Background: Pollicization remains the default treatment for severe thumb hypoplasia, while the metatarsal transfer is an effective choice for metacarpal reconstruction, with competitive outcome of reconstructed thumb. However, rare researches focused on the outcome of donor foot of the metatarsal transfer. The purpose of this study was to evaluate the short-term outcome of donor foot after full-width metatarsal transfer for Manske Type IIIB and IV thumb hypoplasia.Methods: Fourteen patients with Manske Type IIIB and IV thumb hypoplasia were enrolled in the study. A full-width metatarsal graft (vascularised, from the second metatarsal or non-vascularised, from the fourth metatarsal) was harvested; an adjacent half-width graft from the third metatarsal was transposed horizontally to replace the donor defect. Objective and subjective evaluations were performed at least 12 months postoperatively. The appearances of the toes and the radiographic findings of the metatarsals were evaluated by two authors, the length and width of the metatarsals were measured on digital anteroposterior radiographs using a paired sample t test. The parental satisfaction was evaluated using a self-administered questionnaire. Results: Among these 14 patients (eight type ⅢB and six type Ⅳ thumbs), there were ten male and four female patients. The mean age at operation was 34.2 months (range: 14 to 127 months), and the mean follow-up was 16.1 months (range: 12 to 30 months). Toe lengthening, toe overriding, and synostosis between the metatarsals were observed in two, two and two patients; toe shortening, toe deviation, metatarsal lengthening and metatarsal angulation were observed in one, one, one and one patient. The lengths of third and fourth metatarsals in donor site were significantly larger than those in contralateral side, while the widths of third and fourth metatarsals were not significantly different between donor and contralateral sides. The mean score in the parental satisfaction questionnaire (full score, 30) was 27.2, (range: 17 to 30), which rated as “good”. Conclusions: Following full-width metatarsal transfer for Type IIIB and IV thumb hypoplasia, transposition of the adjacent half-width metatarsal for donor reconstruction results in minor donor deficit and overall parenteral satisfaction. Level of evidence: Ⅳ

BACKGROUND:Ewing's sarcoma of the adrenal gland with inferior vena cava (IVC) and right atrium thrombus is extremely rare. Here, we report a case of giant adrenal Ewing's sarcoma with IVC and right atrium tumor thrombus and summarize the anesthesia and perioperative management.CASE SUMMARY:A young female was admitted to the Department of Urology with intermittent pain under the right costal arch for four months. Enhanced abdominal computed tomography revealed a large retroperitoneal mass (22 cm in diameter), which may have originated from the right adrenal gland and was closely related to the liver. Transthoracic echocardiography showed a strong echogenic filling measuring 70 mm extended from the IVC into the right atrium and ventricle. After preoperative preparation with cardiopulmonary bypass, sufficient blood products, transesophageal echocardiography and multiple monitoring, tumor and thrombus resection by IVC exploration and right atriotomy were successfully performed by a multidisciplinary team. Intraoperative hemodynamic stability was the major concern of anesthesiologists and the status of tumor thrombus and pulmonary embolism were monitored continuously. During transfer of the patient to the intensive care unit (ICU), cardiac arrest occurred without external stimulus. Cardiopulmonary resuscitation was performed immediately and cardiac function was restored after 1 min. In the ICU, extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) were provided to maintain cardiac, liver and kidney function. Histopathologic examination confirmed the diagnosis of Ewing's sarcoma. After postoperative treatments and rehabilitation, the patient was discharged from the urology ward.CONCLUSION:An adrenal Ewing's sarcoma with IVC and right atrium thrombus is extremely rare, and its anesthesia and perioperative management have not been reported. Thus, this report provides significant insights in the perioperative management of patients with adrenal Ewing's sarcoma and IVC tumor thrombus. Intraoperative circulation fluctuations and sudden cardiovascular events are the major challenges during surgery. In addition, postoperative treatments including ECMO and CRRT provide essential support in critically ill patients. Moreover, this case report also highlights the importance of multidisciplinary cooperation during treatment of the disease.

OBJECTIVE:Measurements of plasma free metanephrines (MNs), including MN and normetanephrine, provide high sensitivity and specificity for the diagnosis of pheochromocytoma and paraganglioma (PPGL). 3-Methoxytyramine (3-MT) and chromogranin A (CgA) may allow the detection of dopamine-producing or biochemically silent PPGL. The aim of this study was to evaluate whether measurements of plasma 3-MT or CgA as a supplement of plasma MNs offer a better diagnostic strategy for initial testing of PPGL.PATIENTS AND DESIGN:We enroled 125 patients who underwent surgery from 2015 to 2016 for our study and identified 33 patients with PPGL and 92 patients with non-PPGL masses.MEASUREMENT:The levels of plasma free MNs and 3-MT were measured for all 125 patients using liquid chromatography-tandem mass spectrometry. Plasma CgA concentrations were determined using a radioimmunoassay. To evaluate the diagnostic performance of plasma free MNs, 3-MT and CgA, sensitivity and specificity were determined, and receiver operating characteristic curves were constructed.RESULTS:We found that combining 3-MT and MNs increased the diagnostic sensitivity from 93.9% (95% confidence interval [CI]: 78.4%-98.9%) to 97.0% (95% CI: 82.5%-99.8%). In contrast, addition of plasma CgA test reduced the diagnostic specificity significantly from 91.3% (95% CI: 83.1%-95.9%) to 75.0% (95% CI: 64.7%-83.2%).CONCLUSION:Here, we demonstrated that 3-MT represents a valuable supplementary test to plasma MNs, which can further enhance the sensitivity of the assay, while plasma CgA added no additional diagnostic value to MNs due to the lowered diagnostic specificity.

Background: Assessing the preparedness of junior doctors to use vancomycin is important in medical education. Preparedness is typically evaluated by self-reported confidence surveys. Materials and Methods: An eight-item vancomycin prescribing confidence questionnaire was developed, piloted, and evaluated. The questionnaire responses were collected from 195 junior doctors and a series of statistical techniques, such as principal component analysis and confirmatory factor analysis, and were implemented to examine the validity and reliability. Results: The principal component analysis supported a one-factor structure, which was fed into a confirmatory factor analysis model resulting in a good fit [comparative fit index (CFI) = 0.99, Tucker–Lewis index (TLI) = 0.99, root mean square error of approximation (RMSEA) = 0.08, standardized root mean square residual (SRMR) = 0.04]. Ordinal-based α was 0.95, and various ωs were all above 0.93, indicating a high reliability level. The questionnaire responses were further proved to be robust to extreme response patterns via item response tree modeling. Jonckheere–Terpstra test results ( z = 6.5237, p = 3.429e−11) showed that vancomycin prescribing confidence differed based on the experience in order (i.e., four ordinal independent groups: “≤10 times,” “11–20 times,” “21–30 times,” and “≥31 times”) and therefore provided external validity evidences for the questionnaire. Conclusions: The questionnaire is valid and reliable such that teaching hospitals can consider using it to assess junior doctors' vancomycin prescribing confidence. Further investigation of the questionnaire can point to the relationship between the prescribing confidence and the actual performance.

The purpose of this scoping review is to update the recent progress of EPAs research in GME, focusing on the topical concern of EPAs effectiveness, and to provide a reference for medical researchers in countries/regions interested in introducing EPAs. Guided by Arksey and O'Malley's framework regarding scoping reviews, the researchers, in January 2021, conducted a search in five databases to ensure the comprehensiveness of the literature. After the predetermined process, 29 articles in total were included in this study. The most common areas for the implementation and evaluation of EPAs were Surgery (n = 7,24.1%), Pediatric (n = 5,17.2%) and Internal medicine (n = 4,13.8%), a result that shows a relatively large change in the research trend of EPAs in the last two years. Prior to 2018, EPAs research focused on internal medicine, psychiatry, family medicine, and primary care. The articles in the category of EPAs implementation and evaluation had four main themes: (1) validation of EPAs (n = 16,55.2%); (2) describing the experience of implementing EPAs (n = 11,37.9%); (3) examining the factors and barriers that influence the implementation and evaluation of EPAs (n = 6,20.6%); and (4) researching the experiences of faculty, interns, and other relevant personnel in using EPAs. Training programs were the most common EPAs implementation setting (n = 26,89.6%); direct observation and evaluation (n = 12,41.4%), and evaluation by scoring reports (n = 5,17.2%) were the two most common means of assessing physicians' EPA levels; 19 papers (65.5%) used faculty evaluation, and nine of these papers also used self-assessment (31.0%); the most frequently used tools in the evaluation of EPAs were mainly researcher-made instruments (n = 37.9%), assessment form (n = 7,24.1%), and mobile application (n = 6,20.7%). Although EPAs occupy an increasingly important place in international medical education, this study concludes that the implementation and diffusion of EPAs on a larger scale is still difficult.

Purpose No conclusion exists for the optimum duration of preoperative administration of doxazosin (DOX) before adrenalectomy for pheochromocytoma. The purpose of this study is to investigate whether perioperative hemodynamics and postoperative outcomes are related to the duration of DOX administration. Methods In total, 132 patients managed preoperatively with single α-receptor blocker DOX were enrolled. All patients underwent adrenalectomy for pheochromocytoma in the Department of Urology, Peking University First Hospital, between January 2001 and July 2019. Patients were divided into three groups based on the duration of preoperative administration of DOX: group A (≤14 days), group B (15–30 days), and group C (>30 days). Patient and tumor characteristics, intraoperative hemodynamics, and postoperative outcomes were recorded and compared. Results These patients included 57 men and 75 women, with an average age of 48 years. Clinical characteristics, preoperative hemodynamics, medicine management and surgical approaches were comparable between the three groups. Among the three groups, we found that group C (>30 days) had the lowest intraoperative minimum heart rate [group A vs. group B vs. group C = 60 (52–67) vs. 59 (50–61) vs. 51.5 (50–58.75), p = 0.024] and highest risk of postoperative hypotension requiring vasopressor support [group A vs. group B vs. group C = 14 (20.3%) vs. 12 (27.9%) vs. 10 (50.0%), p = 0.032]. Conclusion The current study indicated that preoperative management of pheochromocytoma with single α-receptor blocker DOX for more than 30 days after final dose adjustment might lead to intraoperative bradycardia and more postoperative hypotension requiring vasopressor support. Thus, our study does not support long-term (over 30 days) preoperative administration of pheochromocytoma with single α-receptor blocker DOX in the final dose.

of the tumor on April 29, 2014. A histological examination To the Editor: The complications of pheochromocytoma caused by barely controlled hypertension and the confirmed the diagnosis of pheochromocytoma [Supplemenoverproduction of catecholamine can reduce patients’ life expectancy and quality of life. Herein, we report a case of bilateral multiple renal infarctions on computed tomography (CT) scan related to pheochromocytoma, which achieved complete relief on follow-up after tumor removal. A 47-year-old male with a 3-year history of uncontrolled hypertension (the highest value recorded was 210/160 mmHg) and intermittent severe headache, pallor, and sweating presented to our hospital on April 15, 2014. He did not monitor his blood pressure regularly but occasionally took dihydropyridine calcium-channel blockers. There was no history of kidney disease, thromboembolic disease, or renal artery injury. On admission, physical examination showed a blood pressure of 160/80 mmHg. His heart rate was 90 beats/min, and his respiratory rate was 18 breaths/min. The urinalysis showed slight hematuria. A transient elevation in serum creatinine and blood urea nitrogen was noted, which normalized within 2 days after fluid replacement. The prothrombin time, activated partial thromboplastin time and D-dimer levels were all within the normal range [Supplemental Table 1, http://links.lww.com/ CM9/A206], while the plasma level of epinephrine was 7829.60 (reference interval: 9.16–254.60) pg/mL and that of norepinephrine was 6121.70 (86.30–551.60) pg/mL. An abdominal CT revealed an 8.5 cm tumor on the right adrenal gland and multiple wedge-shaped perfusion defects on the bilateral kidneys [Figure 1A]. The echocardiogram showed no arterial thrombus, and a 24-h Holter study revealed no arrhythmia.

近年来,随着"新电影史学"概念的不断深入发展,媒介考古学作为一种新电影史学研究进入到公众视野,这种电影史写作是建立在历史学基础之上,研究历史发展、变迁、递嬗的历史,也是重写电影史的一种形式.这种新电影史的研究是建立在现代电影理论的基础之上,现代电影理论关注影像与观众的关系,将银幕比作镜子,观众可以透过这面镜子来窥视自己的影子,现代电影理论拓展了电影研究的视野,与影片相关的诸多领域都成为了电影研究范围.从20世纪60年代开始,现代电影理论吸收结构主义语言学、人类学、精神分析学、意识形态批评学以及女性主义等相关研究的学术成果,使得新电影史学研究方法开始出现,我们进入到一个对电影史学重新反省与评估的时期,并对电影史的叙述范围、本质及其材料进行重新检验的时期.1986年,英国学者 Thomas Elsaesser(托马斯?艾尔萨埃瑟)就在《画面与音响》这篇文章中,首次提出"新电影史"的概念,新的历史、哲学思考都被融入到电影史学的研究中,这就使得我们在做电影关系研究路径上的研究方法和观点得到新的启发,于是,媒介考古视野下的新电影史学研究就此诞生,电影被作为一种媒介研究进入学术视野.

中国早期电影的黄金时代与上海的摩登时代同步,东西方文化的碰撞形成了中国早期独特的历史文化景观.在20世纪二三十年代的上海,好莱坞电影文化作为娱乐最显著的一面,影响着这个城市的文化导向与构建,时尚与摩登蔓延在日常生活的各个领域,新的都市娱乐方式的呈现,也在改变着人们创造文化的方法.摩登作为一种概念投射到人们的现实生活中,成为年轻人所追求的一种梦想,这也就构成了都市文化景观.如在《景观现象》这一本书中对景观有过这样的概括:"生活本身就是景观的一种庞大堆聚,是一切生产方式的结果."[1]而这种景观是生活中占主导模式的全部形式,如这座城市的文化景观以及电影文化所引领的时尚风潮都在参与着中国社会的现代化进程.在如此繁华的都市景观下,摩登以多种方式呈现在生活中,如报刊杂志、广告、宣传画、游艺表演等,这些都构成了都市景观的基本要素,摩登女郎成为承载摩登现代性的主要载体,也是最早的时髦制造者,她们勇于打破中国传统审美的认知,用身体演绎着现代性思潮.

作为20世纪20年代中国最大的中美合资电影公司,孔雀电影公司一直处于被主流电影史忽略的位置.本文对孔雀电影公司的建立、人事构成、经营模式进行了初步梳理,尝试探索在早期中美电影关系中,以中美合资形式存在的电影公司在中国电影市场的发展变化中所起到的作用.

Purpose: To assess the accuracy of machine learning to predict and classify quality assurance (QA) results for volumetric modulated arc therapy (VMAT) plans. Methods and Materials: Three hundred three VMAT plans, including 176 gynecologic cancer and 127 head and neck cancer plans, were chosen in this study. Fifty-four complexity metrics were extracted from the QA plans and considered as inputs. Patient-specific QA was performed, and gamma passing rates (GPRs) were used as outputs. One Poisson lasso (PL) regression model was developed, aiming to predict individual GPR, and 1 random forest (RF) classification model was developed to classify QA results as "pass" or "fail." Both technical validation (TV) and clinical validation (CV) were used to evaluate the model reliability. GPR prediction accuracy of PL and classification performance of PL and RF were evaluated. Results: In TV, the mean prediction error of PL was 1.81%, 2.39%, and 4.18% at 3%/3 mm, 3%/2 mm, and 2%/2 mm, respectively. No significant differences in prediction errors between TV and CV were observed. In QA results classification, PL had a higher specificity (accurately identifying plans that can pass QA), whereas RF had a higher sensitivity (accurately identifying plans that may fail QA). By using 90% as the action limit at a 3%/2 mm criterion, the specificity of PL and RF was 97.5% and 87.7% in TV and 100% and 71.4% in CV, respectively. The sensitivity of PL and RF was 31.6% and 100% in TV and 33.3% and 100% in CV, respectively. With 100% sensitivity, the QA workload of 81.2% of plans in TV and 62.5% of plans in CV could be reduced by RF. Conclusions: The PL model could accurately predict GPR for most VMAT plans. The RF model with 100% sensitivity was preferred for QA results classification. Machine learning can be a useful tool to assist VMAT QA and reduce QA workload. (C) 2019 Elsevier Inc. All rights reserved.

Objective To explore the characteristics of resting-state functional connectivity in male adults with attention deficit hyperactivity disorder (ADHD) and the relationship with clinical symptoms.Method Forty-seven male adult ADHD patients diagnosed by DSM-Ⅳ-TR and 47 healthy controls matched with sex,age and IQ were enrolled by clinical interviews.All subjects underwent structural MRI scan and resting-state functional MRI scan.All subjects were rated the ADHD symptom severity with the ADHD symptom rating scale.A two independent-samples t-test was used to analyze the differences of the resting-state functional connectivity strength (FCS) between the male adult ADHD group and the healthy control group.Results Compared with healthy controls,adult ADHD patients had shown the reduced FCS in the right middle temporal gyrus(t=-3.42),inferior temporal gyrus (t=-3.32),right middle occipital gyrus (t=-3.11) and inferior occipital gyrus (t=-4.44,P＜0.05 after multiple correction).The FCS of right inferior occipital gyrus in ADHD group had a tendency to negatively correlated with the severity of symptoms (r=-0.403,P＜0.05).A trend of negative correlation between the FCS in the right inferior occipital gyrus in ADHD group and the attention deficit score was found (r=-0.507,P＜0.05).Conclusion Abnormalities in resting-state brain function connectivity are prominent in male adult ADHD patients.Occipitallobe dysfunction may be more related to the severity of the ADHD symptoms.Temporal lobe and occipital lobe seem to be crucial to the pathogenesis of adult male ADHD.

BACKGROUND:The predominant method for Manske type IIIB and IV thumb hypoplasia is pollicization. However, for those who are not willing to sacrifice the index finger, a method that could reconstruct a functionally capable and aesthetically acceptable thumb remains desirable. This study aimed to investigate and assess the functional and radiographic outcomes of utilizing a reversed vascularized second metatarsal composite flap for thumb reconstruction as a new alternative.METHODS:From May 2014 to January 2017, 15 patients with Manske type IIIB or IV thumb hypoplasia who were admitted to the Department of Hand Surgery, Beijing Jishuitan Hospital were included in this study. An osteocutaneous flap containing a section of second metatarsal and its distal head was transferred in reversed position to reconstruct carpometacarpal joint. The donor site was reconstructed by a split half of the third metatarsal. Various functional reconstructions were commenced at second stage. The reconstructed thumbs were evaluated using the Kapandji score, pinch force, and the capacities of performing daily activities through a detailed questionnaire.RESULTS:Among these 15 patients (seven type IIIB and eight type IV), there were ten boys and five girls with median age of 4.2 years (range: 2.0-7.0 years). There were seven right, three left, and five bilateral thumbs for whom only the right thumb received surgery. There were 14 metatarsal flaps survived (14/15). With an average follow-up of 19.2 months, the reconstructed thumbs had acceptable functional and aesthetic outcomes and the donor foot presented in decent appearance without signs of impaired function. All 15 children have improved the Kapandji score (from 0 to an average of 6.7), pinch force (from 0 to an average of 1.5 kg), with ability of grip and pen holding. X-ray indicated continuous bone growth. Patients and parents had good acceptance of the new thumb.CONCLUSIONS:Reconstruction of an unstable hypoplastic thumb (Manske type IIIB and IV) with use of a vascularized metatarsal is an effective strategy. It offers an alternative solution for parents insisting on saving the thumb.

Objective To explore the factors affecting methylphenidate (MHP)efficacy in children with attention deficit hyperactivity disorder (ADHD). Methods One hunadard eleven DSM-Ⅳ defined ADHD patients were enrolled for 6 weeks systemic MHP titration treatmnet. ADHD Rating Scale-Ⅳ Home Version (ADHD-RS-Ⅳ) were applied as index of clinical efficacy, and Continuous Performance Task (CPT) as index of cognition efficacy. Determining potential influential factors was analyzed on MPH efficacy including demographic,baseline clinical symptoms and cognitive factors. Results Sixty-five (59.1%) were defined as responders and 45 (40.9%) as non-reponders to MHP, respectively. CPT which were conducted in 87 patient showed that 35 (40.2%) were defined as responders on commission errors, 31 (35.6%) on omission errors and 10 (11.5%) on reaction time. Logistic analysis revealed two potential influential factors that predicted better clinical efficacy (P<0.05): better parental relationship (OR=3.516, 95% CI: 1.087~11.375) and baseline ADHD-RS-Ⅳ score above 35 points (OR=3.075, 95%CI: 1.131~8.359). Higher IQ score was the potential influential factor that predicted better commission errors efficacy (OR=1.085, 95%CI: 1.013~1.162) and omission errors efficacy (OR=1.078, 95%CI: 1.008~1.153). Conclusion MHP efficacy may result in better outcomes in children with ADHD who have higher baseline ADHD-RS-Ⅳ score, poorer baseline CPT result, younger onset age, higher IQ and better parental relationship.

AbstractObjectiveThis study aimed to compare the dose distribution and delivery to organs at risk between five‐ and seven‐beam intensity‐modulated radiotherapy (IMRT) and volumetric‐modulated arc radiotherapy (VMAT) for preoperative rectal cancer. The characteristics of the rectal cancer target were analyzed, and the outcomes of the different modalities were evaluated. This research could provide a reference for the selection of treatment modalities in rectal cancer radiotherapy.MethodsThree different treatment plans were used, namely five‐beam IMRT, seven‐beam IMRT, and VMAT, to compare the dose‐volume histograms, conformal index, homogeneity index, and dose delivery to organs at risk.ResultsIn terms of conformal index, the VMAT plan was the best, and the seven‐beam plan was better than the five‐beam plan (0.88 vs 0.91 vs 0.92). The homogeneity indexes were 1.08, 1.06, and 1.08, respectively. Fixed‐field IMRT was better than VMAT in terms of homogeneity index (P < 0.05). No significant differences in maximum dose within targets were found among the three treatment plans. As for organs at risk, such as the bowel and femoral head, VMAT increased V10 and V20, but showed lower values for high‐dose volumes, including V30, V40, and V50. The volumes in the low‐ and high‐dose regions were lower when comparing between the VMAT and fixed‐field plans for dose delivery to the bladder. The VMAT plan decreased the volume delivered to >30 Gy, and less than five‐ and seven‐beam plans (14%, 19%, 17%).ConclusionsFor patients undergoing radiotherapy, five‐beam IMRT, seven‐beam IMRT, and VMAT could meet the requirement of clinical treatment. However, the three modalities showed many differences. Apart from the position and volume of the target, other parameters such as the movement and the priority of organs at risk (OAR) are also important. These OARs include the bladder. VMAT could be used to reduce the high‐dose volume and injury of bone marrow such as radioactive bone marrow suppression. IMRT could reduce the probability of suffering from diarrhea and other complications.

中国早期电影对于歌舞片的想象,一方面来自好莱坞歌舞片的影响,一方面来自黎锦晖的儿童歌舞剧.如果说黎锦晖的明月社是为有声时代而做的准备,那么联华歌舞班的诞生就可看作顺势而为.联华歌舞班的歌舞演员用歌唱和舞蹈塑造着电影中的角色,使转型期的中国电影面貌焕然一新,新的电影类型应运而生.如李道新教授在其论文《作为类型的中国早期歌唱片》中指出:"在1930——1937年的中国有声电影初创期,是中国歌唱片的初步尝试阶段,歌唱电影可算作是中国早期电影的独特景观,但在这个时期因受好莱坞歌舞片的影响,我们的电影已具备了歌舞片类型特征.一方面,我们会利用歌星和舞星作为票房号召力;另一方面,我们将歌舞片作为叙事手段推动故事情节的发展.[1]文中还指出,"对于1930年是歌唱片的初步尝试阶段,这个时期是电影人跟音乐家共同努力的时代,所以出现了中国电影的第一次黄金时代."所以,这个时期的联华影业公司选择与音乐人黎锦晖的明月社联合,开启了中国电影的歌舞时代.

通过对13所医学院校研究生教育结构的深度访谈资料分析发现:在层次结构方面,医学院校对扩大博士研究生招生规模的诉求强烈;在专业结构方面,医学院校学位类型亟待健全,专业类型构成比例需要调整;在区域结构方面,中西部地区的学位构成情况有待完善.结合健康中国战略和医教协同等国家政策背景,提出可借鉴的经验成果,并从政府、学校、医院以及社会组织四个方面提出改革医学研究生教育的相关建议.

To compare and assess different detectors for the profile and output factor (OF) measurement for a Cyberknife system, and provide reference and suggestions for selecting and using the correct detectors. Profiles were acquired using the detectors of PTW-60017, PTW-60018, PTW-60019 and IBA-SFD, at different depths for different collimator sizes, with the detectors stem oriented both perpendicular and parallel to the central beam axis. The differences of profiles among different detectors and orientation of detectors were analyzed. Output factors were measured using PTW ionization chamber 30013, 31010, diode detector PTW 60017, PTW60018 and diamond detector 60019 for different fixed aperture collimators from 5 mm to 60 mm at SAD 800 mm and depth of water 50 mm. EBT3 film measured OF at 5 cm depth in a water phantom with a SAD of 800mm was used as reference for comparison. All full width at half maximum (FWHM) of field measured by four detectors in parallel orientation were larger than actual field size. The deviation increased with the size of collimator and measurement depth, with the maximal deviation of 0.6mm. The deviation of FWHM among four detectors increased with the increase of measurement depth, with the maximum deviation of 0.2mm. The penumbra was the smallest for IBA-SFD, and largest for PTW-60019. The maximal deviation of penumbra was 0.3mm. The IBA-SFD agreed with other detectors but tended to over-respond in the out-of-field region when the collimator size was larger than 30mm. Both FWHM and penumbra in perpendicular orientation were smaller than in parallel orientation for PTW-60017, PTW-60018 and PTW-60019, especially for the 5mm collimator. However, the trend was opposite for IBA-SFD. With the increase of collimator aperture, the difference between the right and left penumbra acquired by four detectors increased, with more obvious stem effects observed. A good agreement among the output factors obtained from these five detectors was found for the collimator size more than 30mm, with the deviations less than 1%. When the collimator size was less than 30mm, the deviations of the OF became large and obviously increased with the decrease of the collimator size. The measured OFs of PTW60019 were basically consistent with EBT3 film, with the deviation less than 2%. The OFs were higher for diodes detectors, and much smaller for Ionization chambers than EBT3 film. Similar profiles were acquired by PTW-60017, PTW-60018, PTW-60019 and IBA-SFD, but the detectors' characteristics and effects of detector orientations should be considered. PTW 30013, 31010, PTW 60017, PTW60018 and 60019 could be directly used for the OFs measurement, when field was greater than 30mm. But if the field was less than 30mm, the measurement results obtained by these detectors need to be corrected. Sensitive volume, the effective measure length and material density of detector affected the measurement of OFs, especially for small filed.

Objective:To study the association between set shifting in ADHD and NRXN1 gene.Methods:According to the diagnostic standard of the Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition (DSM-Ⅳ).Totally 756 Han Chinese ADHD children and 133 Han Chinese unaffected children were involved in the analysis.Set shifting,including number connection time (NOTIM),number connection error times (NOERR),number and letter alternant connection time (LETIM),number and letter altemant error times (LEERR),and shifting time(each value was the difference between LETIM and NOTIM),was recorded by trail making test (TMT).Two SNPs (Single Nucleotide Polymorphisms) of NRXN1 gene,rs1592728 and rs4971652,were chose to detect genotype using Sequenom Mass ARRAY system by real time quantitative polymerase chain reaction.Linear regression analysis was applied to explore the influence of set shifting,then,stratified analysis was used to study the association between set shifting and rs1592728 as well as rs4971652 in ADHD cases and controls separately.Results:Linear regression analysis showed that there was a negative correlation between set shifting and month (β =0.42,P ＜0.001),IQ (β =0.34,P ＜ 0.001),group (β =0.08,P =0.004),GG genotype of rs4971652 (β =0.06,P =0.039).Among ADHD children,there was a negative relationship between set shifting and month (β =0.46,P ＜0.001),IQ (β =0.32,P ＜ 0.001),GG genotype of rs4971652 (β =0.07,P =0.018),a positive association was found between set shifting and ADHDSUB (β =0.06,P =0.033),set shifting damaged higher with ADHD-Ⅰ children than ADHD-C children.While,in controls,set shifting was in inverse relation with month (β =0.25,P =0.002) and IQ (β =0.40,P ＜ 0.001).Conclusion:It suggests that the association between shift in ADHD children and polymorphism of NRXN1 gene is existed,set shifting deficit less seriously in GG genotype.

分析了我国高层次医学应用型人才培养的现状和存在的问题.介绍了北京大学在完善临床医学专业学位博士研究生培养体系,建立高层次全科医学应用型人才培养体系以及探索医学技术、公共卫生、药学专业高层次医学应用型人才的培养模式等方面的实践经验.认为在加强高层次医学应用型人才培养的进程中,应重视顶层设计,完善制度建设;重视权责明晰,完善管理模式;重视质量评价,完善评估机制.