Avaliação ecocardiográfica do paciente com choque circulatório: uma abordagem contemporânea / Echocardiographic evaluation of a patient in circulatory shock: a contemporary approach

O choque circulatório é caracterizado por um estado de ineficiência da oferta de oxigênio tecidual e disfunção múltipla de órgãos. Necessita de diagnóstico e terapias rápidas e assertivas para redução de sua alta letalidade. O ecocardiograma já se estabeleceu como método fundamental no manejo do paciente com choque circulatório. Auxilia de forma crucial no diagnóstico etiológico, prognóstico, monitorização hemodinâmica e estimativa volêmica desses pacientes, tendo como potenciais vantagens a portabilidade, ausência de contraste ou radiação, baixo custo e avaliação em tempo real e de forma seriada. Em ambiente de UTI, demonstra alta correlação com formas invasivas (cateter de artéria pulmonar) e minimamente invasivas (termodiluição transpulmonar) de monitorização hemodinâmica. Atualmente, outras técnicas, como ultrassom pulmonar e VExUS score, têm se agregado à avaliação ecocardiográfica, tornando o método mais abrangente e acurado. Essas técnicas acrescentam dados relevantes na estimativa da volemia do paciente crítico, influenciando na decisão probabilística de fluidoresponsividade e agregando informações no raciocínio diagnóstico das causas do choque, otimizando o prognóstico desses pacientes. O point of care ultrasound (POCUS) tem como objetivo tornar mais acessível, ao médico não especialista em radiologia, habilidades para se obter informações a beira leito, por meio do ultrassom, que o ajudem na tomada de decisões. Esse artigo aborda as diversas aplicabilidades do ecocardiograma em pacientes com choque circulatório, incluindo avaliação prognóstica e diagnóstico etiológico por meio dos parâmetros encontrados nas principais causas de choque, além da monitorização hemodinâmica, avaliação de fluido-responsividade e utilização prática do ultrassom pulmonar.(AU)

Circulatory shock is characterized by a state of inefficient tissue oxygen supply and multiple organ dysfunction. Patients with circulatory shock require fast and assertive diagnosis and therapies to reduce its high lethality. Echocardiography has already been established as a fundamental method in managing patients with circulatory shock. It provides crucial assistance in etiological diagnosis, prognosis, hemodynamic monitoring, and volume estimation in these patients; its potential advantages include portability, absence of contrast or radiation, low cost, and real-time serial assessment. In the intensive care unit setting, it demonstrates a high correlation with invasive (pulmonary artery catheter) and minimally invasive (transpulmonary thermodilution) forms of hemodynamic monitoring. Currently, other techniques, such as pulmonary ultrasound and VExUS score, have been added to echocardiographic assessment, making the method more comprehensive and accurate. These techniques add relevant data to blood volume estimation in critical patients, influencing the probabilistic decision of fluid responsiveness and providing additional information in the diagnostic reasoning of the causes of shock, thus optimizing these patients' prognosis. Point of care ultrasound (POCUS) aims to make abilities to obtain information at the bedside more accessible to physicians who are not specialists in radiology, by means of ultrasound, which assists them in decision-making. This article addresses the diverse applications of echocardiography in patients with circulatory shock, including prognostic evaluation and etiological diagnosis by means of the parameters found in the main causes of shock, in addition to hemodynamic monitoring, evaluation of fluid responsiveness, and practical use of pulmonary ultrasound.(AU)

A redox-responsive self-assembling COA-4-arm PEG prodrug nanosystem for dual drug delivery suppresses cancer metastasis and drug resistance by downregulating hsp90 expression

Metastasis and resistance are main causes to affect the outcome of the current anticancer therapies. Heat shock protein 90 (Hsp90) as an ATP-dependent molecular chaperone takes important role in the tumor metastasis and resistance. Targeting Hsp90 and downregulating its expression show promising in inhibiting tumor metastasis and resistance. In this study, a redox-responsive dual-drug nanocarrier was constructed for the effective delivery of a commonly used chemotherapeutic drug PTX, and a COA-modified 4-arm PEG polymer (4PSC) was synthesized. COA, an active component in oleanolic acid that exerts strong antitumor activity by downregulating Hsp90 expression, was used as a structural and functional element to endow 4PSC with redox responsiveness and Hsp90 inhibitory activity. Our results showed that 4PSC/PTX nanomicelles efficiently delivered PTX and COA to tumor locations without inducing systemic toxicity. By blocking the Hsp90 signaling pathway, 4PSC significantly enhanced the antitumor effect of PTX, inhibiting tumor proliferation and invasiveness as well as chemotherapy-induced resistance in vitro. Remarkable results were further confirmed in vivo with two preclinical tumor models. These findings demonstrate that the COA-modified 4PSC drug delivery nanosystem provides a potential platform for enhancing the efficacy of chemotherapies.

Capacidade de resposta do NASF em saúde mental / NASF responsiveness in mental health

Resumo Objetivou-se analisar a capacidade de resposta do Núcleo de Apoio à Saúde da Família (NASF) em saúde mental em três estados nordestinos a partir do II e III Ciclos do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB). Os resultados foram analisados em nível estadual, nos municípios pertencentes ao G1 e nos 48 municípios que concentram simultaneamente assentamentos rurais e comunidades quilombolas. Identificaram-se aspectos mais e menos favoráveis em termos da oferta de ações em saúde mental que atravessam os dois ciclos avaliativos. Os dados demonstram a possibilidade de um efetivo compartilhamento de responsabilidades e de coordenação do cuidado entre o NASF e as equipes de AB. Entretanto, em relação às demandas de cuidado referentes ao uso de substâncias psicoativas, em ambas as avaliações e nos três níveis de estratificação, as equipes NASF obtiveram desempenho menos favorável, indicando que a capacidade de resposta ao sofrimento associado ao uso de álcool e outras drogas é menos efetiva, precisando ser reforçada e aprimorada na APS.

Abstract The article aimed to analyze the responsiveness of the Family Health Support Center (NASF) in mental health in three northeastern states from the II and III Cycles of National Program for Improving Access and Quality of Primary Care (PMAQ-AB). The results were analyzed at the state level, in the municipalities belonging to G1 and in the 48 municipalities that concentrate both rural settlements and quilombola communities. We identified more and less favorable aspects in terms of the offer of mental health actions across the two evaluation cycles. The data show the possibility of an effective sharing of responsibilities and care coordination between NASF and the Primary Health Care (PHC) teams. However, regarding the demands of care related to the use of psychoactive substances, in both evaluations and in the three levels of stratification, the NASF teams performed less favorably, indicating that the response capacity to the suffering associated with the use of alcohol and other drugs is less effective, needing to be strengthened and improved in PHC.

Evaluación de la concordancia entre las variaciones de la velocidad pico aórtico y velocidad pico carotídeo con la ventilación mecánica en una población pediátrica sometida a cirugía electiva bajo anestesia general / Evaluation of the agreement between variations in aortic peak velocity and carotid peak velocity with mechanical ventilation in a pediatric population undergoing elective surgery under general anesthesia

Introducción. La variación de la velocidad máxima aórtica con la ventilación mecánica (ΔVpeakAo) ha demostrado ser el mejor predictor de respuesta a volumen en pediatría. Existe evidencia en adultos de que la variación de velocidad máxima de flujo carotídeo (ΔVpeakCar) es predictor de respuesta a fluidos. Al momento es escasa la información sobre este índice en pediatría. Su beneficio se basa en la no-invasividad, y que para su medición no es necesaria la ecocardiografía ni el acceso al tórax del paciente. Objetivo. El objetivo general de este trabajo fue estudiar la correlación y la concordancia de ΔVpeakCar con ΔVpeakAo en una población pediátrica bajo ventilación mecánica. Metodología. Se incluyeron pacientes de 0 a 12 años. Se registraron flujos aórtico y carotídeos máximos y mínimos y se calculó ΔVpeakCar y ΔVpeakAo. Para analizar correlación y concordancia entre las variables se utilizó el test de Pearson, análisis de Bland-Altman y análisis de los 4-cuadrantes. Resultados. Se estudiaron 58 pacientes, 13 lactantes (menores 12 meses), 21 preescolares (12-60 meses) y 24 escolares (mayores a 60 meses). Se observó una correlación significativa entre ΔVpeakAo y ΔVpeakCar (r=0,85; p<0,05) con un coeficiente de determinación de r2=0,72. El análisis de Bland-Altman mostró un sesgo del 0,15% (IC95%, -0.7-1.0) con un límite de concordancia del -6,1 a 6,2%. La concordancia fue 85%, con un sesgo angular de 4,5°±31°. El análisis por subgrupos mostró un r2 de 0.89 en escolares, 0.56 en preescolares y 0.45 en lactantes. La concordancia fue de 100% en escolares, 95% en prescolares y 93% en lactantes. Discusión y conclusiones. El registro de ΔVpeakCar fue viable. Al analizar la capacidad de ΔVpeakCar de sustituir a ΔVpeakAo en el total de la muestra, no es buena La correlación y concordancia son mejores en escolares. Es necesario continuar estudiando este nuevo índice.

Introduction. The variation in maximum aortic velocity with mechanical ventilation (ΔVpeakAo) has proven to be the most effective predictor of fluid response in pediatrics. While there is evidence in adults that the variation in maximum carotid flow velocity (ΔVpeakCar) predicts fluid response, information on this index in pediatrics remains limited. Its advantage lies in its non-invasive nature, eliminating the need for echocardiography or thoracic access for recording. Objective. This study aims to examine the correlation and concordance between ΔVpeakCar and ΔVpeakAo in a pediatric population. Methodology. The study included patients aged 0 to 12 years. Maximum and minimum aortic and carotid flows were recorded, and ΔVpeakCar and ΔVpeakAo were calculated. Correlation and agreement between variables were analyzed using the Pearson test, Bland Altman analysis, and 4-quadrant analysis. Results. A total of 58 patients were studied, comprising 13 infants (under 12 months), 21 preschoolers (12-60 months), and 24 school-aged children (over 60 months). A significant correlation was observed between ΔVpeakAo and ΔVpeakCar (r=0.85; p<0.05) with a coefficient of determination, r²=0.72. The Bland-Altman analysis revealed a bias of 0.15% (95% CI, -0.7-1.0) with an agreement limit of -6.1% to 6.2%. The concordance rate was 85%, with an angular bias of 4.5°±31°. Subgroup analysis showed r² values of 0.89 in school-aged children, 0.56 in preschoolers, and 0.45 in infants. Concordance rates were 100% in school-aged children, 95% in preschoolers, and 93% in infants. Discussion and Conclusions. The measurement of ΔVpeakCar proved feasible. However, when considering its ability to replace ΔVpeakAo, the results are suboptimal. Correlation and concordance are stronger in school-aged children. Further investigation into this new index is warranted.

Care-recipient perspectives on the responsiveness of Orthopedic surgical services in a tertiary center in Nigeria

Responsiveness optimisesthe system-based approach to meeting legitimate demands by healthcare recipients. This study assessed the responsiveness of orthopaedic services at the University of Port Harcourt Teaching Hospital (UPTH) from the perspectives of the care recipients. Methods:Descriptive cross-sectional study among 442 consecutively recruited recipients of orthopaedic services at UPTH from March to June 2020. Close-ended questionnaire with responsiveness conceptualised by five constructs: dignity, autonomy, confidentiality, quality of basic amenities and choice of care provider, each measured along 4-point response scale. The internal consistency reliability of the responsiveness scale was determined by the Cronbach's alpha coefficient. Descriptive (frequency, percentages, bar charts) and inferential (ordinal logistic regression) statistics were conducted and p-values ≤ 0.05 were considered statistically significant. Results: Response rate was 97.3% and the Cronbach's alpha coefficient for the responsiveness scale was 0.83. Participants' mean age was 38.5±14.8years with more being males (55.8%), privately employed (34.9%) and completed secondary education (82.5%). Proportion of respondents who gave excellent ratings across responsiveness domains were dignity (32.8%), autonomy (34.2%), confidentiality (26.3%), amenities (25.8%) and no excellent rating for choice of provider. Marital, employment and visit status were the most consistent factors associated with feedback on autonomy, choice of providers, confidentiality domains.Conclusion: More orthopaedic patients were pleased with the level of autonomy and dignity than choice of providers and quality of basic amenities. There is the need for enhanced responsiveness of orthopedic services to meeting the unique needs of patients and achieving improved quality of care and patient outcomes

Validity, Reliability and Responsiveness of the Malay Shoulder Pain and Disability Index (M-SPADI) for Patients with Shoulder Pain

@#Introduction: The purpose of this study is to determine the validity, reliability, and responsiveness of the Malay Shoulder Pain and Disability Index (M-SPADI) in Malay speakers suffering from shoulder pain. Materials and methods: The M-SPADI, the Numerical Rating Scale (NRS), and measurements of shoulder active range of motion (AROM) were completed by 140 patients with shoulder pain (68 with rotator cuff pathology and 72 with other shoulder pathology). Thirty-four patients were retested for test-retest reliability with M-SPADI after an average of 9.2 days. M-SPADI was performed on twenty-one individuals three months after completing treatment for rotator cuff disorders to assess response. Results: The results of exploratory factor analysis revealed a bidimensional structure for M-SPADI. M-SPADI disability score was significantly greater in patients with rotator cuff pathologies (median = 31.87, IQR 82.50) than in patients with other shoulder pathologies (median = 20.00, IQR 23.84). In multi-group factor analysis, measurement invariance revealed no significant difference between the two groups (p>0.05). There was a significant positive correlation between M-SPADI and NRS (Pain = 0.86, Disability = 0.75, Total = 0.82, p=0.005), and a significant negative correlation between M-SPADI and shoulder AROM (Pain = -0.34 to -0.67, Disability =-0.44 to -0.73, Total =- 0.43 to -0.72, p=0.005). M-SPADI had a high degree of internal consistency (Cronbach's 0.92 for pain and 0.95 for disability). Test-retest reliability was moderate to excellent (ICC Pain = 0.84, ICC Disability = 0.78, ICC Total = 0.81, p=0.001), and the smallest detectable change ranges (Pain = 8.74, Disability = 3.21, Total = 3.83) were less than the minimal detectable change ranges (Pain = 21.57, Disability = 6.82, Total = 8.79). The area under the receiver operating characteristic curve (AUC) for M-SPADI was greater than 0.90 (Pain = 0.99, Disability = 0.94, Total = 0.96). Conclusion: The M-SPADI has established construct validity, internal consistency, test-retest reliability, and responsiveness. The M-SPADI is a reliable and valid instrument for evaluating shoulder pain among Malayspeaking individuals. In addition, the M-SPADI disability subscale may be useful for monitoring functional score changes in patients with rotator cuff pathology.

Autism Spectrum Disorder Categories and Social Responsiveness among Adults with Autism Spectrum Disorder.

Introduction: Autism spectrum disorder (ASD), refers to a broad range of conditions characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication. Individuals with autism spectrum disorder usually have problems with social responsiveness which in turns effects their social communication and results in confined repetitive pattern of behaviour and interests. However the existing literature is limited in demonstrating the importance of social responsiveness and its impact on gender and ASD categories. Objective: The purpose of this study was to determine the impact of ASD categories on social responsiveness in adults with ASD and investigate social responsiveness among male and female adults with ASD. Methodology: The study utilized data from 60 adults diagnosed with autism spectrum disorder with categories mainly, mild, moderate and high functioning. Adults of both genders (male and female) participated in this study with Social Responsiveness (SR) as a variable over 7 months from October 2021 to February 2022, using the Social Responsiveness Scale-2 (SRS-2 Adult Relative/Other online form). Results and Conclusion: One-way ANOVA test showed significant difference (p<0.001, df=2) between ASD categories. Tukey's Post Hoc Analysis revealed significant (p<0.001) difference between ASD categories from each other. Gender had no significant impact on ASD, and the severity of ASD varies between groups. Thus, this study fills a large knowledge gap on the influence of gender, categories and social responsiveness on adults with ASD.

End-tidal carbon dioxide partial pressure to assess the value of passive leg-raising test in predicting volume responsiveness in patients with septic shock / 中华危重病急救医学

Objective:To investigate the value of partial pressure of end-tidal carbon dioxide (P ETCO 2) combined with passive leg raising test (PLR) in predicting volume responsiveness in patients with septic shock. Methods:A total of 43 patients with septic shock admitted to the second department of critical care medicine, People's Hospital of Xinjiang Uygur Autonomous Region from December 2019 to June 2021 were selected as the research subjects. P ETCO 2, cardiac index (CI), stroke volume variation (SVV), mean arterial pressure (MAP) and other hemodynamic indexes were monitored before and after PLR and volume stress test (VE). Subjects were grouped according to the CI variation rate (ΔCI) after VE test. Patients with ΔCI ≥ 15% were the responding group, and patients with ΔCI < 15% were the non-responding group. The receiver operator characteristic curve (ROC curve) was drawn to analyze the evaluation value of the change in P ETCO 2 after PLR on the evaluation value of fluid responsiveness. Results:Among the 43 patients, 22 cases were in the responding group, accounting for 51.2%; 21 cases were in the non-responding group, accounting for 48.8%. After the PLR test, the change values of MAP, SVV, CI and P ETCO 2 in the responding group were higher than those in the non-responding group, and the differences were statistically significant [MAP (mmHg): 3.8±2.1 vs. 1.4±2.0, SVV (%): -5.3±2.5 vs. 2.7±2.0, CI (mL·s -1·m -2): 0.48±0.13 vs. 0.14±0.18, P ETCO 2 (mmHg): 3.4±1.8 vs. 1.1±1.0, all P < 0.05, 1 mmHg≈0.133 kPa]. After the VE test, the changes of HR, MAP, SVV, CI and P ETCO 2 in the responding group were higher than those in the non-responding group [HR (times/min): -8.3±2.8 vs. -2.3±3.7, MAP (mmHg): 3.8±2.4 vs. 1.2±1.7, SVV (%): -6.3±3.1 vs. -3.3±2.0, CI (mL·s -1·m -2): 0.51±0.14 vs. 0.16±0.12, P ETCO 2 (mmHg): 3.3±1.2 vs. 1.3±1.1, all P < 0.05]. The area under the ROC curve (AUC) of the change in P ETCO 2 before and after the PLR test (ΔP ETCO 2 PLR) for evaluating fluid responsiveness was 0.881. When the critical value was 5.9%, the sensitivity was 76.7%, the specificity was 89.5%, and the correct index was 0.68; the AUC for SVV baseline assessment of fluid responsiveness was 0.835, and when the cut-off value was 12.8%, the sensitivity was 84.6%, the specificity was 80.0%, and the correct index was 0.65. The predictive value of ΔP ETCO 2 was not lower than the SVV baseline. Conclusion:After the PLR test, the change of P ETCO 2 can be used as a non-invasive, simple, safe and reliable indicator for predicting the volume responsiveness of patients with septic shock.

Correlation between perceived partner responsiveness and fear of disease progression in young patients with cervical cancer after surgery / 中国实用护理杂志

Objective:To explore the status quo of young patients′ perception of partner responsiveness and fear of disease progression after surgery of cervical cancer, and to analyze the correlation between the two to provide a basis for targeted intervention.Methods:From October 2018 to June 2020, a convenient sampling method was used to select 121 young patients after radical resection of cervical cancer who were treated in East Branch of Qingdao Municipal Hospital. It was investigated by the Perceived Partner Responsiveness Scale and the Fear of Progression Questionnaire-Short Form in cancer patients.Results:The total score of perceived partner responsiveness of young patients with cervical cancer after surgery was (41.30 ± 6.14) points, and the total score of fear of disease progression was (31.10 ± 6.58) points; perceived partner responsiveness was negatively correlated with fear of disease progression ( r=-0.72, P<0.05). Multiple linear regression analysis showed that work status and perceived partner responsiveness were the influencing factors of patients' fear of disease progression ( t=11.54, 18.40, all P<0.05). Conclusions:The perception of partner responsiveness in young patients with cervical cancer after surgery is closely related to the fear of disease progression. Perception of partner responsiveness can affect patients′ fear of disease progression; it can improve the patients′ perception of partner responsiveness to improve their fear of disease progression.

Application of asthenopia survey scale in patients with accommodative asthenopia / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To investigate the visual fatigue of patients with accommodative asthenopia and the difference in scores before and after treatment by using the asthenopia survey scale(ASS), and to evaluate its reliability, validity and responsiveness in this population.METHODS: A total of 112 patients with accommodative asthenopia were admitted to the department of ophthalmology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine and recruited online were investigated using the ASS questionnaire, and 48 subjects were randomly selected and retested 1wk later. A variety of reliability, validity and responsiveness indicators were used to evaluate the scale.RESULTS: The overall Cronbach's α coefficients of the scale entries was 0.91; The split-half reliability coefficients was 0.86; Repeated measurement correlation coefficient of the scale total score was 0.74, there was no significant difference before and after(P&#x003E;0.05); The results of confirmatory factor analysis showed that the absolute fit index of the three-factor structural model was χ2/df&#x003C;2.0, RMSEA=0.08; The correlation coefficients of each dimension's total score and the scale's total score were 0.92, 0.90 and 0.83 respectively; The standard association validity analysis showed statistically significant differences between groups(P&#x003C;0.01). Response analysis was statistically significant before and after treatment(P&#x003C;0.01).CONCLUSION: The ASS has high reliability, validity and responsiveness in the clinical evaluation of accommodative asthenopia, and it's an effective tool for clinical research and screening of asthenopia in this population.

GSH-sensitive polymeric prodrug: Synthesis and loading with photosensitizers as nanoscale chemo-photodynamic anti-cancer nanomedicine

Precisely delivering combinational therapeutic agents has become a crucial challenge for anti-tumor treatment. In this study, a novel redox-responsive polymeric prodrug (molecular weight, MW: 93.5 kDa) was produced by reversible addition-fragmentation chain transfer (RAFT) polymerization. The amphiphilic block polymer-doxorubicin (DOX) prodrug was employed to deliver a hydrophobic photosensitizer (PS), chlorin e6 (Ce6), and the as-prepared nanoscale system [NPs(Ce6)] was investigated as a chemo-photodynamic anti-cancer agent. The glutathione (GSH)-cleavable disulfide bond was inserted into the backbone of the polymer for biodegradation inside tumor cells, and DOX conjugated onto the polymer with a disulfide bond was successfully released intracellularly. NPs(Ce6) released DOX and Ce6 with their original molecular structures and degraded into segments with low MWs of 41.2 kDa in the presence of GSH. NPs(Ce6) showed a chemo-photodynamic therapeutic effect to kill 4T1 murine breast cancer cells, which was confirmed from a collapsed cell morphology, a lifted level in the intracellular reactive oxygen species, a reduced viability and induced apoptosis. Moreover, ex vivo fluorescence images indicated that NPs(Ce6) retained in the tumor, and exhibited a remarkable in vivo anticancer efficacy. The combinational therapy showed a significantly increased tumor growth inhibition (TGI, 58.53%). Therefore, the redox-responsive, amphiphilic block polymeric prodrug could have a great potential as a chemo-photodynamic anti-cancer agent.

Effect of transitional nursing combined with resistance breathing training on elderly obese obstructive sleep apnea-hypopnea syndrome / 中国实用护理杂志

Objective:To analyze the effect of transitional care model (TCM) mode combined with resistance breathing training on hypoxic reactivity of respiratory center in elderly obese obstructive sleep apnea-hypopnea syndrome(OSAHS).Methods:Totally 78 patients with OSAHS who met the criteria were selected from the geriatric department of Nanjing Drum Tower Hospital from January 2018 to December 2020 and divided into observation group and control group by random digits table method, with 39 cases in each group; the control group was intervened by basic nursing combined with resistance breathing training mode, and the observation group was intervened by TCM mode on the basis of the control group. Before nursing and 1 month after discharge, Pittsburgh Sleep Quality Index (PSQI), Short-Form 36-item Health Survey (SF-36), Montreal Cognitive Assessment (MoCA) were used to evaluate the sleep quality, quality of life and cognitive function of the patients. Besides, FVC, FEV 1, FEV 1/FVC were also tested before nursing and 1 month after discharge. Results:One month after discharge, the daytime dysfunction, use of sleep drugs, habitual sleep efficiency, subjective sleep quality, sleep disorder, sleep latency, sleep duration and total score of PSQI in the observation group were significantly lower than those in the control group (the control group: 2.27 ± 0.34, 2.03 ± 0.31, 2.09 ± 0.23, 1.85 ± 0.28, 2.11 ± 0.28, 1.40 ± 0.24, 2.12 ± 0.41, 13.87 ± 0.56; the observation group: 1.63 ± 0.33, 1.22 ± 0.29, 1.63 ± 0.29, 1.12 ± 0.31, 1.35 ± 0.34, 1.09 ± 0.28, 1.74 ± 0.26, 9.78 ± 0.59) ( t values were 4.91-31.61, all P<0.01). One month after discharge, the scores of mental health, physical pain, physiological function, physiological function, emotional function, life vitality, social function and overall health of SF-36 in the observation group were significantly higher than those in the control group (the control group: 62.83 ± 6.31, 68.94 ± 5.91, 61.99 ± 5.98, 64.85 ± 6.13, 43.28 ± 5.74, 64.85 ± 6.12, 61.21 ± 5.74, 62.31 ± 6.85; the observation group: 69.81 ± 5.74, 76.12 ± 6.02, 70.84 ± 6.08, 71.74 ± 5.99, 50.93 ± 6.12, 70.52 ± 5.94, 69.89 ± 5.53, 68.41 ± 4.99)( t values were 4.18-7.77, all P<0.01). One month after discharge, the scores of visual space and executive function, attention, language, delayed recall, orientation, abstraction and total score of MoCA in the observation group were significantly higher than those in the control group (the control group: 4.48 ± 0.37, 5.23 ± 0.29, 2.43 ± 0.27, 3.37 ± 0.31, 5.01 ± 0.33, 5.27 ± 0.26, 25.79 ± 1.17; the observation group:4.95 ± 0.31, 5.68 ± 0.27, 2.67 ± 0.24, 3.98 ± 0.19, 5.47 ± 0.28, 5.64 ± 0.23, 28.39 ± 1.09)( t values were 4.17-10.51, all P<0.01). One month after discharge, the levels of FVC, FEV 1 and FEV 1/FVC in the observation group were significantly higher than those in the control group, the control group: (2.59 ± 0.18) L, (1.60 ± 0.14) L, (61.78 ± 4.01)%; the observation group: (2.89 ± 0.19) L, (1.99 ± 0.17) L, (68.86 ± 3.99)% ( t = 7.21, 11.14, 7.87, all P<0.05). Conclusions:TCM combined with resistance breathing training can effectively improve the hypoxic response of respiratory center in elderly obese patients with OSAHS.

Clinical study of internal jugular vein dilatation index in predicting septic shock volume responsiveness / 中华急诊医学杂志

Objective:To explore the value of severe ultrasound measurement of internal jugular vein dilation index (ΔIJV) combined with passive leg raising (PLR) in predicting the volume responsiveness of septic shock.Methods:Patients diagnosed with septic shock under complete mechanical ventilation in the ICU of Jinshan Hospital Affiliated to Fudan University from January 2020 to March 2021 were prospectively selected as the research objects. After 500 mL crystals were injected within 30 min, the patients having the "gold standard" left stroke volume (SV) increased by 15% were allocated to the volume response positive group, and patient having an SV increased by less than 15% to the volume response negative group. First, the maximum anterior posterior diameter (IJV max) and the minimum anterior posterior diameter (IJV min) in the respiratory cycle of internal jugular vein were measured by ultrasound, then SV before and after PLR was measured, and finally SV, IJV max and IJV min were measured again after rapid infusion of 500 mL crystals, and ΔIJV=(IJV max-IJV min)/(IJV mean)×100%. The Wilcoxon rank-sum test was used to compare the hemodynamic indexes before and after capacity expansion and PLR. Spearman rank method was used to analyze the change rate of SV (ΔSV) after PLR and the correlation between ΔIJV and ΔSV of the "gold standard". The sensitivity, specificity and relevant cut-off values were obtained by drawing the subject function curve to evaluate the value of ΔIJV and PLR in predicting the volume responsiveness of patients with sepsis. Results:A total of 56 patients were enrolled in the study, and they were divided into two groups: 32 patients in the volume response positive group and 24 patients in the volume response negative group. There was a positive correlation between ΔIJV and ΔSV after capacity expansion ( r=0.778, P<0.01). Taking ΔIJV>17.3% as the threshold, the area under the curve (AUC) was 0.846 (95% CI: 0.716~0.977), the sensitivity was 84.4% and the specificity was 83.3%. PLR was also positively correlated with ΔSV ( r=0.698, P<0.01). Taking ΔSV>15.5% after PLR as the threshold, the AUC was 0.895 (95% CI: 0.796~0.993), the sensitivity was 96.9%, and the specificity was 79.2%. When ΔIJV combined with PLR predicted volume reactivity, the AUC was 0.944 (95% CI: 0.862~1.000), the sensitivity was 99.8% and the specificity was 87.5%. Conclusions:The measurement of internal jugular vein respiratory dilation index by bedside ultrasound is a reliable index to predict volume responsiveness in patients with sepsis. When combined with PLR, the sensitivity and specificity of prediction can be improved.

Relationship between clopidogrel responsiveness and CYP2C19 genotype by thromboelastography in patients with coronary heart disease after PCI / 中国输血杂志

【Objective】 To explore the relationship between clopidogrel responsiveness and CYP2C19 gene polymorphism by thromboelastography(TEG) after PCI in patients with coronary heart disease, and its guiding significance for the use of clopidogrel after PCI. 【Methods】 A total of 246 patients who underwent PCI surgery in our hospital from June 2018 to May 2021 and routinely took clopidogrel maintenance treatment after the operation were selected.The platelet inhibition rate of the patients was detected by TEG to obtain their response to clopidogrel.The CYP2C19 genotype was detected, and the relationship between the patient′s responsiveness to clopidogrel and the CYP2C19 genotype was analyzed. 【Results】 The CYP2C19 genotypes in 246 patients were fast metabolizer (n=95), intermediate metabolizer (n=104) and slow metabolizer (n=47), with the mean ADP inhibition rate(%) at 46.27±21.41, 40.99±25.53 and 24.77±21.68, respectively.They were divided into clopidogrel resistant group (n=98) and clopidogrel normal response group (n=148). The three groups of patients with different CYP2C19 genotypes had no statistically significant differences in gender composition, age and platelet count (P>0.05), while significant differences in hypertension, diabetes and hyperlipidemia(P0.05), but they were all lower than those with slow metabolism patients (both P0.5). Statistically significant difference was noticed in the low responsiveness to clopidogrel by different CYP2C19 genotypes (P<0.05). The drug responsiveness of clopidogrel measured by TEG had strong correlation with the patient′s CYP2C19 genotype.When the ADP inhibition rate was the best cut-off value (27.10%), the sensitivity and specificity of CYP2C19 genotype being diagnosed as the slow metabolite type, was 73.37% and 70.21%, respectively. 【Conclusion】 The response of clopidogrel after PCI in patients with coronary heart disease is associated with CYP2C19 genotype polymorphism.The use of TEG to detect the ADP inhibition rate of patients has strong predictive effect on CYP2C19 genotype and has guiding significance on antiplatelet therapy in patients with coronary heart disease after PCI.

Clinical value of point of care ultrasound on cardiac output and volume responsiveness in patients with septic shock / 中华危重病急救医学

Objective:To assess the value of point of care ultrasound on cardiac output (CO) and volume responsiveness in patients with septic shock.Methods:A prospective investigation study was conducted. Twenty-four mechanical ventilation patients with septic shock who needed pulse-indicated continuous cardiac output (PiCCO) monitoring in the department of critical care medicine of Zhengzhou University People's Hospital, Henan Provincial People's Hospital from November 25, 2020 to April 30, 2021 were selected as the subjects, the patient's basic information and laboratory test results were recorded. PiCCO was used as standard to monitor CO and stroke volume variability (SVV) at 0, 2, 6, 12, 24 and 48 hours. At the same time, point of care transthoracic echocardiography (TTE) was used to measure velocity time integral (VTI) and inferior vena cava diameter (dIVC), the CO, VTI variation rate (△VTI) and dIVC variation rate (△dIVC) were calculated. Then, using the value monitored by PiCCO as the standard, the consistency and correlation analysis were carried out between point of care ultrasound with PiCCO.Results:Twenty-two out of 24 patients obtained satisfactory ultrasound Doppler images, the heart rate (HR), mean arterial pressure (MAP) and body temperature of the enrolled patients were consistent with the pathophysiological characteristics of septic shock. With the extension of treatment time, HR and CO both gradually decreased, and MAP gradually increased, reaching a peak or trough at 48 hours after admission. The difference were statistically significant compared with the time of admission [HR (bpm): 90.36±15.35 vs. 116.82±19.82, MAP (mmHg, 1 mmHg = 0.133 kPa): 87.82±11.06 vs. 58.82±9.85, CO (L/min): 4.80±0.56 vs. 6.78±1.31, all P < 0.05]. The CO obtained by PiCCO and point of care ultrasound had good agreement [5.36 (4.78, 6.33) L/min and 5.21 (4.88, 6.35) L/min, respectively], the average difference value at each time point was (-0.02±0.69) L/min, the 95% agreement limit range was -1.35-1.34, and there was a high degree of correlation ( rs = 0.800, P < 0.001); The SVV by PiCCO and the △dIVC by point of care ultrasound were in good agreement [18.00% (14.00%, 24.00%) and 21.00% (14.00%, 25.75%), respectively], the average difference value at the time point was (-3.16±6.89)%, the 95% agreement limit range was -16.89-10.54, and there was a moderate correlation ( rs = 0.702, P < 0.001); The SVV by PiCCO and the △VTI by point of care ultrasound were in good agreement [18.00% (14.00%, 24.00%) and 16.00% (11.25%, 20.75%), respectively], the average difference value at each time point was (13.03±14.75)%, and the 95% agreement limit range was 1.72-27.78, and there was a high correlation ( rs = 0.918, P < 0.001). Conclusion:Point of care ultrasound can accurately assess CO and volume responsiveness of patients with septic shock, and the △VTI is better than the △dIVC in assessing volume responsiveness.

Application progress of point-of-care ultrasound monitoring inferior vena cava in volume management of critically ill patients / 中华危重病急救医学

Determining whether patients have volume-responsiveness is one of the frequently asked questions in the intensive care unit, especially in shock patients. Evaluating the volume status and volume responsiveness can help clinical medical staff accurately grasp the patient's cardiac preload, guide reasonable volume management, and help improve patient prognosis. Therefore, many non-invasive and invasive methods have been proposed to evaluate volume responsiveness. Inferior vena cava ultrasound has been widely used to guide the fluid management of critically ill patients due to its simplicity, non-invasiveness, and good repeatability. This article reviews the clinical applications of inferior vena cava ultrasound in fluid management of critically ill patients, so as to provide a reference for circulatory management of critically ill patients.

Hepatitis B Vaccination and Factors Related with Unresponsiveness in Healthy Children

ABSTRACT Background: The aim of this study was to assess the effectiveness of hepatitis B vaccination and factors associated with vaccine unresponsiveness in healthy children. Methods: A total of 141 healthy children aged between two and five years were included in the study. All of the cases had received 20 μg of recombinant DNA vaccine for hepatitis B (0, 1 and 6 months). Demographic features and factors such as duration of breastfeeding, exposure to HBsAg-positive family members, administration of concomitant vaccines and exposure to smoke were determined. Hepatitis B vaccination serological markers were evaluated. Post-vaccination serologic evaluation was performed one month after the last dose of primary vaccination, one month after the booster dose. Human leukocyte antigens typing was performed in non-responders. Results: Only 87.9% of the children achieved seroprotection antibodies to hepatitis B surface antigen (anti-HBsAG titers ≥ 10 mIU/ml) one month after primary vaccination. No difference was observed between vaccine responsiveness and age, gender, birthweight, maturity, duration of breastfeeding, exposure to HBsAg-positive family members, and mid-upper arm circumference (p > 0.05). HLA types, DRB 111 (64.7%), B5 (52.9%), DRB 104 (52.9%) and DRB 11001 (47%) were detected at increased frequency in non-responders. The antibody titers were significantly higher in children who breastfed for the first six months and longer and who were vaccinated concomitantly with other common vaccines. Conclusion: The seroprotection antibodies to hepatitis B surface antigen correlated with breast feeding and hepatitis B vaccination concomitant with other common vaccines. HLA types DRB 111, B5, DRB 104 and DRB 11001 had increased frequency in non-responders.

Predictive value of carotid ultrasound in combination with passive leg raising on fluid responsiveness in critically ill patients / 中华危重病急救医学

Objective:To investigate the value of monitor carotid velocity time integral (VTI) and corrected flow time (FTc) by bedside ultrasound before and after passive leg raising (PLR) in predicting fluid responsiveness in critically ill patients.Methods:A prospective observational study was conducted. Fifty patients with critical illness admitted to the First People's Hospital of Fuyang Hangzhou from January 2020 to March 2021 were enrolled. The clinical data including the gender, age, body mass index (BMI), acute physiology and chronic health evaluationⅡ(APACHEⅡ) score, and the duration of mechanical ventilation were recorded. The changes of carotid VTI and FTc were measured by bedside ultrasound, and the values of heart rate, mean arterial pressure (MAP), central venous pressure (CVP), stroke volume index (SVI), and intrathoracic blood volume index (ITBVI) were measured by pulse indicated continuous cardiac output (PiCCO) monitor before and after PLR in all patients. According to the changes of SVI before and after PLR, the patients were divided into fluid responsiveness positive group with the change rate of SVI≥15% and fluid responsiveness negative group with the change rate of SVI < 15%. The differences in the values of VTI, FTc, CVP, and ITBVI obtained before and after PLR (ΔVTI, ΔFTc, ΔCVP and ΔITBVI) were calculated and then compared between the two groups. The predictive values of these indicators on fluid responsiveness in critically ill patients were analyzed by receiver operator characteristic curve (ROC curve), and their relationship with the difference in SVI (ΔSVI) obtained before and after PLR was evaluated by Pearson correlation analysis.Results:Fifty patients were all enrolled in this study, in which 27 patients were fluid response and 23 patients were fluid nonresponse. Basic clinical data were not different between the two groups. The values of ΔVTI, ΔFTc, ΔCVP, and ΔITBVI in fluid response were all significantly higher than those in fluid nonresponse [ΔVTI (cm): 2.07±1.16 vs. 0.67±0.86, ΔFTc (ms): 4.00±6.10 vs. 0.01±2.26, ΔCVP (cmH 2O, 1 cmH 2O = 0.098 kPa): 1.67±1.14 vs. 1.00±1.17, ΔITBVI (mL/m 2): 98±69 vs. 48±70, all P < 0.05]. ROC curve analysis showed that ΔVTI, ΔFTc, ΔCVP and ΔITBVI were all positive for predicting fluid responsiveness, their area under ROC curve (AUC) and 95% confidence interval (95% CI) were 0.870 (0.769-0.972), 0.694 (0.547-0.841), 0.684 (0.535-0.832) and 0.709 (0.564-0.855), respectively. When using ΔVTI 0.92 cm, ΔFTc 1.45 ms, ΔCVP 1.50 cmH 2O and ΔITBVI 44.50 mL/m 2 as the threshold values, the sensitivities were 96.3%, 63.0%, 44.4% and 81.5%, and the specificities were 65.2%, 78.3%, 82.6% and 56.5%, respectively, in which the predictive value of ΔVTI was the largest. Pearson correlation analysis indicated that ΔVTI, ΔFTc, ΔCVP, and ΔITBVI were positively associated with ΔSVI ( r values were 0.971, 0.334, 0.440, 0.650, P values were 0.000, 0.018, 0.001, 0.000, respectively). Conclusion:Carotid ΔVTI and ΔFTc monitored by bedside ultrasound before and after PLR could be as effective as conventional indicators in predicting fluid responsiveness in critically ill patients, and the predictive value of ΔVTI was better than others.

Autonomía farmacéutica y biotecnológica frente a emergencias sanitarias / Autonomous pharmaceutical and biotechnological capabilities during sanitary emergencies

La pandemia de COVID 19, ha puesto de presente la necesidad de contar con políticas de autonomía farmacéutica y biotecnológica para cada país. Esta autonomía es necesaria porque en eventos ocasionados por agentes de riesgo biológico, la afectación masiva de la población mundial hace imposible que se cubran las necesidades para todos los países. Muchos medicamentos de interés en salud pública no son producidos por la industria farmacéutica privada dado que los márgenes de ganancia no son importantes para ellos y se encuentran situaciones de desabastecimiento ante brotes de infecciones inusitados.

The COVID 19 pandemic has highlighted the need for pharmaceutical and biotechnology autonomy policies for each country. This autonomy is necessary because in events caused by biological risk agents, the massive involvement of the world population makes it impossible to cover the needs of all countries. Many drugs of public health interest are not produced by the private pharmaceutical industry because the profit margins are not important for them and there are situations of shortages in the event of outbreaks of unusual infections.

O comportamento da pressão arterial após elevação da pressão parcial positiva final pode auxiliar na determinação do status de fluido-responsividade em pacientes com choque séptico? / Can the behavior of blood pressure after elevation of the positive end-expiratory pressure help to determine the fluid responsiveness status in patients with septic shock?

RESUMO Objetivo: Avaliar se a diminuição da pressão arterial provocada pela elevação da pressão parcial positiva final corresponde à variação da pressão de pulso como indicador de fluido-responsividade. Métodos: Estudo de caráter exploratório que incluiu prospectivamente 24 pacientes com choque séptico ventilados mecanicamente e submetidos a três etapas de elevação da pressão parcial positiva final: de 5 para 10cmH2O (nível da pressão parcial positiva final 1), de 10 para 15cmH2O (nível da pressão parcial positiva final 2) e de 15 para 20cmH2O (nível da pressão parcial positiva final 3). Alterações da pressão arterial sistólica, da pressão arterial média e da variação da pressão de pulso foram avaliadas durante as três manobras. Os pacientes foram classificados como responsivos (variação da pressão de pulso ≥ 12%) e não responsivos a volume (variação da pressão de pulso < 12%). Resultados: O melhor desempenho para identificar pacientes com variação da pressão de pulso ≥ 12% foi observado no nível da pressão parcial positiva final 2: variação de pressão arterial sistólica de -9% (área sob a curva de 0,73; IC95%: 0,49 - 0,79; p = 0,04), com sensibilidade de 63% e especificidade de 80%. A concordância foi baixa entre a variável de melhor desempenho (variação de pressão arterial sistólica) e a variação da pressão de pulso ≥ 12% (kappa = 0,42; IC95%: 0,19 - 0,56). A pressão arterial sistólica foi < 90mmHg no nível da pressão parcial positiva final 2 em 29,2% dos casos e em 41,6,3% no nível da pressão parcial positiva final 3. Conclusão: Variações da pressão arterial em resposta à elevação da pressão parcial positiva final não refletem de modo confiável o comportamento da variação da pressão de pulso para identificar o status da fluido-responsividade.

Abstract Objective: To evaluate whether the decrease in blood pressure caused by the increase in the positive end-expiratory pressure corresponds to the pulse pressure variation as an indicator of fluid responsiveness. Methods: This exploratory study prospectively included 24 patients with septic shock who were mechanically ventilated and subjected to three stages of elevation of the positive end-expiratory pressure: from 5 to 10cmH2O (positive end-expiratory pressure level 1), from 10 to 15cmH2O (positive end-expiratory pressure level 2), and from 15 to 20cmH2O (positive end-expiratory pressure level 3). Changes in systolic blood pressure, mean arterial pressure, and pulse pressure variation were evaluated during the three maneuvers. The patients were classified as responsive (pulse pressure variation ≥ 12%) or unresponsive to volume replacement (pulse pressure variation < 12%). Results: The best performance at identifying patients with pulse pressure variation ≥ 12% was observed at the positive end-expiratory pressure level 2: -9% systolic blood pressure variation (area under the curve 0.73; 95%CI: 0.49 - 0.79; p = 0.04), with a sensitivity of 63% and specificity of 80%. Concordance was low between the variable with the best performance (variation in systolic blood pressure) and pulse pressure variation ≥ 12% (kappa = 0.42; 95%CI: 0.19 - 0.56). The systolic blood pressure was < 90mmHg at positive end-expiratory pressure level 2 in 29.2% of cases and at positive end-expiratory pressure level 3 in 41.63% of cases. Conclusion: Variations in blood pressure in response to the increase in positive end-expiratory pressure do not reliably reflect the behavior of the pulse pressure as a measure to identify the fluid responsiveness status.