochemical analyses, the values of NLR were lower in group P compared to group C (p<0.0001) and ratio of CD4/CD8 were higher in group P compared to group C (p<0.05) on day three after surgery. NLR showed excellent predictive capability for immunosuppression, with an area under the curve (AUC) of 0.92 [95% confidence interval (CI), 0.86-0.98, P < 0.0001]. Conclusion: Opioid-sparing pain management strategies may affect postoperative immunosuppression and NLR could be a reliable indicator of opioid-related immunosuppression. Moreover, opioid-sparing pain management strategies could improve patient's satisfaction in VATS.

Alendronate-anchored PEGylation of ceria nanoparticles promotes human hepatoma cell proliferation via AKT/ERK signaling pathways.

Previous work has suggested that ceria nanoparticles (CNPs) have regenerative antioxidant properties, which have motivated researchers to consider CNPs as therapeutic agents for treating a number of diseases, including cancer. Recent studies have shown CNPs to be toxic to cancer cells, to inhibit invasion and sensitize cancer cells to radiotherapy. In addition, several hydrophilic polymers have been used to coat the CNP surface in order to enhance its properties of extensive biocompatibility and systemic nontoxicity to normal cells and tissues. However, the results of previous studies were based on high CNP doses (10 µg/mL or more), and these doses may cause serious side effects in clinical applications. The impact of low CNP doses on tumor cells remains unknown. In this study, we report experiments indicating that CNPs-AL- polyethylene glycol (PEG)600, a type of surface-modified CNP that is more stable and less toxic than traditional CNPs could promote proliferation of hepatoma cells in a dose-dependent manner. In addition, further research showed that a low dose (0.01 µg/mL) of CNPs-AL-PEG600 could reduce hepatoma cell apoptosis and activate AKT/ERK signaling pathways. These results may provide information that is important for using CNPs-AL-PEG600 as a therapeutic agent in clinical cancer treatments.

Patients' and Family Members' Decision-Making and Information Disclosure Preferences in a Single-Center Survey in China: A Pilot Study.

BACKGROUND: Understanding the medical decision-making and information disclosure preferences is important for care quality. OBJECTIVES: To examine the feasibility of using the questionnaires and to identify modifications needed in the following study. DESIGN: Thirty-three pairs of patients with advanced cancers and their caregivers were asked to complete the questionnaires. RESULTS: More than 60% of patients and caregivers had an educational level of middle school and below. The active, passive, or shared decision-making preferences for patients were 33.3%, 39.4%, and 27.3%, respectively. Twenty of 33 patients and 24 of 33 caregivers misunderstood the questions. CONCLUSIONS: Low educational levels may be the reason for poor understanding imprecision. It is necessary to use the modification version of the questionnaires in developing countries.

Small Bowel Endoscopy Diagnostic Yield and Reasons of Obscure GI Bleeding in Chinese Patients.

Aim. To investigate the diagnostic yield and etiologies of patients with obscure gastrointestinal bleeding (OGIB) using capsule endoscopy (CE) or double-balloon enteroscopy (DBE). Method. We studied the data of 532 consecutive patients with OGIB that were referred to Xinqiao Hospital in Chongqing from December 2005 to January 2012. A lesion that was believed to be the source of the bleeding (ulceration, mass lesion, vascular lesion, visible blood, inflammation, or others) was considered to be a positive finding. We analyzed the diagnostic yield of CE and SBE and the etiologies of OGIB. Result. CE and SBE have similar diagnostic yields, at 71.9% (196/231) and 71.8% (251/304), respectively. The most common etiology was erosions/ulceration (27.1%) followed by mass lesion (19.4%) and angiodysplastic/vascular lesions (13.9%). By stratified analysis, we found that erosions/ulceration (27.1%) was the most common etiology for the 21-40-year age group. Mass lesion was the most common etiology in the 41-60-year age group. However, in the >60 years age group, angiodysplastic/vascular lesions were significantly increased compared with the other groups, even though erosions/ulceration was most common. Conclusion. In this study, we found that CE and SBE have similar diagnostic yields and erosions/ulceration was the most common reason for OGIB, followed by mass lesion and angiodysplasias.

Assessment of cancer pain management knowledge in southwest China: a survey of 259 physicians from small city and county hospitals.

BACKGROUND: Pain management is a critical issue in the care of cancer patients in China, especially in small city and county hospitals in southwest China. OBJECTIVE: The study intended to determine Chinese physicians' competence in cancer pain management and to assess their opinions on barriers to optimal pain management. DESIGN: A questionnaire on pain management was given to 259 fellows after their general orientation meeting at a tertiary teaching hospital. The questionnaire was adapted from an earlier study by the Eastern Cooperative Oncology Group (ECOG). RESULTS: The majority of the fellows believed that 70% of cancer patients suffer pain. Nearly 90% (224/259) indicated that their training in cancer pain management was poor. The fellows stated that concern about morphine addiction was the primary reason they hesitated to prescribe opioids, and they identified inadequate assessment of cancer pain as the most significant barrier to optimal management of cancer pain. CONCLUSION: The study reflects to some extent the state of pain management in hospitals in southwest China. Medical students and physicians in China need improved pain management education.

Epidemiology of drug-induced liver injury in China: a systematic analysis of the Chinese literature including 21,789 patients.

BACKGROUND: The epidemiology of drug-induced liver injury (DILI) in China has rarely been studied before. The aim of the present study was to determine the etiology of DILI in a Chinese population by reporting a systematic analysis of the Chinese literature published from 1994 to 2011. METHODS: A comprehensive database search of the Chinese literature was performed to obtain all the relevant studies. The data, including the drug names and patients' sex, age, clinical classification, and prognosis, were collected and analyzed. RESULTS: In this research, we found 279 studies including 24 112 patients. There were 265 studies that reported the sex of 21 789 patients, 11 787 men and 10 002 women. The therapeutics included (but were not limited to) tuberculostatics, complementary and alternative medicines (CAMs), antibiotics, NSAIDs, antineoplastics, central nervous system agents, antithyroid drugs, and immunomodulators. Of these drugs, tuberculostatics and CAMs were the most common etiologies of DILI in China. CONCLUSION: DILI in China has a different etiology from that in Europe and USA. NSAIDs, which are the most common causes of DILI in western populations, are uncommon in China. Therefore, government, physicians, and patients should pay more attention to these drugs in DILI.

Diepitope multiple antigen peptide of hTERT trigger stronger anti-tumor immune responses in vitro.

Rapid advances in immune system knowledge have led to the exploration of immunologic approaches for eliminating tumor cells. Human telomerase reverse transcriptase (hTERT) is considered to be an ideal universal target for novel immunotherapies against cancers. Thus far, studies of effective antitumor immunotherapies have focused on the quantity and quality of the effector function of the CD8 compartment. However, increasing evidence has demonstrated that CD4+ T cells play important roles in generating and maintaining antitumor immune responses in animal models. The aim of this work was to verify whether diepitope multiple antigen peptides (MAPs) that were composed of the cytotoxic T lymphocyte (CTL) epitope of hTERT and the T-helper epitope of hTERT could improve upon the immunogenicity of a monoepitope MAP of hTERT. Dendritic cells (DCs) pulsed with diepitope MAPs composed of the CTL epitope hTERT-540 and the T-helper epitope hTERT-766 were used to evaluate immune responses against various tumor cells. A standard in vitro 4-h 5¹Cr-release assay was employed in this study. The results demonstrated that CTLs activated by the diepitope MAP that consisted of hTERT-540 and hTERT-766 could cause 8.56% more lysis than CTLs activated by the monoepitope MAP containing hTERT-540. Moreover, the activated CTLs could kill neither hTERT-negative tumor cells, such as U2OS cells, nor HLA-A2 negative cells, such as HepG2 cells. Our results indicate that diepitope MAPs that are generated from hTERT can be exploited for cancer immunotherapy.

A survey on the current trends in the management of hepatitis B in China.

OBJECTIVE: Hepatitis B virus (HBV) infection is a highly endemic disease in China. The guidelines of the European Association for the Study of the Liver and the Asian Pacific Association for the Study of the Liver have improved in recent years. Here, we present a survey of physicians in terms of trends in the management of HBV at a teaching hospital in Southwest China. METHODS: A questionnaire adopted from an earlier Spanish study was used. Physicians in an affiliated hospital of a Chinese medical university were surveyed. RESULTS: A total of 120 (100%) physicians (including 68 fellows) answered the questionnaire voluntarily. Eighty percent (96/120) reported experience in the treatment of hepatopathy. Although a huge majority (90.9%, 109/120) were aware of the Chinese consensus recommendations on HBV, only 51.8% (62/120) correctly identified the indications for the treatment of chronic hepatitis B and 42.5% (51/120) correctly described the end-points in treating HBeAg-positive or HBeAg-negative chronic hepatitis. Serum HBV-DNA levels were used to monitor therapy by 84.2% (101/120) of the respondents, the HBV drug resistance test was used by 77.5% (93/120) of the responders, and antiviral prophylaxis was recommended by 65% (78/120) for HBV carriers who would receive immunosuppressive therapy. About 27.5% (33/120) recommended interferon or pegylated interferon as the initial treatment for HBeAg-positive patients; 93.3% (112/120) recommended oral antiviral therapy to HBeAg-negative patients. Physicians working at teaching hospitals were significantly more likely to recommend antiviral prophylaxis for HBV patients who receive immunosuppressive therapy than physicians working at nonuniversity hospitals (83 vs. 51%; P<0.001). CONCLUSION: The inadequate management of chronic hepatitis B by Chinese physicians calls for an improvement in education, especially for physicians in county hospitals or clinics.

hTERT-based therapy: a universal anticancer approach (Review).

Human telomerase reverse transcriptase (hTERT) has been identified as a major protein involved in aberrant cell proliferation, immortalization, metastasis and stemness maintenance in a majority of tumors, yet it has little or no expression in normal somatic cells. During the past few years, the development of hTERT-based therapies such as immunotherapy, suicide gene therapy and small-molecule interfering therapy have become critical and specific for eradicating all types of cancer. Here, current knowledge regarding hTERT and its involvement in various cancers and its role as a target of cancer therapies are reviewed. Additionally, hurdles to new cancer therapy development and new therapeutic opportunities are described, along with areas that require further investigation.

Palliative care education in China: insight into one medical university.

CONTEXT: There has been an increase in the amount of palliative care available in developing countries, including in China. However, palliative care is still very limited, and it is not mandatory to teach courses on palliative care in Chinese medical universities. OBJECTIVES: To assess Chinese interns' awareness of palliative care concepts. METHODS: Using a questionnaire selected from an earlier Austrian study, interns in a Chinese medical university were surveyed. All those surveyed had already been interns for at least six months. RESULTS: Four hundred interns from a Chinese medical university (response rate 99.5%) were surveyed. Twenty-one percent were female (84 of 400), and the average age was 23 years. Approximately one-third (34.5%) of interns were familiar with the pain scale, and 31% of interns were familiar with the concept of pain management. Only 7.5% of interns felt adequately trained in basic pain management, and 13% felt adequately trained to manage symptoms of dying patients. Seventy-seven percent of interns reported inadequate education regarding discussion of death with patients and family members. More than 80% of interns felt that more education about palliative care should be included in the basic medical curriculum and clinical intern training. CONCLUSION: Palliative care education is inadequate from the perspective of the Chinese medical interns. An improvement in the medical school curriculum is needed.