Current progress of source control in the management of intra-abdominal infections / 中华创伤杂志(英文版)

Intra-abdominal infection (IAI) is a deadly condition in which the outcome is associated with urgent diagnosis, assessment and management, including fluid resuscitation, antibiotic administration while obtaining further laboratory results, attaining precise measurements of hemodynamic status, and pursuing source control. This last item makes abdominal sepsis a unique treatment challenge. Delayed or inadequate source control is an independent predictor of poor outcomes and recognizing source control failure is often difficult or impossible. Further complicating issue in the debate is surrounding the timing, adequacy, and procedures of source control. This review evaluated and summarized the current approach and challenges in IAI management, which are the future research directions.

Chinese Trauma Surgeon Association for management guidelines of vacuum sealing drainage application in abdominal surgeries-Update and systematic review / 中华创伤杂志(英文版)

Vacuum sealing drainage (VSD) is frequently used in abdominal surgeries. However, relevant guidelines are rare. Chinese Trauma Surgeon Association organized a committee composed of 28 experts across China in July 2017, aiming to provide an evidence-based recommendation for the application of VSD in abdominal surgeries. Eleven questions regarding the use of VSD in abdominal surgeries were addressed: (1) which type of materials should be respectively chosen for the intraperitoneal cavity, retroperitoneal cavity and superficial incisions? (2) Can VSD be preventively used for a high-risk abdominal incision with primary suture? (3) Can VSD be used in severely contaminated/infected abdominal surgical sites? (4) Can VSD be used for temporary abdominal cavity closure under some special conditions such as severe abdominal trauma, infection, liver transplantation and intra-abdominal volume increment in abdominal compartment syndrome? (5) Can VSD be used in abdominal organ inflammation, injury, or postoperative drainage? (6) Can VSD be used in the treatment of intestinal fistula and pancreatic fistula? (7) Can VSD be used in the treatment of intra-abdominal and extra-peritoneal abscess? (8) Can VSD be used in the treatment of abdominal wall wounds, wound cavity, and defects? (9) Does VSD increase the risk of bleeding? (10) Does VSD increase the risk of intestinal wall injury? (11) Does VSD increase the risk of peritoneal adhesion? Focusing on these questions, evidence-based recommendations were given accordingly. VSD was strongly recommended regarding the questions 2-4. Weak recommendations were made regarding questions 1 and 5-11. Proper use of VSD in abdominal surgeries can lower the risk of infection in abdominal incisions with primary suture, treat severely contaminated/infected surgical sites and facilitate temporary abdominal cavity closure.

Impaired Coagulation Status in the Crohn's Disease Patients Complicated with Intestinal Fistula / 中华医学杂志(英文版)

<p><b>Background</b>Intestinal fistula is one of the common complications of Crohn's disease (CD) that might require surgical treatment. The clinical characteristics and outcomes of CD with intestinal fistula are much different from CD alone. This study was to investigate whether the coagulation status of CD is changed by intestinal fistula.</p><p><b>Methods</b>Data were retrospectively analyzed for 190 patients with a definitive diagnosis of CD who were registered at the Jinling Hospital between January 2014 and September 2015. Baseline clinical characteristics and laboratory indices of initial admission and 7 days after intestinal fistula resections were collected. Student's t-test and the Wilcoxon rank-sum test were used to compare differences between the two groups.</p><p><b>Results</b>Compared with CD patients without intestinal fistula, prothrombin time (PT) in patients with intestinal fistula was significantly longer (12.13 ± 1.27 s vs. 13.18 ± 1.51 s, P < 0.001 in overall cohort; 11.56 ± 1.21 s vs. 12.61 ± 0.73 s, P = 0.001 in females; and 12.51 ± 1.17 s vs. 13.37 ± 1.66 s, P = 0.003 in males). Platelet (PLT) count was much lower in intestinal fistula group than in nonintestinal fistula group (262.53 ± 94.36 × 10/L vs. 310.36 ± 131.91 × 10/L, P = 0.009). Multivariate logistic regression showed that intestinal fistula was significantly associated with a prolonged PT (odds ratio [OR] = 1.900, P < 0.001), a reduced amount of PLT (OR = 0.996, P = 0.024), and an increased operation history (OR = 5.408, P < 0.001). Among 65 CD patients receiving intestinal fistula resections, PT was obviously shorter after operation than baseline (12.28 ± 1.16 s vs. 13.02 ± 1.64 s, P = 0.006).</p><p><b>Conclusions</b>Intestinal fistula was significantly associated with impaired coagulation status in patients complicated with CD. Coagulation status could be improved after intestinal fistula resections.</p>

Clinical study on endoscopic closure of gastrointestinal fistula using the over-the-scope-clip system / 医学研究生学报

Objective Gastrointestinal fistula is a serious complication after operation. It is reported that the over-the-scope-clip(OTSC) can close intestinal full-thickness wall and treat gastrointestinal fistula effectively. This study was to investigate the efficacy of OTSC in the treatment of gastrointestinal fistula.Methods We analyzed the clinical data of 28 postoperative patients with gastrointestinal fistula who underwent endoscopic closure using OTSC in Endoscopy Center of Research Institute of General Surgery in our hospital from October 2014 to October 2017, and recorded the course of disease, the site of gastrointestinal fistula, the diameter of fistula and the efficacy of OTSC. Patients with successful closure were followed up for half a year after hospital discharge to observe the recurrence of fistula.Results Endoscopic closure with OTSC was successful in all the 28 patients without complications like bleeding and falling off. In the sinus tract or digestive tract radiography at 1-2 weeks after OTSC closure, 23 patients were successful in endoscopic closure(82.14%). In the six months′ follow-up of 23 patients with successful treatment, 4 patients were lost to follow-up and 19 patients were successful without recurrence of fistula.Conclusion The endoscopic closure of gastrointestinal fistula using OTSC is safe and effective, avoiding reoperation and reducing trauma.

Clinical characteristics of non-perianal fistulating Crohn's disease in China: a single-center experience of 184 cases / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>There is little information of non-perianal fistulating Crohn's disease in the consensus published by the European Crohn's and Colitis Organization in 2006 and 2010. This study was designed to demonstrate the clinical characteristics of non-perianal fistulating Crohn's disease among homogenous Chinese population.</p><p><b>METHODS</b>One-hundred-and-eighty-four patients were retrospectively collected. All of these patients were diagnosed of Crohn's disease between February 2001 and April 2011.</p><p><b>RESULTS</b>The male-to-female ratio was 2.7:1. The most common symptoms at onset were abdominal pain (88.0%), diarrhea (34.7%), and fever (28.3%). The most common disease location and behavior at diagnosis were small bowel (56.0%) and penetrating (51.6%). Among 324 non-perianal fistulae, the most common types were ileocolonic anastomotic (30.9%), terminal ileocutaneous (19.7%), and enteroenteric anastomotic (11.4%). One-hundred-and-thirty- eight (75.0%) patients received antibiotics, and β-lactam (85.5%) and metronidazole (67.4%) are most frequently used. One-hundred-and-seventy-eight (96.7%) patients suffered 514 surgical operations, and the cumulative surgical rates after 1, 3, and 5 years were 38.0%, 52.2%, and 58.7% respectively. Nine patients died during the follow-up period, and the cumulative survival rates after 1, 3, and 5 years were 97.8%, 96.7%, and 96.2% respectively.</p><p><b>CONCLUSIONS</b>This study displayed the clinical characteristics of non-perianal fistulating Crohn's disease in our center. Large population-based studies are required for further investigation in China.</p>

Efficacy of polyglycosides of Tripterygium wilfordii in preventing postoperative recurrence of Crohn disease / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To observe the efficacy of polyglycoside of Tripterygium wilfordii(GTW) in preventing postoperative recurrence of Crohn disease(CD).</p><p><b>METHODS</b>Thirty-nine post-operative CD patients in whom all of the diseased gut had been removed from January 2005 to December 2006 were enrolled in a randomized, placebo-controlled trial. The patients took GTW(21 cases) or SASP(18 cases) in two weeks after operation. Crohn disease activity index(CDAI), ESR and CRP were collected at week 0, 13, 26, 52 or at the onset of symptoms. Ileocolonoscopy was performed at the end of the trial or at the onset of symptoms.</p><p><b>RESULTS</b>One patient in GTW group and 2 patients in SASP group were lost and 2 patients in GTW were excluded from the trial for non-compliance. Clinical recurrence was ascertained in one patient (5.6%) received GTW and in four (25.0%) received SASP. Four of eighteen patients in GTW(22.2%) had endoscopic recurrence compared with nine of sixteen(56.2%) in SASP. There were significant differences between the two groups(P<0.05).</p><p><b>CONCLUSION</b>Tripterygium wilfordii showed good efficacy in preventing recurrence of postoperative CD which can maintain remission and prevent recurrence.</p>

Application of abdominal packing in non-trauma patients with severe abdominal hemorrhage / 中华外科杂志

<p><b>OBJECTIVE</b>To assess the efficacy and safety of damage control surgery with abdominal packing in non-trauma patients with severe abdominal hemorrhage.</p><p><b>METHODS</b>A retrospective review of consecutive non-trauma patients who underwent abdominal packing to control severe abdominal hemorrhage between February 2002 and February 2007 were performed. The demographics, physiological parameters, surgical indications and procedures, mortality, morbidity and volumes of resuscitation were retrieved. The observed mortality was compared to those calculated from the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) and Portsmouth Predictor Equation (P-POSSUM) scores.</p><p><b>RESULTS</b>A total of 26 non-trauma patients were included in this study, with a mean age of (42.6 +/- 15.8) years (range, 18 - 72 years). The most common etiologies associated with the severe hemorrhage was necrotizing pancreatitis (11 cases), intestinal fistula (5 cases) and tumor (4 cases). Of the patients, 24 cases (92.4%) achieved hemostasis by simple packing, 1 achieved hemostasis by using packing and angiographic embolization, and the other one failed and died. The mean intra-operative blood loss during the initial procedure was 1253.8 ml. The physiological parameters which improved significantly after rewarming and resuscitation in ICU phase included: body temperature, systolic blood pressure, heart rate, arterial pH, base excess, hemoglobin, hematocrit, prothrombin time, and international normalized ratio. The mean duration of packing was 4.3 days. The mean length of SICU stay and hospital stay was 40.5 and 67.4 days, respectively. Mortality rate predicted by POSSUM and P-POSSUM was 77.7% and 63.4%, respectively. Seven patients (26.9%) died after operation, brought an observed mortality rate significantly lower than predicted (P = 0.001 and 0.025, respectively). The most common complications included pneumonia (57.7%), bacteremia (50.0%), and re-bleeding (26.9%).</p><p><b>CONCLUSIONS</b>Damage control laparotomy with packing is an effective procedure in the management of severe non-trauma abdominal hemorrhage, it can prevent the aggravation of "lethal triad" characterized by hypothermia, coagulopathy and acidosis. Appropriate application of the technique in strictly selected patients can result in a lower mortality rate.</p>

Problems and Their Solutions of PBL Teaching in Medical Microbiology / 微生物学通报

PBL(Problem-Based Learning, PBL) is a problem-oriented and effective supplementary teaching method. PBL is giving a great help to improve self-learning, communication and cooperation, thinking and problems solving abilities for the students. In the process of PBL teaching, attention should be paid to two important items. One item is the role transfer for the teacher. Teacher is only a guider in PBL teaching, teacher should avoid excessive interfere of the process for keeping the passion and enthusiasm of the students. Meanwhile, students should always be realized that they are the main part in PBL teaching, they should not depend on their teacher too much. Another important item is how to find and solve the frequently encountered problems, in order to avoid students wandering from the subject, and lead them toward the main goal to get effective teaching and learning.

Enteral refeeding syndrome after long-term total parenteral nutrition / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Early enteral feeding (EF) may result in fever, elevated white blood cell count, increased serum levels of liver enzymes, and diarrhea. We name the complications "enteral refeeding syndrome", as a subtype of refeeding syndrome, because they are likely to result from long-term lack of lumen nutrition. The aim of this study was to investigate the characteristics of enteral refeeding syndrome after long-term total parenteral nutrition (TPN), and the solution for the disease.</p><p><b>METHODS</b>We collected the clinical data of 100 patients with gastrointestinal fistula, who were cured from Apirl 2001 to July 2002. Their fasting time, daily stool frequency, body temperature, heart rate, respiratory rate, levels of transaminases, alkaline phosphatase (AKP), and gamma-glutamylcyclotransferase (gamma-GT), white blood cell count, and systemic inflammatory reaction syndrome (SIRS) score were recorded before and 1, 3, 5, 10, and 15 days after EF. Student's t test and analysis of variance were used to analyze the data.</p><p><b>RESULTS</b>Of the 100 patients, 56 were cured after selective resection of intestinal fistula, 15 were cured by emergency operation, and 29 recovered spontaneously. The levels of AKP and gamma-GT increased significantly on the 3rd day after EF [On the 3rd day after EF, (243.0 +/- 121.6) U/L and (177.2 +/- 109.9) U/L vs. before EF (181.5 +/- 127.5) U/L and (118.4 +/- 94.2) U/L, P < 0.05], and decreased gradually afterwards. The SIRS scores on the 1st day (1.05 +/- 1.08) and 3rd day (0.96 +/- 1.11) after EF were significantly higher than that before EF (0.72 +/- 0.84), then decreased to 0.83 +/- 0.91, 0.49 +/- 0.73 and 0.32 +/- 0.60 on the 5th, 10th and 15th days after EF. The number of patients with diarrhea at 1, 3, 5, 10 and 15 days post-EF were 31, 26, 12, 13, and 7, respectively.</p><p><b>CONCLUSIONS</b>The longer the TPN lasts, the more severe the enteral refeeding syndrome becomes. Continuous EF is effective for the syndrome. Early enteral nutrition is useful in preventing it.</p>

Management of tertiary peritonitis in the patients complicated with intestinal fistula / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the etiology and management of tertiary peritonitis in the patients with intestinal fistula.</p><p><b>METHODS</b>One hundred and fifty-three cases of intestinal fistula complicated with tertiary peritonitis were reviewed. The microbiological characteristics, treatment Methods and outcomes were analyzed.</p><p><b>RESULTS</b>There were 114 males and 39 females with a mean age of (42+/- 19) years. The main causes of intestinal fistula included gastrointestinal surgery (40.5%), trauma (31.4%) and severe pancreatitis (14.4%), etc. The most common cultured bacteria of 157 specimens from 79 patients with tertiary peritonitis were Escherichia coli (24.2%), Pseudomonas aeruginosa (12.1%), Staphylococcus aureus (10.8%), Enterobacter cloacae (10.2%), Klebsiella pneumoniae (8.3%). Debridement of the necrotic tissues, drainage of the abscess, continuous rinsing plus negative pressure drainage and antibiotics treatment were performed in 52 cases. Nineteen patients only changed from simple tube drainage to continuous rinsing plus negative pressure drainage. Twenty- eight patients changed to continuous rinsing plus negative pressure drainage and received antibiotics as well. Thirty- six patients received antibiotics and ecoimmune nutrition, while 18 patients only received ecoimmun nutrition.</p><p><b>CONCLUSIONS</b>Intestinal fistula complicated with tertiary peritonitis was mainly caused by residual infectious focus and inappropriate drainage. The rational treatments include reoperation for debridement of the necrotic and infectious tissues, changing drainage to continuous rinsing plus negative pressure drainage, appropriate usage of antibiotics, and ecoimmune nutrition.</p>

Prokaryotic Expression and Acetylation Assays of Histone Acetyltransferase PCAF / 中国生物工程杂志

P300/CBP-associated factor(PCAF),an important member of histone acetyltransferase family(HATs) within eukaryotic cells,is capable of inducing the acetylation of histone,promoting the transcription of specific genes and involving in many biological effects.In the present study,full-length cDNA of PCAF was inserted into plasmid pGEX-5x-1,then the soluble protein GST-PCAF was expressed in E.coli BL21(DE3) after the optimization of inducing conditions.The recombinant protein was further purified with affinity chromatography and tested the activity by in vitro acetylation assays.High efficient PCAF protein produced by this method could serve for the study on the role of PCAF in gene regulation and the interaction between PCAF and other proteins.

Cloning，Sequence Analysis and Expression in E.coli of the EP0 Gene of Pseudorabies Virus Ea Strain / 中国病毒学

The 1.23 kb DNA fragment encoding the early protein EP0 of pseudorabies virus (PRV) Ea strain was amplified by PCR technique and cloned into pBluescriptII sk+.Three sequencing plasmids containing the partial fragment of the EP0 gene were constructed and the sequences were obtained by Sanger's sequencing technique. Compared with PRV InFh strain, there were multipile site-mutations and a deleted-mutation in the EP0 gene of PRV strain Ea，and the diversity of amino acid residues also existed.Then, the EP0 gene was inserted into an expression vector, pET-28a, fused into the downstream of the 6ΧHis-Tag in frame, to yield the expression plasmid pETEP0. After induction by IPTG, a high expression of fusion protein was obtained, SDS-PAGE analysis and Western blotting showed that the fusion protein was 62kD and the protein was specific to antisera against PRV Ea strain. This indicated that the EP0 gene be expressed in BL21(DE3) and the expression products have immuno-genicity.