Mixed venous to arterial CO 2 gap as a marker to identify fluid responsiveness in septic shock patients / 中华急诊医学杂志

Objective:To investigate the value of the venous-to-arterial CO 2 gap (Δ CO 2 gap) before and after the fluid challenge (FC) in determining the fluid responsivenessin septic shock patients. Methods:A total of 104 septic shock patients admitted to the Medical Intensive Care Unit (MICU) of Peking Union Medical College Hospital were included in the retrospective study. All patients were monitored by Swan Ganz floating catheter during the FC. Hemodynamics and blood gas indices were collected before FC (T0) and immediately (T1), 10 min (T2), 30 min (T3) and 60 min (T4) after FC. Responders were defined as patients with a > 10% increase in cardiac output (CO) after FC. Spearman correlation analysis was used to evaluate the correlation between CO 2 gap and CO. The value of ΔCO2 gap were calculated by the area under the receiver operating characteristic (AUROC) curve in the whole population. Results:Among 104 patients, the effective rates of FC at T1, T2, T3 and T4 were 59% (61/104), 72% (75/104), 73% (76/104), and 77% (80/104), respectively. CO of patients in the reactive group was lower than that in the non-reactive group at T2 [6.0 (4.7, 7.5) vs. 7.2 (6.4, 8.5) L/min, P=0.019], and there was no significant difference in CO 2 gap between the two groups before FC. Spearman correlation analysis showed that CO 2 gap was negatively correlated with CO, and the correlations between CO 2 content gap and CO was -0.34, and -0.33 of CO 2 pressure gap and CO, respectively (both P <0.05). ROC curve analysis showed that the ΔCO 2 gap at T1 could weakly judge the reactivity at T2, T3 and T4, but could not judge the reactivity at T1. The AUROC at T2 was 0.669 of ΔCO 2 content gap and 0.684 of ΔCO 2 pressure gap (both P <0.05). Conclusions:The evaluate time judging the effect of FC should be appropriately extended. The change value of CO 2 gap before and immediately after volume expansion in septic shock patients can judge the fluid responsiveness within 10 min after FC.

Transanal drainage tube for prevention of anastomotic leak after anterior resection for rectal cancer: a meta-analysis / 中华胃肠外科杂志

Objective: To assess the effectiveness of transanal drainage tube (TDT) in reducing the incidence of anastomotic leak following anterior resection in patients with rectal cancer. Methods: We conducted a systematic search for relevant studies published from inception to October 2022 across multiple databases, including PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang, and VIP. Meta-analysis was performed using Review Manager 5.4 software. The primary outcomes included total incidence of anastomotic leak, grade B and C anastomotic leak rates, reoperation rate, anastomotic bleeding rate, and overall complication rate. Results: Three randomized controlled trials involving 1115 patients (559 patients in the TDT group and 556 in the non-TDT group) were included. Meta-analysis showed that the total incidences of anastomotic leak and of grade B anastomotic leak were 5.5% (31/559) and 4.5% (25/559), respectively, in the TDT group and 7.9% (44/556) and 3.8% (21/556), respectively, in the non-TDT group. These differences are not statistically significant (P=0.120, P=0.560, respectively). Compared with the non-TDT group, the TDT group had a lower incidence of grade C anastomotic leak (1.6% [7/559] vs. 4.5% [25/556]) and reoperation rate (0.9% [5/559] vs. 4.3% [24/556]), but a higher incidence of anastomotic bleeding (8.2% [23/279] vs. 3.6% [10/276]). These differences were statistically significant (P=0.003, P=0.001, P=0.030, respectively). The overall complication rate was 26.5%(74/279) in the TDT group and 27.2% (75/276) in the non-TDT group. These differences are not statistically significant (P=0.860). Conclusions: TDT did not significantly reduce the total incidence of anastomotic leak but may have potential clinical benefits in preventing grade C anastomotic leak. Notably, placement of TDT may increase the anastomotic bleeding rate.

Visual and quantitative assessment of the effectiveness of non-vascularized bone grafting in osteonecrosis of the femoral head via CT-based radiomics and clinical data / 中国修复重建外科杂志

OBJECTIVE@#To investigate the value of CT-based radiomics and clinical data in predicting the efficacy of non-vascularized bone grafting (NVBG) in hip preservation, and to construct a visual, quantifiable, and effective method for decision-making of hip preservation.@*METHODS@#Between June 2009 and June 2019, 153 patients (182 hips) with osteonecrosis of the femoral head (ONFH) who underwent NVBG for hip preservation were included, and the training and testing sets were divided in a 7∶3 ratio to define hip preservation success or failure according to the 3-year postoperative follow-up. The radiomic features of the region of interest in the CT images were extracted, and the radiomics-scores were calculated by the linear weighting and coefficients of the radiomic features after dimensionality reduction. The clinical predictors were screened using univariate and multivariate Cox regression analysis. The radiomics model, clinical model, and clinical-radiomics (C-R) model were constructed respectively. Their predictive performance for the efficacy of hip preservation was compared in the training and testing sets, with evaluation indexes including area under the curve, C-Index, sensitivity, specificity, and calibration curve, etc. The best model was visualised using nomogram, and its clinical utility was assessed by decision curves.@*RESULTS@#At the 3-year postoperative follow-up, the cumulative survival rate of hip preservation was 70.33%. Continued exposure to risk factors postoperative and Japanese Investigation Committee (JIC) staging were clinical predictors of the efficacy of hip preservation, and 13 radiomic features derived from least absolute shrinkage and selection operator downscaling were used to calculate Rad-scores. The C-R model outperformed both the clinical and radiomics models in predicting the efficacy of hip preservation 1, 2, 3 years postoperative in both the training and testing sets ( P<0.05), with good agreement between the predicted and observed values. A nomogram constructed based on the C-R model showed that patients with lower Rad-scores, no further postoperative exposure to risk factors, and B or C1 types of JIC staging had a higher probability of femoral survival at 1, 2, 3 years postoperatively. The decision curve analysis showed that the C-R model had a higher total net benefit than both the clinical and radiomics models with a single predictor, and it could bring more net benefit to patients within a larger probability threshold.@*CONCLUSION@#The prediction model and nomogram constructed by CT-based radiomics combined with clinical data is a visual, quantifiable, and effective method for decision-making of hip preservation, which can predict the efficacy of NVBG before surgery and has a high value of clinical application.

Clinical outcomes of reverse shoulder arthroplasty for the treatment of failed fixation of proximal humeral fracrtures in the elderly patients / 中国骨伤

OBJECTIVE@#To evaluate the clinical outcomes of reverse total shoulder arthroplasty as a revision procedure for the failed fixation of proximal humeral fractures in the elderly patients.@*METHODS@#A retrospective analysis was performed on 8 patients with failed internal fixation of proximal humeral fractures from May 2014 to March 2020, including 3 males and 5 females, aged from 65 to 75 years old. All 8 patients underwent reverse total shoulder arthroplasty, and the mean time between initial fixation and reverse total shoulder arthroplasty ranged from 8 to 16 months. Range of motion(ROM), University of California at Los Angeles(UCLA) shoulder score, visual analogue scale (VAS), self-rating anxiety scale(SAS), and Constant-Murley score of shoulder function were assessed pre-operatively and at the last follow-up. Complications relating to the surgery were recorded.@*RESULTS@#All 8 patients successfully followed up. The mean follow-up after reverse total shoulder arhroplasty ranged from 16 to 28 months. The range of motion (forward flexion, external rotation, abduction and internal rotation) of the affected shoulder was significantly improved after surgery, and the post-operative VAS, SAS and UCLA scores were also significantly improved. For the Constant-Murley score of shoulder joint function, the total scores and the subscores of pain, daily activities, range of motion and strength test at the last follow-up were all significantly improved. Scapular glenoid notch was observed in patient, which was evaluated as grade 1 on imaging. All the other patients did not develop specific or non-specific complications.@*CONCLUSION@#Reverse total shoulder arhroplasty is an appropriate treatment as a revision surgery for failed fixation of proximal humeral fractures. It has shown satisfactory clinical outcomes, accelerating the rehabilitation of shoulder function and improving the quality of life.

Construction and evaluation of early prediction model for severe acute pancreatitis complicated with acute renal injury / 中华胰腺病杂志

Objective:To establish an early prediction Nomogram model for severe acute pancreatitis(SAP) complicated with acute renal injury (AKI), and evaluate the prediction efficiency of the model.Methods:The clinical data of 295 SAP patients hospitalized in Zhejiang Rongjun Hospital from July 2017 to June 2021 were retrospectively analyzed, and the patients were divided into AKI group ( n=61) and non-AKI group ( n=234) according to whether complicated with AKI. The common characters, clinical data and laboratory examination results were compared. The risk factors for SAP complicated with AKI was analyzed by multivariate logistic regression analysis, and a nomogram prediction model was established by R software. The receiver operating characteristic (ROC) curve was drawn and the area under the curve (AUC) was calculated to evaluate its prediction performance. Results:The acute physiology and chronic health assessment Ⅱ (APACHEⅡ) and Ranson score, the incidence of abdominal compartment syndrome (ACS) and systemic inflammatory response syndrome (SIRS), the cases of shock and mechanical ventilation, and the levels of blood lactic acid (BLA), blood creatinine (Scr), urea nitrogen (BUN), C-reactive protein (CRP), procalcitonin (PCT) and cystatin C(Cys C) in peripheral blood were significantly higher in AKI group than those in non-AKI group, while the levels of blood calcium were lower than those in non-AKI group, and the differences were statistically significant (all P value <0.05). Multivariate logistic regression analysis showed that APACHEⅡ score ( OR=1.185, 95% CI 1.074-1.308, P=0.001), Ranson score ( OR=12.668, 95% CI 5.102-31.456, P<0.001), Scr ( OR=1.028, 95% CI 1.002-1.054, P=0.034), PCT ( OR=4.298, 95% CI 1.379-13.395, P<0.001) and Cys C ( OR=38738.38, 95% CI 43.190-347459.41, P<0.001) were independent risk factors for SAP complicated AKI. Serum calcium ( OR=0.0001, 95% 0.000-0.048, P<0.001) was an independent protective factor for SAP complicated AKI. A Nomogram prediction model based on the six factors above were established, and its AUC, sensitivity and specificity to predict AKI were 0.987, 99.0% and 98.5% in the training set, and were 0.976, 98.6% and 94.2% in the validation set. Conclusions:This study successfully established an early prediction model with high predict value for SAP complicated with AKI, which can efficiently predict the risk of SAP with concurrent AKI.

Safety and efficacy of intra-arterial tirofiban infusion in patients with acute cardiogenic cerebral embolism undergoing endovascular reperfusion therapy / 中华内科杂志

Objective:To evaluate the safety and efficacy of intra-arterial tirofiban infusion during endovascular reperfusion therapy in patients with acute cardiogenic cerebral embolism.Methods:Clinical data of 72 patients with acute cardiogenic cerebral embolism caused by large artery occlusion were retrospectively analyzed in Department of Neurology, Strategic Support Force Medical Center from August 2015 to August 2020.Among those, 52 patients were treated with intra-arterial tirofiban, the other 20 patients were treated with control medication. The baseline characteristics, modified thrombolysis in cerebral infarction (mTICI) score of responsible vessels, modified Rankin scale (mRS) score 90 days after operation, incidence of symptomatic intracranial hemorrhage and mortality were evaluated and compared in two groups.Results:The proportion of effective recanalization of the offending vessels (mTICI≥2b) in tirofiban group was higher than that in control group (92.3% vs. 75.0%), but the difference was not statistically significant ( P=0.104). At 90 days after operation, the rate of patients with good prognosis (mRS≤2) in tirofiban group (61.5%) was significantly higher than that in control group (35.0%) ( P<0.05). The incidence of symptomatic intracranial hemorrhage and mortality were comparable between the two groups ( P>0.05). Conclusion:Intra-arterial tirofiban infusion in patients with acute cardiogenic cerebral embolism is effective and feasible, which improves the prognosis without increasing the risk of intracranial bleeding complications.

The clinical feature and treatment strategy of the transsyndesmotic ankle fracture dislocation / 中华骨科杂志

Objective:To explore the clinical features and treatment strategies of the transsyndesmotic ankle fracture dislocation.Methods:Data of 26 patients of transsyndesmotic ankle fracture dislocation who were treated in our hospital from December 2013 to November 2020 were retrospectively analyzed. There were 16 men and 10 women with an average age of 49.54±12.81 years (range, 26-68 years). Open injuries in 17 cases, of which the Gustilo-Anderson II type in 6 cases, IIIA type in 11 cases, closed injuries in 9 cases. According to the AO/OTA fracture classification, 44B type in 4 cases, 44C type in 22 cases. According to the Lauge-Hansen classification, there were 16 cases of pronation-abduction, 10 cases of pronation-external rotation, including 4 cases of Maisonneuve fractures, and of the 4 cases of Maisonneuve fractures, there were 3 cases of double Maisonneuve fracture. The talar dislocation was anterior, neutral, and posterior within the distal tibiofibular joint in 10 cases, 7 cases, and 9 cases. Fibular fractures in 26 cases, medial malleolar fractures in 24 cases, deltoid ligament rupture in 2 cases, posterior malleolar fractures in 13 cases, and anterior malleolar fractures in 8 cases. All closed injuries were closed reduction and plaster fixation and all open injuries were emergently debridement and reduced under the tibial plafond in the emergency department. Surgical treatment was taken until the soft tissue conditions to be allowed. The reduction quality was assessed by postoperative radiography according to the criteria proposed by Burwell-Charnley. The function of the ankle joint was assessed by the ankle-hindfoot rating system of the American Orthopaedic Foot and Ankle Society (AOFAS), and the posttraumatic arthritis and objectively quantified was assessed using the Kellgren-Lawrence grading scale.Results:There were 4 cases were unreduced due to the tibial posterior tendon to flip through the ankle joint and dislocate anterior to the tibia through the interosseous membrane. Stabilization of fibular fractures were achieved with plate in 25 cases. There were 24 cases of medial malleolar fractures, and the fixation were achieved with cannulated screws in 23 cases and with K-wire fixation in 1 case. There were 12 cases of posterior malleolar fractures treated with open reduction and internal fixation including cannulated screws in 9 cases and antiglide plates in 3 cases. There were 7 cases of anterior malleolar fractures treated with open reduction and internal fixation including suture anchors in 1 case and cannulated screws in 6 cases. Stabilization of syndesmosis was achieved with syndesmotic screws in 14 cases and with TightRope in 2 cases. All patients were followed up for 20.23±9.70 months (range, 12-60 months). According to the Burwell-Charnley criteria of reduction quality, anatomic reduction was obtained in 22 cases, and satisfactory reduction was gained in 4 cases. All fractures healed in 16.31±3.64 weeks (range, 10-24 weeks). Functional examination of the ankle joint (angle measurement method): dorsiflexion average angle 10.38°±6.66°, plantarflexion average angle 34.04°±7.20°. At latest follow up, the AOFAS score was 83.30±13.94 (range, 24-100). Ten (38%) of 26 patients had radiographic evidence of posttraumatic ankle arthritis. According to the Kellgren-Lawrence grading scale criteria, there were grade I in 5 cases, II in 2 cases, III in 2 cases, and IV in 1 case. 2 cases of wound dishence were recovered through changing dressing and 2 cases of skin necrosis were recovered by skin graft and flap transposition respectively. There were no significant complications such as infection, nonunion, or implant failure.Conclusion:The transsyndesmotic ankle fracture dislocation, represents an exceptional pattern of high-energy fractures with significant syndesmotic disruption, and potential soft tissue compromise. Careful attention to radiographic findings can identify unique fracture characteristics relative to operative decision-making. Tibialis posterior tendon dislocation, a rare complication in the transsyndesmotic ankle fracture dislocation injuries, can impede anatomical reduction of the ankle mortise. The open reduction and internal fixation may be an optimal approach to treat transsyndesmotic ankle fracture dislocation injuries. However, the rate of posttraumatic arthritis is relatively high.

Hemodynamic effects of different fluid volumes for a fluid challenge in septic shock patients / 中华医学杂志(英文版)

BACKGROUND@#It is still unclear what the minimal infusion volume is to effectively predict fluid responsiveness. This study was designed to explore the minimal infusion volume to effectively predict fluid responsiveness in septic shock patients. Hemodynamic effects of fluid administration on arterial load were observed and added values of effective arterial elastance (Ea) in fluid resuscitation were assessed.@*METHODS@#Intensive care unit septic shock patients with indwelling pulmonary artery catheter (PAC) received five sequential intravenous boluses of 100 mL 4% gelatin. Cardiac output (CO) was measured with PAC before and after each bolus. Fluid responsiveness was defined as an increase in CO >10% after 500 mL fluid infusion.@*RESULTS@#Forty-seven patients were included and 35 (74.5%) patients were fluid responders. CO increasing >5.2% after a 200 mL fluid challenge (FC) provided an improved detection of fluid responsiveness, with a specificity of 80.0% and a sensitivity of 91.7%. The area under the ROC curve (AUC) was 0.93 (95% CI: 0.84-1.00, P  < 0.001). Fluid administration induced a decrease in Ea from 2.23 (1.46-2.78) mmHg/mL to 1.83 (1.34-2.44) mmHg/mL (P = 0.002), especially for fluid responders in whom arterial pressure did not increase. Notably, the baseline Ea was able to detect the fluid responsiveness with an AUC of 0.74 (95% CI: 0.59-0.86, P < 0.001), whereas Ea failed to predict the pressure response to FC with an AUC of 0.50 (95% CI: 0.33-0.67, P = 0.086).@*CONCLUSION@#In septic shock patients, a minimal volume of 200 mL 4% gelatin could reliably detect fluid responders. Fluid administration reduced Ea even when CO increased. The loss of arterial load might be the reason for patients who increased their CO without pressure responsiveness. Moreover, a high level of Ea before FC was able to predict fluid responsiveness rather than to detect the pressure responsiveness.@*TRIAL REGISTRATION@#ClinicalTrials.gov, NCT04515511.

A multicenter prospective cohort study of Xuebijing injection in the treatment of severe coronavirus disease 2019 / 中华危重病急救医学

Objective:To evaluate the effect of Xuebijing injection on the improvement of pneumonia severity index (PSI) and prognosis in patients with severe coronavirus disease 2019 (COVID-19).Methods:A multicenter prospective cohort study was designed. Adult patients with COVID-19 admitted to the intensive care unit (ICU) of 28 designated COVID-19 hospitals in 15 provinces and cities of China from January to March 2020 were enrolled. All patients were treated according to the standard treatment plan of COVID-19 issued by the National Health Commission of the People's Republic of China. They were divided into Xuebijing group and standard treatment group according to whether they received Xuebijing injection or not. In the standard treatment group, routine medical care measures such as antiviral, respiratory support, circulatory support and symptomatic treatment were taken. In the Xuebijing group, on the basis of standard treatment, Xuebijing was used within 12 hours of admission to the ICU, 100 mL each time, twice daily. The minimum duration of Xuebijing administration was 1 day. The improvement rate of PSI risk rating on the 8th day and clinical outcome on the 28th day were recorded.Results:A total of 276 COVID-19 patients were screened continuously, and the data of 144 severe patients who met PSI risk rating Ⅲ-Ⅴ were analyzed. Seventy-two cases were involved each in standard treatment group and Xuebijing group. The average age of the standard treatment group and Xuebijing group were (65.7±7.9) years old and (63.5±10.9) years old, and male accounted for 75.0% (54/72) and 70.8% (51/72), respectively. There were no significant differences in general conditions, comorbidities, PSI risk rating and score, sequential organ failure assessment (SOFA) score, oxygenation index (PaO 2/FiO 2), respiratory support mode and other baseline indicators between the two groups. Compared with the standard treatment group, the improvement rate of PSI risk rating in Xuebijing group on the 8th day after admission was significantly improved [56.9% (41/72) vs. 20.8% (15/72), between-group difference and 95% confidence interval (95% CI) was 36.1% (21.3% to 50.9%), P < 0.01], PSI score, SOFA score and PaO 2/FiO 2 were significantly improved [PSI score: 83.7±34.8 vs. 108.2±25.6, between-group difference (95% CI) was -24.5 (-34.9 to -14.1); SOFA score: 2.0 (1.0, 4.0) vs. 7.0 (4.0, 10.0), between-group difference (95% CI) was -3.5 (-5.0 to -2.0); PaO 2/FiO 2 (mmHg, 1 mmHg = 0.133 kPa): 289.4±111.6 vs. 188.5±98.1, between-group difference (95% CI) was 100.9 (65.3 to 136.5); all P < 0.01]. The 28-day discharge rate of Xuebijing group was 44.5% higher than that of standard treatment group [66.7% (48/72) vs. 22.2% (16/72), P < 0.01], and the 28-day survival rate was 9.8% [91.7% (66/72) vs. 81.9% (59/72), P < 0.01]. There was no significant difference in the combination of antiviral drugs, antibiotics, anticoagulants and vasopressor drugs between the two groups. There was no significant difference in the incidence of adverse events between the Xuebijing group and standard treatment group [41.7% (30/72) vs. 43.1% (31/72), P > 0.05], and no serious adverse events and adverse reactions of Xuebijing were reported. Conclusion:Standard treatment combined with Xuebijing injection can significantly improve the PSI risk score and clinical prognosis of patients with severe COVID-19 without increasing drug safety risk.

Effect of high-flow nasal cannula oxygen on patients with chronic obstructive pulmonary disease and mild hypercapnia: a retrospective cohort study based on the Medical Information Mart for Intensive Care-Ⅳ database / 中华危重病急救医学

Objective:To observe the effect of high-flow nasal cannula oxygen therapy (HFNC) in patients with chronic obstructive pulmonary disease (COPD) and mild hypercapnia, and to evaluate the early predictive ability of physiological parameters in these patients.Methods:A retrospective cohort study was conducted based on Medical Information Mart for Intensive Care-Ⅳ (MIMIC-Ⅳ) updated in September 2020 and the data of adult patients with COPD and mild hypercapnia [45 mmHg (1 mmHg = 0.133 kPa) < arterial partial pressure of carbon dioxide (PaCO 2)≤ 60 mmHg] from 2008 to 2019 were collected. These patients were assigned to the HFNC group or non-invasive ventilation (NIV) group according to whether they received HFNC or NIV. Baseline data such as gender, age, body mass index (BMI), simplified acute physiology scoreⅡ (SAPSⅡ), Charlson comorbidity index (CCI) and physiological parameters were collected. A propensity score matching was conducted according to the baseline data of the HFNC group patients. The 48-hour and 28-day intubation rates, 28-day mortality, length of intensive care unit (ICU) stay, the length of hospital stay, and the changes in physiological parameters within 48 hours after treatment were compared between the two groups. The receiver operating characteristic curve (ROC curve) was drawn and the ratio of heart rate over pulse oxygen saturation (HR/SpO 2) and ROX index [SpO 2 / (inhaled oxygen concentration, FiO 2×respiratory rate, RR)] were analyzed to predict the 24-hour and 48-hour intubation rates. Results:A total of 524 520 inpatient records were screened and 153 patients were included, while 37 patients in the HFNC group and 116 patients in NIV group. There were 31 patients in the HFNC group and 84 patients in the NIV group remained after propensity score matching according to the baseline data. There were no significant differences in the baseline data of gender, age, BMI, SAPSⅡ, CCI score, physiological parameters and prognosis data except the length of ICU stay. The length of ICU stay in HFNC group was significant longer than that of the NIV group [days: 4.6 (3.1, 10.0) vs. 3.1 (1.6, 5.8), P < 0.05]. HR and RR at 40- 48 hours were significantly lower than those at 0-8 hours after treatment only in the HFNC group [HR (bpm): 84.1±12.2 vs. 91.1±16.4, RR (times/min): 19.8±4.9 vs. 21.6±4.1, both P < 0.05]. Both in the HFNC group and NIV group the pH increased (7.42±0.08 vs. 7.36±0.05 and 7.41±0.06 vs. 7.36±0.05, both P < 0.05) and PaCO 2 decreased significantly [mmHg: 46.3 (39.5, 51.0) vs. 49.8 (45.5, 54.0) and 46.0 (40.5, 51.5) vs. 49.5 (45.5, 55.3), both P < 0.05]. The HR, PaO 2 were higher in the HFNC group than those in the HFNC group at 40-48 hours after treatment [HR (bpm): 91.1±15.4 vs. 84.1±12.2, PaO 2 (mmHg): 99.5 (86.0, 132.3) vs. 85.8 (76.5, 118.0), both P < 0.05], PaO 2/FiO 2 were lower in the HFNC group than that in the HFNC group at 40-48 hours after treatment [mmHg: 223.8 (216.5, 285.0) vs. 278.0 (212.3, 306.0), P < 0.05]. Both HR/SpO 2 and ROX index at 4 hours after treatment had predictive value for 24-hour and 48-hour intubation in the HFNC group. The areas under ROC curve (AUC) of HR/SpO 2 at 4 hours after treatment in the HFNC group were larger than those of ROX index for predicting 24-hour and 48-hour intubation (24-hour: 0.649 vs. 0.574, 48-hour: 0.692 vs. 0.581, both P < 0.01); the 95% confidence interval (95% CI) of 4 hours HR/SpO 2 and for ROX index predicting 24 hours and 48 hours intubation were 0.497-0.780, 0.567-0.799, 0.450-0.694 and 0.454-0.716, respectively. The high sensitivity of HR/SpO 2 and ROX index in predicting 24-hour and 48-hour intubation were 84.6%, 92.9%, 88.2% and 94.4%, respectively, and the low specificity were 52.3%, 23.7%, 54.7% and 29.6%, respectively. Conclusions:HFNC can be used in COPD patients with mild hypercapnia, but it cannot replace NIV. The accuracy of ROX index at 4 hours after HFNC treatment in predicting intubation in COPD patients with mild hypercapnia is poor.

Epidemiological analysis of jellyfish stings in coastal bathing beaches in Qinhuangdao City from 2017 to 2019 / 中华危重病急救医学

Objective:To analyze the distribution and composition characteristics of jellyfish stings in various coastal baths in Qinhuangdao City from 2017 to 2019, and to provide scientific basis for the prevention, control and early warning of jellyfish stings.Methods:Statistics and analysis of the age, gender, time of stings, location of injury, first symptoms, and playing time in the sea at the time of the sting, etc. of people with jellyfish stings in various bathing beaches along the coast of Qinhuangdao from 2017 to 2019 (July to August) were conducted.Results:The number of jellyfish stings in the coastal bathing beaches of Qinhuangdao City in 2017, 2018, and 2019 was decreasing year by year, with 1 890, 492, and 171 cases respectively. Among them, Qianshuiwan Bathing Beach and Dongshan Bathing Beach had more stings (60.90% and 35.08% respectively in 2017, 24.39% and 64.23% respectively in 2018, 16.96% and 16.42% respectively in 2019). There was no significant change in the gender and age distribution of jellyfish stings each year [57.99% males in 2017, with a median age of 13 (8, 31) years old; 63.21% males in 2018, with a median age of 25 (8, 29) years old; and 59.65% males in 2019, with a median age of 12 (7, 31) years old]. Stings were mainly located at the lower limbs (the proportion of lower limb injuries: 46.54% in 2018, 45.61% in 2019), followed by upper limbs (upper arm, elbow, forearm), trunk, etc. The first symptom was mainly pain (89.43% in 2018, 38.29% in 2019), followed by rash (64.43% in 2018, 59.43% in 2019), numbness, blisters, etc. Sting incidents mainly occurred from 13:00 to 17:59 (the proportion of sting incidents in this time period in 2018 and 2019 were 68.09% and 52.63%, respectively).Conclusions:Jellyfish stings in coastal baths in Qinhuangdao City are mainly distributed in Qianshuiwan Baths and Dongshan Baths. The management of these sea areas should be strengthened, and scientific publicity and medical rescue should be strengthened to prevent jellyfish stings in peak hours and related baths.

Early predictors of high flow oxygen treatment failure for post-operation patients with hypoxemia / 中华急诊医学杂志

Objective:To explore the early predictors of high flow oxygen treatment failure for post-operation patients with hypoxemia.Methods:The post-operation adult patients with hypoxemia (100 mmHg<PaO 2/FiO 2≤300 mmHg) received high flow nasal cannula (HFNC) oxygen were retrospectively screened in the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The patients were assigned to the treatment success or failure group according to whether receiving reintubation with 48 h after extubation. The risk factors of 48-h reintubation were screened and analyzed by extreme gradient boosting (XGBoost) algorithm. And the predictors were formulated according to the risk factors. The changes of predictors were collected from extubation to 48 h later. The predictors were compared at different time points after extubation between patients weaning successfully and failed with t test. The values at different time after extubation were also compared to the baseline data. The areas under the receiver operating characteristic (ROC) curve were calculated for 48-h reintubation prediction according to values at 4 h before and after extubation, which were compared with those of rapid shallow breathing index (RSBI) and ROX index. The RSBI was defined as the ratio of respiratory rate to tidal volume. The ROX index was defined as the ratio of SpO 2/FiO 2 to respiratory rate. Results:A total of 524 520 medical records were screened and 318 patients were included. There were 38 patients (11.95%) received reintubation within 48 h. According to the XGBoost model, the important features of 48-h reintubation were the duration before extubation, body mass index, simplified acute physiology scoring II, heart rate (HR), PaO 2, mean blood pressure, tidal volume, age, SpO 2 and respiratory rate. Thus HR/PaO 2 and HR/SpO 2 were formulated as predictors for 48-h reintubation according to the above features. The areas under the ROC of HR/PaO 2 and HR/SpO 2 were 0.640 and 0.617 for 48-h reintubation prediction according values at 4 h before extubation, which were larger than those of RSBI (0.537) and ROX index (0.539). According values at 4 h after extubation, the area under the ROC of HR/SpO 2 was 0.657, which was larger than that of ROX index (0.587). When the HR/SpO 2 reached 1.2 at 4 h after extubation, the specificity for 48-h reintubation was 92%. There was significant difference of HR/SpO 2 at 4 h after extubation between patients weaning successfully and failed (1.02 vs 0.92, P<0.05), and no significant difference of ROX index at the same time (8.14 vs 9.27, P>0.05). There were significant differences of HR/SpO 2 and ROX index at 8 to 12 h after extubation between the two groups (both P<0.05). Conclusions:HR/SpO 2 is more early and accurate in predicting HFNC failure than ROX index for post-operation patients with hypoxemia. However, both the predictors should be further evaluated.

Cancer incidence and mortality in Zhejiang Province, Southeast China, 2016: a population-based study / 中华医学杂志(英文版)

BACKGROUNDS@#Cancer is one of the main causes of death worldwide, seriously threatening human health and life expectancy. We aimed to analyze the cancer incidence and mortality rates during 2016 in Zhejiang Province, Southeast China.@*METHODS@#Data were collected from 14 population-based cancer registries across Zhejiang Province of China. Cancer incidence and mortality rates stratified by sex and region were analyzed. The crude rate, age-standardized rate, age-specific and region-specific rate, and cumulative rate were calculated. The proportions of 10 common cancers in different groups and the incidence and mortality rates of the top five cancers in different age groups were also calculated. The Chinese national census of 2000 and the world Segi population was used for calculating the age-standardized incidence and mortality rates.@*RESULTS@#The 14 cancer registries covered a population of 14,250,844 individuals, accounting for 29.13% of the population of Zhejiang Province. The total reported cancer cases and deaths were 55,835 and 27,013, respectively. The proportion of morphological verification (MV%) was 78.95% of the population, and percentage of incident cases identified through death certificates only (DCO%) was 1.23% with a mortality-to-incidence ratio (M/I ratio) of 0.48. The crude incidence rate in Zhejiang cancer registration areas was 391.80/105; the age-standardized incidence rate of the Chinese standard population (ASIRC) and the age-standardized incidence rate of the world standard population (ASIRW) were 229.76/105 and 220.96/105, respectively. The incidence rate in men was higher than that in women. The incidence rate increased rapidly after 45 years of age and peaked in individuals aged 80 to 84 years. The top 10 incidence rates of cancers were lung cancer, female breast cancer, thyroid cancer, colorectal cancer, stomach cancer, liver cancer, prostate cancer, cervical cancer, esophageal cancer, and pancreatic cancer (from highest to lowest). The crude mortality rate in Zhejiang cancer registration areas was 189.55/105; the age-standardized mortality rate of the Chinese standard population (ASMRC) and the age-standardized mortality rate of the world standard population (ASMRW) were 94.46/105 and 93.42/105, respectively. The mortality rate in men was higher than that in women, and the male population in rural areas was higher than that in urban areas. The cancer mortality rate increased rapidly after 50 years of age and peaked in individuals aged 85+ years. The top 10 mortality rates of cancers were lung cancer, liver cancer, stomach cancer, colorectal cancer, pancreatic cancer, esophageal cancer, female breast cancer, prostate cancer, lymphoma, and leukemia (from highest to lowest).@*CONCLUSIONS@#Lung cancer, female breast cancer, thyroid cancer, colorectal cancer, prostate cancer, liver cancer, and stomach cancer were the most common cancers in Zhejiang Province. Effective prevention and control measures should be established after considering the different characteristics of cancers in urban and rural areas.

Effective arterial elastance in evaluating the fluid challenge in septic shock patients / 中华危重病急救医学

Objective:To explore the validity of the effective arterial elastance (Ea) before and after fluid challenge in evaluating the fluid challenge in septic shock patients.Methods:A retrospective study was conducted in the medical intensive care unit (MICU) of Peking Union Medical College Hospital from October 2016 to October 2020. 116 septic shock patients were enrolled. All patients received fluid challenge by 500 mL Gelatin or normal saline under invasive hemodynamic monitoring. Heart rate (HR), mean arterial pressure (MAP), cardiac output (CO) and other hemodynamic variables were collected at 10 minutes before and immediately after fluid challenge. An increase in CO greater than 10% after fluid challenge was defined as the positive preload responsiveness, as well as the definition of positive pressure responsiveness was an increase in MAP greater than 10%. Receiver operating characteristic curves (ROC curves) were established to evaluate the predictive abilities of baseline Ea and other arterial load indices in detecting the preload responders and pressure responders. The correlation of the baseline Ea with CO changes after fluid challenge as well as MAP changes were tested by Pearson correlation analysis. Patients with positive preload responsiveness were divided into two groups according to the pressure responsiveness. The changes in Ea and other arterial load indices were analyzed.Results:A total of 116 patients were finally analyzed. Sixty-three patients were preload responders and 53 patients were preload non-responders. There was no significant difference in demographics and baseline physical variables between the two groups. Ea in preload responders was higher than that in preload non-responders (mmHg/mL: 2.51±1.08 vs. 1.87±0.68, P < 0.01). ROC curve analysis showed that the baseline Ea could predict the preload responsiveness at an area under ROC curve (AUC) = 0.71 [95% confidence interval (95% CI) was 0.62-0.81, P < 0.001]. The cut-off value was 1.97 mmHg/mL with a sensitivity of 71.4% and a specificity of 60.4%. The baseline Ea did not present the predictive ability to detect the pressure responders and pressure non-responders (AUC = 0.52, 95% CI was 0.41-0.63, P = 0.73). Pearson correlation analysis showed that the changes in CO after fluid challenge was moderately correlated to the baseline Ea ( r = 0.47, P < 0.001), meanwhile a weak positive correlation between the changes in MAP and baseline Ea was found ( r = 0.20, P = 0.03). In preload responders, 27 (42.9%) of 63 patients were pressure responders and 36 (57.1%) patients were pressure non-responders. No statistical difference was found in the baseline Ea or other arterial load indices between the two groups. Fluid challenge decreased Ea both in pressure non-responders and pressure responders (mmHg/mL: 2.13±0.94 vs. 2.51±1.08, P < 0.01; 2.47±1.18 vs. 2.69±1.30, P < 0.05). Moreover, the changes in CO and changes in MAP were strongly correlated with the changes in Ea ( r values were -0.50 and 0.58, respectively, both P < 0.001). Conclusions:The Ea > 1.97 mmHg/mL before fluid challenge could predict fluid responsiveness in septic shock patients. The baseline Ea was not able to predict the subsequent changes in arterial pressure through fluid challenge. A significant decrease in Ea inducing by fluid administration explained why patients increased their CO without improving blood pressure.

Notoginsenoside R1 attenuates breast cancer progression by targeting CCND2 and YBX3 / 中华医学杂志(英文版)

BACKGROUND@#Breast cancer (BC) is a common malignancy with highly female incidence. So far the function of notoginsenoside R1 (NGR1), the extract from Panax notoginseng, has not been clearly elucidated in BC.@*METHODS@#Optimal culture concentration and time of NGR1 were investigated by cell counting kit-8 assay. Cell proliferation ability was measured by colony formation assays. Transwell assay was used to detect the effect of NGR1 on cell migration and invasion. The apoptosis rate of cells between each group was measured by TUNEL assay.@*RESULTS@#NGR1 treatment has an inhibitory effect on proliferation, migration, invasion, and angiogenesis and a stimulating effect on cell cycle arrest and apoptosis of Michigan Cancer Foundation-7 (MCF-7) cells. The 50% growth inhibitory concentration for MCF-7 cells at 24 h was 148.9 mmol/L. The proportions of MCF-7 cells arrested in the G0/G1 phase were 36.94±6.78%, 45.06±5.60%, and 59.46±5.60% in the control group, 75, and 150 mmol/L groups, respectively. Furthermore, we revealed that NGR1 treatment attenuates BC progression by targeted downregulating CCND2 and YBX3 genes. Additionally, YBX3 activates phosphatidylinositol 3-phosphate kinase (PI3K)/protein kinase B (Akt) signaling pathway by activating kirsten rat sarcoma viral oncogene, which is an activator of the PI3K/Akt signaling pathway.@*CONCLUSION@#These results suggest that NGR1 can act as an efficacious drug candidate that targets the YBX3/PI3K/Akt axis in patients with BC.

Exploration on the therapeutic mechanisms and safety of blood components of convalescents without erythrocytes on severe acute respiratory syndrome and coronavirus disease 2019 / 中华危重病急救医学

Coronavirus disease 2019 (COVID-19) is sweeping the world with strong infectivity and high mortality, but by now, we still lack specific treatment. The leading cause of death from COVID-19 is failure to eliminate those viruses effectively. Cellular immunity plays a crucial role in the body's elimination of coronavirus, so it is necessary to study cellular immunity on the basis of plasma therapy. Blood components of convalescents without erythrocytes contains all the components of cellular immunity and humoral immunity in blood. Current studies had shown that all neutrophils, specific antibodies, interferons, platelets, specific effect cells and memory cells, play irreplaceable roles in the immune process of eradicating coronavirus. This article summarizes the infusion safety, therapeutic mechanism of all above components, and their effects on immunologic derangement and excessive inflammatory response, in order to provide an alternative reference for the treatment of COVID-19.

Stratified outcomes of "Kidney Disease: Improving Global Outcomes" serum creatinine criteria in critical ill patients: a secondary analysis of a multicenter prospective study / 中华危重病急救医学

Objective:To investigate the different outcomes of two types of acute kidney injury (AKI) according to standard of Kidney Disease: Improving Global Outcomes-AKI (KDIGO-AKI), and to analyze the risk factors that affect the prognosis of intensive care unit (ICU) patients in China.Methods:A secondary analysis was performed on the database of a previous study conducted by China Critical Care Clinical Trial Group (CCCCTG), which was a multicenter prospective study involving 3 063 patients in 22 tertiary ICUs in 19 provinces and autonomous regions of China. The demographic data, scores reflecting severity of illness, laboratory findings, intervention during ICU stay were extracted. All patients were divided into pure AKI (PAKI) and acute on chronic kidney disease (AoCKD). PAKI was defined as meeting the serum creatinine (SCr) standard of KDIGO-AKI (KDIGO-AKI SCr) and the estimated glomerular filtration rate (eGFR) at baseline was ≥ 60 mL·min -1·1.73 m -2, and AoCKD was defined as meeting the KDIGO-AKI SCr standard and baseline eGFR was 15-59 mL·min -1·1.73 m -2. All-cause mortality in ICU within 28 days was the primary outcome, while the length of ICU stay and renal replacement therapy (RRT) were the secondary outcome. The differences in baseline data and outcomes between the two groups were compared. The cumulative survival rate of ICU within 28 days was analyzed by Kaplan-Meier survival curve, and the risk factors of ICU death within 28 days were screened by Cox multivariate analysis. Results:Of the 3 063 patients, 1 042 were enrolled, 345 with AKI, 697 without AKI. The AKI incidence was 33.11%, while ICU mortality within 28 days of AKI patients was 13.91% (48/345). Compared with PAKI patients ( n = 322), AoCKD patients ( n = 23) were older [years old: 74 (59, 77) vs. 58 (41, 72)] and more critical when entering ICU [acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) score: 23 (19, 27) vs. 15 (11, 22)], had worse basic renal function [eGFR (mL·min -1·1.73 m -2): 49 (38, 54) vs. 115 (94, 136)], more basic complications [Charlson comorbidity index (CCI): 3 (2, 4) vs. 0 (0, 1)] and higher SCr during ICU stay [peak SCr for diagnosis of AKI (μmol/L): 412 (280, 515) vs. 176 (124, 340), all P < 0.01]. The mortality and RRT incidence within 28 days in ICU of AoCKD patients were significantly higher than those of PAKI patients [39.13% (9/23) vs. 12.11% (39/322), 26.09% (6/23) vs. 4.04% (13/322), both P < 0.01], while no significant difference was found in the length of ICU stay. Kaplan-Meier survival curve analysis showed that the 28-day cumulative survival rate in ICU in AoCKD patients was significantly lower than PAKI patients (Log-Rank: χ2 = 5.939, P = 0.015). Multivariate Cox regression analysis showed that admission to ICU due to respiratory failure [hazard ratio ( HR) = 4.458, 95% confidence interval (95% CI) was 1.141-17.413, P = 0.032], vasoactive agents treatment in ICU ( HR = 5.181, 95% CI was 2.033-13.199, P = 0.001), and AoCKD ( HR = 5.377, 95% CI was 1.303-22.186, P = 0.020) were independent risk factors for ICU death within 28 days. Conclusion:Further detailed classification (PAKI, AoCKD) based on KDIGO-AKI SCr standard combined with eGFR is related to ICU mortality in critical patients within 28 days.

Application of the rain classroom mobile-learning platforms aided for the teaching of pathology / 中华医学教育探索杂志

Rain classroom provides a convenient and fast learning platform for mobile learning and instant interactive teaching. On the basis of the accumulated resources in the previous, the Department of Pathology in Jinan University utilizes the rain classroom platform as teaching aid, improves the platform construction of curriculum resources and the function of resource release, constructs the interactive teaching mode without time and space constraints, creates a whole process and diversified learning evaluation system, and carries out reforms from the aspects of teaching resources construction, teaching interaction, learning process supervision and teaching evaluation, so as to give full play to the mobile teaching and interactive teaching functions of rain classroom, which is conducive to improving the informationization level of pathology teaching.

Predictive value of serum microRNA-155-5p on prognosis in sepsis patients with acute liver injury / 中国医师进修杂志

Objective:To explore the predictive value of serum microRNA (miR)-155-5p on prognosis in sepsis patients with acute liver injury.Methods:The clinical data of 103 sepsis patients with acute liver injury from March 2017 to March 2019 in Rongjun Hospital, Zhejiang Province, were retrospectively analyzed. Among them, 57 patients were improved (survival group) and 46 patients died in hospital (death group). The clinical data and serum miR-155-5p were compared between 2 groups, and the influencing factors of prognosis in sepsis patients with acute liver injury were analyzed. The receiver operating characteristic (ROC) curve was used to evaluate the prognosis value of miR-155-5p.Results:The incidence of septic shock, age, procalcitonin (PCT), C-reactive protein (CRP), D-dimer, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ), sequential organ failure score (SOFA) and miR-155-5p in death group were significantly higher than those in survival group: 95.65% (44/46) vs. 45.61% (26/57), (50.82 ± 10.52) years vs. (43.84 ± 7.32) years, (16.42 ± 4.97) μg/L vs. (7.20 ± 2.19) μg/L, (23.21 ± 8.59) mg/L vs. (16.73 ± 5.04) mg/L, (10.84 ± 3.17) mg/L vs. (4.16 ± 2.15) mg/L, (22.37 ± 3.16) scores vs. (16.72 ± 4.10) scores, (10.98 ± 3.74) scores vs. (6.84 ± 2.47) scores and 3.10 ± 0.97 vs. 2.25 ± 0.63, and there were statistical differences ( P<0.05). Multivariate Logistic regression analysis result showed that the APACHE Ⅱ, SOFA, PCT and miR-155-5p were the independent risk factors of prognosis in sepsis patients with acute liver injury ( OR=3.173, 2.732, 2.553 and 2.153; 95% CI 2.127 to 6.312, 2.018 to 6.056, 1.249 to 4.466 and 1.234 to 4.153; P<0.01 or <0.05). ROC curve analysis result showed that the cut-off value of miR-155-5p was 2.89, and the area under curve was 0.871 (95% CI 0.782 to 0.951), with a sensitivity of 86.1% and a specificity of 80.4%. Conclusions:Serum miR-155-5p is closely related to the clinical prognosis in sepsis patients with acute liver injury. It can be used as one of the potential prognostic indicators for patients, and is worthy of further clinical study and analysis.

The early diagnosis and therapy of septic shock caused by soft tissue infection / 中华急诊医学杂志

Objective To assess the prognostic accuracy of the quick Sequential Organ Failure Assessment (qSOFA) score for septic shock of adults with soft tissue infections.The clinical characteristics of these patients were analyzed to provide reference for their multidisciplinary treatment.Methods A retrospective study was conducted.The patients with soft tissue infections admitted to the General Surgery Department of Beijing Hospital and the Burn and Plastic Surgery Department of Fourth Medical Center of PLA General Hospital from January 2012 to December 2018 were enrolled and patients combined with other infections were excluded.Patients were divided into the septic shock group and the non-septic group according to whether septic shock occurred during hospitalization.The baseline data,non-operative management and prognosis were compared between the two groups with Fisher's exact test.The sensitivity,specificity,positive predictive value,negative predictive value and the area under the receiver operating characteristic curve (AUC) of the qSOFA for diagnosis of sepsis and septic shock were calculated.Patients were also divided into four groups according to the etiology of soft tissue infection.The pathogens,surgical treatment and morbidity of septic shock among the four groups were also compared.Results A total of 192 patients were enrolled,including 28 (14.6％) patients with septic shock.Compared with the non-septic shock group,there were more proportion of patients with qSOFA ≥ 2 (60.7％ vs 18.3％,P=0.001) within 24 h of diagnosis of infection,and higher morbidity of sepsis (82.1％ vs 32.9％,P＜0.01)within 48 h of diagnosis of infection in the septic shock group.At the cut-off value of qSOFA ≥ 2,the sensitivity,specificity,positive predictive value,negative predictive value and the AUC were 60.7％,81.7％,36.2％,92.4％ and 0.767 (95％CI:0.665-0.869,P＜0.01) respectively for diagnosis of septic shock.The morbidity of septic shock (36.4％) and 28-day mortality (13.6％) in patients with necrotizing fasciitis were higher than those in patients with other causes (both P＜0.05).The most common pathogens were methicillin-sensitive Staphylococcus (6.8％),methicillin-resistant Staphylococcus (6.2％),Enterobacter (5.7％) and Enterococcus (5.2％).Conclusions qSOFA ≥ 2 can be used as a rapid septic shock screening tool for adults with soft tissue infection.Early diagnosis of sepsis,thorough debridement and effective antibiotic treatment are essential for these patients.