Role of coagulation dysfunction in thrombocytopenia-related death in patients with septic shock / 中华危重病急救医学

OBJECTIVE@#To explore the effect of thrombocytopenia on the prognosis of patients with septic shock and its mechanism in leading to death.@*METHODS@#A retrospective case-control study was conducted. Patients with septic shock admitted to emergency intensive care unit (EICU) and intensive care unit (ICU) in Peking University People's Hospital from April 1, 2015 to January 31, 2023 were enrolled. Patients were divided into the thrombocytopenia group and the non-thrombocytopenia group, according to whether the minimum platelet count was less than 100×109/L within 24 hours after admission to ICU. The outcome index was the mortality during ICU stay. The baseline data, hospitalization information and laboratory test results of the two groups were compared, and the risk factors of in-hospital death were analyzed by Logistic regression, and the mediation effect was performed by Bootstrap method.@*RESULTS@#A total of 301 patients with septic shock were enrolled, of which 172 (57.1%) had thrombocytopenia and 129 (42.9%) did not. There were significant differences between the two groups in age, mortality, disseminated intravascular coagulation (DIC), continuous renal replacement therapy, and level of creatinine, urea nitrogen, total bilirubin, white blood cell count, lymphocyte count, prothrombin time (PT) and activated partial thromboplastin time (APTT). Univariate Logistic regression analysis showed thrombocytopenia [odds ratio (OR) = 4.478], continuous renal replacement therapy (OR = 4.601), DIC (OR = 6.248), serum creatinine (OR = 1.005), urea nitrogen (OR = 1.126), total bilirubin (OR = 1.006) and PT (OR = 1.126) were risk factors of death during hospitalization in patients with septic shock (all P < 0.05). Multivariate Logistic regression analysis showed that thrombocytopenia [OR = 3.338, 95% confidence interval (95%CI) was 1.910-5.834, P = 0.000], continuous renal replacement therapy (OR = 3.175, 95%CI was 1.576-6.395, P = 0.001) and PT (OR = 1.077, 95%CI was 1.011-1.147, P = 0.021) were independent risk factors for in-hospital mortality in patients with septic shock. Mediation analysis showed that 51% of the deaths due to thrombocytopenia in patients with septic shock were due to coagulopathy.@*CONCLUSIONS@#Thrombocytopenia is a powerful predictor of death in septic shock patients, and half of all thrombocytopenia-related deaths may be due to abnormal coagulation function.

Stress hyperglycemia and nutritional therapy / 中华危重病急救医学

Stress induced hyperglycemia is the body's protect response against strong (patho-physiological and/or psychological) stress, sometimes the blood glucose level is too high due to out of the body's adjustment. Renal glucose threshold (about 9 mmol/L) is a window of glucose leak from capillary to interstitial tissue. It is important to keep blood glucose level < 9 mmol/L, for reducing vascular sclerosis as well as organs hypoperfusion, meanwhile pay attention to preventing more dangerous hypoglycemia. Glucose, as the main energy substrate, should be daily supply and its metabolism should be monitored. We used to talk "nutritional support". Support is conform the physiological ability of host, but therapy is to coordinate and change pathophysiology. So, nutritional support is not equal to nutritional therapy. For critical ill patients, we need to emphasize "nutritional therapy", i.e, do not give nutritional treatment without metabolic monitoring, make up for deficiencies and avoid metabolites overloading, rational adjustment to protect and coordinate organs function.

Risk factors for perioperative hypotension in severe patients after liver cancer surgery / 临床肝胆病杂志

Objective To investigate the risk factors for perioperative hypotension in severe patients after liver cancer surgery and its influence on prognosis. Methods A retrospective analysis was performed for the clinical data of 422 patients who underwent surgical treatment due to primary liver cancer or metastatic liver cancer and were then admitted to the intensive care unit (ICU) of Peking University People's Hospital from January 2014 to December 2019. The 107 patients requiring continuous intraoperative or postoperative pumping of vasoactive drugs (norepinephrine, dopamine, phenylephrine, and epinephrine) to maintain blood pressure were included in the hypotension group, and the 315 patients who did not require the pumping of vasoactive drugs to maintain blood pressure were included in the non-hypotension group. Related clinical data were collected from all patients, including sex, age, body mass index, history of liver surgery, comorbidities, underlying liver diseases, preoperative laboratory examinations, surgical data, and anesthesia, and the two groups were compared in terms of related prognostic indicators (in-hospital mortality, length of ICU stay, length of hospital stay, duration of mechanical ventilation, acute kidney injury, hypoxemia, pulmonary infection, and myocardial injury). The independent samples t -test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test was used for comparison of categorical data between two groups. The clinical indices with P < 0.1 were included in the binary logistic regression analysis to investigate the risk factors for hypotension. Results The overall mortality rate was 1.9% for the severe patients after liver cancer surgery, with a mortality rate of 3.7% in the hypotension group and 1.3% in the non-hypotension group. Compared with the non-hypotension group, the hypotension group had a significantly longer length of ICU stay ( Z =-6.440, P < 0.001), a significantly longer duration of mechanical ventilation ( Z =-6.082, P < 0.001), and a significantly higher proportion of patients with acute kidney injury, hypoxemia, and pulmonary infection after surgery ( χ 2 =25.661, 25.409, and 20.126, all P < 0.001). The clinical indices with P < 0.1 between the two groups (coronary heart disease, ascites, preoperative levels of albumin/platelets/fibrinogen, time of operation and hepatic portal occlusion, laparotomy, blood loss) were included in the binary logistic regression analysis, and the results showed that time of operation (odds ratio [ OR ]=1.004, 95% confidence interval [ CI ]: 1.002-1.006, P < 0.05) and blood loss ( OR =1.151, 95% CI : 1.009-1.313, P < 0.05) were independent risk factors for hypotension in patients undergoing liver cancer surgery, while preoperative albumin level ( OR =0.950, 95% CI : 0.907-0.995, P < 0.05) was a protective factor. Conclusion There is a relatively high incidence rate of hypotension among severe patients after liver cancer surgery, and a longer time of operation and greater blood loss are independent risk factors for hypotension, while a higher preoperative albumin level is a protective factor.

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.

Comparison of pulmonary circulation hemodynamics and respiratory mechanics induced by drowning with equal volume of freshwater and seawater in sheep: a randomized controlled study / 中华危重病急救医学

Objective:To compare the effects of freshwater and seawater drowning on sheep's pulmonary circulation hemodynamics and respiratory mechanics.Methods:According to the random number table method, healthy crossbred sheep were divided into freshwater drowning group ( n = 12) and seawater drowning group ( n = 12). 30 mL/kg of freshwater or seawater was infused respectively through trachea for approximately 5 minutes. Before the drowning, immediately after drowning, and 30, 60, 120 minutes after drowning, the systemic circulation hemodynamic parameters [heart rate (HR), mean arterial pressure (MAP), cardiac output (CO)] were monitored by pulse indicator continuous cardiac output (PiCCO); the respiratory parameters were obtained through the ventilator, including tidal volume (VT), lung compliance (Cdyn), oxygenation index (PaO 2/FiO 2), peak airway pressure (Ppeak)]; PiCCO and the right heart floating catheter (Swan-Ganz catheter) was used to measure pulmonary hemodynamic parameters [pulmonary systolic pressure (PAS), pulmonary diastolic pressure (PAD), pulmonary artery wedge pressure (PAWP), and extravascular lung water (EVLW)]. The animals were sacrificed at the end of the experiment, and the amount of residual water in the respiratory tract was measured; the pathological changes in the lung tissue were observed by hematoxylin-eosin (HE) staining. Results:① Systemic circulation hemodynamics: compared with the values before drowning, HR, MAP, and CO at the time of immediately after drowning in both freshwater and seawater were significantly increased and peaked. In addition, all indicators in the freshwater drowning group were significantly higher than those in the seawater drowning group [HR (bpm): 170.75±1.87 vs. 168.67±2.27, MAP (mmHg, 1 mmHg = 0.133 kPa): 172.92±1.62 vs. 159.42±3.18, CO (L/min): 13.27±0.71 vs. 10.33±0.73, all P < 0.05].② Respiratory parameters: compared with values before drowning, PaO 2/FiO 2, VT, and Cdyn decreased immediately in both freshwater and seawater drowning groups, Ppeak was significantly increased; in addition, the values in the seawater drowning group were decreased or increased more significantly than freshwater drowning group [PaO 2/FiO 2 (mmHg): 37.83±1.99 vs. 60.42±5.23, VT (mL): 86.25±7.66 vs. 278.75±9.67, Cdyn (mL/cmH 2O): 8.86±0.33 vs. 23.02±0.69, Ppeak (cmH 2O, 1 cmH 2O = 0.098 kPa): 42.17±2.69 vs. 17.67±1.15, all P < 0.01]. In addition, PaO 2/FiO 2 in the freshwater drowning group was gradually increased over time, while the seawater group continued to decline.③ Pulmonary circulation hemodynamic parameters: PAS, PAD, PAWP at the time of immediately after drowning in both freshwater and seawater groups were significantly higher than before drowning; in addition, the freshwater drowning group was significantly higher than the seawater drowning group [PAS (mmHg): 34.58±2.87 vs. 26.75±1.66, PAD (mmHg): 27.25±1.22 vs. 16.75±0.87, PAWP (mmHg): 27.83±1.85 vs. 11.75±1.82, all P < 0.01]. Thereafter, PAS and PAD in the freshwater drowning group gradually decreased, while the parameters in the seawater drown group continued to increase. PAWP gradually decreased after freshwater or seawater drowning, and recovered to pre-drowning levels 120 minutes after drowning and 30 minutes after drowning, respectively. EVLW continued to increase after freshwater drowning, reaching a peak at 30 minutes, and then decreased, until 120 minutes after drowning was still significantly higher than that before drowning (mL/kg: 10.73±1.27 vs. 7.67±0.69, P < 0.01); EVLW could not be measured.④ Residual water in the respiratory tract: residual water in the freshwater drowning group was significantly less than that in the seawater drowning group (mL: 164.33±25.21 vs. 557.33±45.23, P < 0.01).⑤ HE staining: partial alveolar atrophied in the freshwater drowning group, some alveolar spaces were broken, alveolar spaces and alveolar cavity showed a little powdery substance deposition; it was noted that alveolar expanded in the seawater drowning group, alveolar spaces were broken and bleeding and edema were obvious in the interstitial space. Conclusion:The effect of seawater drowning on the respiratory mechanics and pulmonary circulation of animals is more obvious than that of freshwater drowned animals, and the amount of residual water in the respiratory tract is also significantly more than that of freshwater drowned animals.

Cytokine-like protein 1 enhances the pro-inflammatory functions of neutrophils in septic mice / 中华急诊医学杂志

Objectives:To analyze the effect of cytokine-like protein 1 (CYTL1) on the pro-inflammatory functions of neutrophils in septic mice.Methods:C57BL/6 mice were randomly (random number)divided into the sepsis group and control group, with 6-12 mice in each group. A septic mouse model was established by the procedure of cecal ligation and puncture (CLP). Neutrophils were isolated from peripheral venous blood 8 h after the procedures according to the density gradient centrifugation method, and the neutrophils were treated with CYTL1 recombinant protein. The Boyden chemotaxis assays were used to detect the activity of CYTL1. fMLF and interleukin-8 were used as positive controls. Phagocytosis was determined by confocal microscopy or on a FACSVerse. Reactive oxygen species generation in neutrophils were monitored with the commercial CellROX Green fluorescent probe.Results:Compared with the control group, CYTL1 showed strong chemotactic activity on neutrophils of septic mice [(10.0 ± 2) vs (66.3 ± 4), t=-21.6, P <0.0001]. CYTL1 has stronger chemotactic activity than IL-8 [(66.3 ± 4.0) vs (21.7 ± 6.5), t = 10.1, P = 0.001]. But the chemotactic activity of fMLF and CYTL1 changed little on neutrophils of septic mice [(66.3 ± 4.0) vs (86.0 ± 13.5), t=-2.4, P = 0.073]. CYTL1 could augment the uptake of E.coli by neutrophils compared with the sepsis group [(7.35 ± 1.66) vs (2.84 ± 0.62), t = 4.4, P = 0.012]. The number of E.coli particles swallowed intracellular by a single cell significantly increased upon the stimulation of CYTL1. CYTL1 could also enhance the intracellular reactive oxygen species production of neutrophils of septic mice [(84340.1 ± 5353.5) vs (351018.7 ± 72291.7), t = 6.4, P = 0.003]. Conclusions:CYTL1 can prompt the pro-inflammatory functions of neutrophils in septic mice. In the early phase of bacterial infection, this protein may play an important role in regulating the inflammation.

Comparison between daptomycin plasma concentration in left ventricle and that in right ventricle of rats / 中国中西医结合急救杂志

Objective To detect the plasma concentrations of daptomycin in the left ventricle and right ventricle of rats by high-performance liquid chromatography-mass spectrometry(LC-MS/MS), and evaluate the therapeutic effect of daptomycin on left ventricular endocarditis. Methods Thirty-five healthy Sprague-Dawley (SD) rats were divided into a normal saline group (5 rats) and a daptomycin group (30 rats) according to the random number table method. The daptomycin group was subdivided into 6 subgroups according to the times of blood collection (0.25, 0.5, 1, 2, 4, 8 hours), with 5 rats in each subgroup. The normal saline group was given 4 mL/kg normal saline; the daptomycin group was injected with 50 mg/kg daptomycin into the tail vein. The blood samples from left ventricle and right ventricle were extracted at the corresponding time points, the plasma concentrations of daptomycin group were determined by high performance liquid chromatography-mass spectrometry (HPLC-MS) and the differences of left ventricular and right ventricular plasma concentrations were compared at different time points. The plasma in normal saline group was the blank plasma that was used for HPLC-MS methodological evaluation. Results There were no statistical significant differences between the left ventricle and right ventricle in plasma concentrations of daptomycin at 0.25, 0.5, 1, 2, 4, and 8 hours after administration (g/L: 2.67±0.30 vs. 2.77±0.31, 1.77±1.27 vs. 1.64±0.55, 1.35±0.40 vs. 1.36±0.41, 0.97±0.07 vs. 0.92±0.09, 0.73±0.16 vs. 0.65±0.18, 0.07±0.06 vs. 0.06±0.05, respectively all P > 0.05). Conclusion There are no significant differences between the left ventricle and right ventricle in plasma concentrations of daptomycin. It is speculated that daptomycin may have the same therapeutic effect on left endocarditis.

Characteristics and failure risk factors of sequential high-flow nasal cannula oxygen therapy after weaning from invasive ventilation in patients of surgical intensive care unit / 中华危重病急救医学

Objective To investigate the characteristics and failure risk factors of sequential high-flow nasal cannula oxygen therapy (HFNC) after weaning from invasive ventilation. Methods The patients who received sequential HFNC after weaning from invasive ventilation admitted to surgical intensive care unit (ICU) of Peking University People's Hospital from June 1st 2016 to May 31st 2018 were retrospectively analyzed. Clinical variables, respiratory therapy parameters, respiratory variables, cardiac variables and outcomes were reviewed and analyzed. Treatment characteristics of HFNC after weaning was analyzed. Patients were divided into HFNC success group and HFNC failure group according to the failure of HFNC, and the differences between the two groups were compared. The independent risk factors of HFNC treatment failure were analyzed by Logistic regression analysis. The value of predictive treatment failure of risk factors and regression models were analyzed by receiver operating characteristic (ROC) curve. Results A total of 99 patients were included, 61 men, and the median age was 67.0 (57.0, 76.0) years old. The medianinitial HFNC flow was 50 (50, 60) L/min, and inspired oxygen concentration (FiO2) was 0.50 (0.40, 0.60). Eighteen patients experienced HFNC failure (18.2%). Compared with the HFNC success group, the sequential organ failure assessment (SOFA) score in the HFNC failure group was higher [4 (3, 5) vs. 2 (1, 3), P < 0.01], B type natriuretic peptide (BNP) before HFNC therapy were significant higher [ng/L: 647.2 (399.2, 1 331.3) vs. 127.2 (55.2, 369.5), P < 0.01], and respiratory frequency (RR) and heart rate (HR) were significant faster, mean arterial pressure (MAP) was significant higher, oxygen index (PaO2/FiO2) was significant lower after 30 minutes HFNC treatment [RR (times/min): 26 (22, 28) vs. 19 (17, 21), HR (bpm): 105 (97, 107) vs. 85 (77, 90), MAP (mmHg, 1 mmHg = 0.133 kPa): 104.3 (101.7, 110.7) vs. 92.3 (88.3, 97.7), PaO2/FiO2 (mmHg): 207.3 (185.8, 402.8) vs. 320.2 (226.2, 361.5), all P < 0.05]. It was shown by multiple Logistic regression analysis that the SOFA score [odds ratio (OR) = 2.818, P = 0.022, β = 1.036], BNP before HFNC treatment (OR = 1.002, P = 0.033, β = 0.002) and HR after HFNC treatment 30 minutes (OR = 1.140, P = 0.032, β = 0.131) were independent risk factors for HFNC treatment failure. It was shown by ROC curve that the area under the ROC curve (AUC) for the prediction of HFNC failure was 0.840, 0.859, 0.860 and 0.962 for SOFA, BNP before HFNC treatment, HR after HFNC treatment 30 minutes, and regression model, all had good forecast values (all P < 0.01). Conclusions HFNC is one of the commonly used oxygen therapy methods in the ICU, but not all patients who are treated as a sequential therapy after invasive mechanical ventilation weaning can benefit from it. SOFA score, BNP before HFNC treatment and HR after 30 minutes HFNC treatment were independent risk factors of HFNC failure. Each independent risk factor and regression model can predict the success of HFNC treatment.

Application of venous return curve in hemodynamic intervention of shock patients / 中华危重病急救医学

In the cardiac output (CO) and venous return (VR) balance theory proposed by Guyton in the 1950s, the right atrial pressure (Pra) was used as the dependent variable, and the VR and right cardiac function curves were recorded simultaneously. The intersection of the two curves is the current circulating blood flow under the Pra at this moment. In patients with hemodynamically unstable shock, the primary treatment goal is to restore circulating blood volume and tissue perfusion with primary methods including fluid resuscitation and the use of vasoactive drugs. This review described the dynamic evolution of VR curve in hemodynamic intervention of shock patients and the changes in physiological indicators such as mean systemic filling pressure (Pmsf), venous resistance (Rv), and stressed volume (Vs), in order to more accurately interpret changes in hemodynamic parameters and guide the clinical treatment of shock from a goal-oriented perspective.

Promoting patient- and family-centered care services in intensive care unit / 中华危重病急救医学

In recent years, more and more people have recognized the importance of patients' family in the intensive care unit (ICU) in medical care, and advocated the use of patient- and family-centered care (PFCC) in the ICU. This article explains the content (family presence, family support, communication with family members, consultations and ICU team members, environmental issues) and significance of PFCC in the ICU, and provides guidance for the practice of PFCC in China.

Role of adenosine A2b receptors in pulmonary microvascular endothelial inflammation induced by lipopolysaccharide / 中华危重病急救医学

Objective To explore the role of the low-affinity A2b adenosine receptors (Adora2b) in pulmonary microvascular endothelial inflammation induced by lipopolysaccharide and its mechanism. Methods Rat pulmonary microvascular endothelial cells (PMVECs) were isolated and cultured in vitro. After serum deprivation for 24 hours, cells were pretreated with Adora2b specific agonist BAY60-6583 (0.1, 1, 10 μmol/L) or Adora2b specific antagonist PSB1115 (1 μmol/L) for 1 hour, respectively, and then challenged with LPS (100 μg/L). Cells without treatment were served as the control group, and those treated with LPS, BAY60-6583 or PSB1115 alone were served as single challenge groups. After incubation with specific drugs for 24 hours, the apoptosis of PMVECs was analyzed by flow cytometry using Annexin V/propidium iodide (PI) technique. The levels of early inflammatory factors in cultured medium were measured using enzyme linked immunosorbent assay (ELISA). The mRNA expressions of chemotactic factors and adhesion molecules were determined by real-time quantitative-polymerase chain reaction (RT-qPCR). Polymorph nuclear neutrophils (PMNs) from venous blood of healthy rats were isolated, and PMN migration through PMVECs monolayer under stimulation of drugs was observed in transwell inserts. The monolayer permeability of PMVECs after adhesion of PMNs was determined by fluorescein isothiocyanate (FITC)-albumin assay. Oxidative stress was detected by DCFH-DA assay. Results Compared with the control group, more cells entered into the apoptosis stage after LPS challenge. Meanwhile, the levels of interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α) in cultured medium were significantly increased, as well as the mRNA expressions of chemotactic factors [C-X-C motif chemokine ligand 1 (CXCL-1), CXCL-3 and monocyte chemoattractant protein-1 (MCP-1)] and adhesion molecules [E-selectin, intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1)]. More PMNs migrated through PMVECs following adhesion and the monolayer permeability of PMVECs was rapidly enhanced. The oxidative stress was upregulated. Compared with LPS group, BAY60-6583 pretreatment could dose-dependently decrease the rate of apoptosis, attenuate trans-endothelial migration of PMNs and decrease the endothelial cell barrier leakage. There were significant differences even after incubation of 0.1 μmol/L BAY60-6583 [apoptosis rate: (21.12±2.12)％vs. (27.66±3.57)％, number of migrated PMNs/HP: 260.60±18.24 vs. 290.20±16.48, permeability coefficient (Pd, ×10-6 cm/s): 28.28±2.04 vs. 32.55±2.13, all P < 0.05]. Meanwhile, BAY60-6583 pretreatment also downregulated the levels of early proinflammatory factors in a dose-dependent manner as well as the mRNA expressions of chemotactic factors and adhesion molecules. The statistic difference was significant while treated with 1 μmol/L BAY60-6583 [IL-1β(ng/L): 475.75±63.15 vs. 755.25±67.42, TNF-α (ng/L): 560.25±69.96 vs. 818.75±60.92, CXCL-1 mRNA (2-ΔΔCt):3.57±0.28 vs. 5.27±0.69, CXCL-3 mRNA (2-ΔΔCt): 4.56±0.48 vs. 7.32±0.54, MCP-1 mRNA (2-ΔΔCt): 2.21±0.31 vs. 3.35±0.21, E-selectin mRNA (2-ΔΔCt): 4.64±0.09 vs. 7.28±0.73, ICAM-1 mRNA (2-ΔΔCt): 4.14±0.30 vs. 5.89±0.25, VCAM-1 mRNA (2-ΔΔCt): 2.23±0.19 vs. 2.92±0.33, all P < 0.05]. Furthermore, pretreatment of 10 μmol/L BAY60-6583 could decrease the oxidative stress [reactive oxygen species (RFU): 629.05±33.10 vs. 781.45±64.59, P < 0.05]. Contrast, PSB1115 pretreatment aggravated apoptosis of PMVECs after LPS incubation [(34.36±4.57)％ vs. (27.66±3.57)％], upregulated expressions of proinflammatory and chemotactic factors as well as adhesion molecules [IL-1β (ng/L): 889.00±63.11 vs. 755.25±67.42, TNF-α (ng/L): 939.00±43.44 vs. 818.75±60.92, CXCL-1 mRNA (2-ΔΔCt): 6.66±0.65 vs. 5.27±0.69, CXCL-3 mRNA (2-ΔΔCt): 10.42±0.51 vs. 7.32±0.54, MCP-1 mRNA (2-ΔΔCt):4.85±0.34 vs. 3.35±0.21, E-selectin mRNA (2-ΔΔCt): 8.42±0.47 vs. 7.28±0.73, ICAM-1 mRNA (2-ΔΔCt): 7.46±0.72 vs. 5.89±0.25, VCAM-1 mRNA (2-ΔΔCt): 4.35±0.26 vs. 2.92±0.33], aggravated trans-endothelial migration of PMNs (cells/HP: 348.40±22.68 vs. 290.20±16.48), enhanced the leakage of PMVECs monolayer [Pd (×10-6 cm/s):39.65±2.69 vs. 32.55±2.13] and increased oxidative stress in PMVECs [reactive oxygen species (RFU): 847.04±29.26 vs. 781.45±64.59], with statistically significant difference (all P < 0.05). Conclusion Activation of endothelial Adora2b attenuates LPS-induced pulmonary microvascular inflammation by decreasing the release of early inflammatory factors, downregulating expressions of chemotactic factors and adhesion molecules, attenuating trans-endothelial migration of PMNs and oxidative stress in PMVECs, which suggest endothelial Adora2b is apotential anti-inflammatory target in the treatment of LPS-induced acute lung injury.

Role of adenosine A2b receptors in pulmonary microvascular endothelial inflammation induced by lipopolysaccharide / 中华危重病急救医学

Objective@#To explore the role of the low-affinity A2b adenosine receptors (Adora2b) in pulmonary microvascular endothelial inflammation induced by lipopolysaccharide and its mechanism.@*Methods@#Rat pulmonary microvascular endothelial cells (PMVECs) were isolated and cultured in vitro. After serum deprivation for 24 hours, cells were pretreated with Adora2b specific agonist BAY60-6583 (0.1, 1, 10 μmol/L) or Adora2b specific antagonist PSB1115 (1 μmol/L) for 1 hour, respectively, and then challenged with LPS (100 μg/L). Cells without treatment were served as the control group, and those treated with LPS, BAY60-6583 or PSB1115 alone were served as single challenge groups. After incubation with specific drugs for 24 hours, the apoptosis of PMVECs was analyzed by flow cytometry using Annexin V/propidium iodide (PI) technique. The levels of early inflammatory factors in cultured medium were measured using enzyme linked immunosorbent assay (ELISA). The mRNA expressions of chemotactic factors and adhesion molecules were determined by real-time quantitative-polymerase chain reaction (RT-qPCR). Polymorph nuclear neutrophils (PMNs) from venous blood of healthy rats were isolated, and PMN migration through PMVECs monolayer under stimulation of drugs was observed in transwell inserts. The monolayer permeability of PMVECs after adhesion of PMNs was determined by fluorescein isothiocyanate (FITC)-albumin assay. Oxidative stress was detected by DCFH-DA assay.@*Results@#Compared with the control group, more cells entered into the apoptosis stage after LPS challenge. Meanwhile, the levels of interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α) in cultured medium were significantly increased, as well as the mRNA expressions of chemotactic factors [C-X-C motif chemokine ligand 1 (CXCL-1), CXCL-3 and monocyte chemoattractant protein-1 (MCP-1)] and adhesion molecules [E-selectin, intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1)]. More PMNs migrated through PMVECs following adhesion and the monolayer permeability of PMVECs was rapidly enhanced. The oxidative stress was upregulated. Compared with LPS group, BAY60-6583 pretreatment could dose-dependently decrease the rate of apoptosis, attenuate trans-endothelial migration of PMNs and decrease the endothelial cell barrier leakage. There were significant differences even after incubation of 0.1 μmol/L BAY60-6583 [apoptosis rate: (21.12±2.12)% vs. (27.66±3.57)%, number of migrated PMNs/HP: 260.60±18.24 vs. 290.20±16.48, permeability coefficient (Pd, ×10-6 cm/s): 28.28±2.04 vs. 32.55±2.13, all P < 0.05]. Meanwhile, BAY60-6583 pretreatment also downregulated the levels of early proinflammatory factors in a dose-dependent manner as well as the mRNA expressions of chemotactic factors and adhesion molecules. The statistic difference was significant while treated with 1 μmol/L BAY60-6583 [IL-1β (ng/L): 475.75±63.15 vs. 755.25±67.42, TNF-α (ng/L): 560.25±69.96 vs. 818.75±60.92, CXCL-1 mRNA (2-ΔΔCt): 3.57±0.28 vs. 5.27±0.69, CXCL-3 mRNA (2-ΔΔCt): 4.56±0.48 vs. 7.32±0.54, MCP-1 mRNA (2-ΔΔCt): 2.21±0.31 vs. 3.35±0.21, E-selectin mRNA (2-ΔΔCt): 4.64±0.09 vs. 7.28±0.73, ICAM-1 mRNA (2-ΔΔCt): 4.14±0.30 vs. 5.89±0.25, VCAM-1 mRNA (2-ΔΔCt): 2.23±0.19 vs. 2.92±0.33, all P < 0.05]. Furthermore, pretreatment of 10 μmol/L BAY60-6583 could decrease the oxidative stress [reactive oxygen species (RFU): 629.05±33.10 vs. 781.45±64.59, P < 0.05]. Contrast, PSB1115 pretreatment aggravated apoptosis of PMVECs after LPS incubation [(34.36±4.57)% vs. (27.66±3.57)%], upregulated expressions of proinflammatory and chemotactic factors as well as adhesion molecules [IL-1β (ng/L): 889.00±63.11 vs. 755.25±67.42, TNF-α (ng/L): 939.00±43.44 vs. 818.75±60.92, CXCL-1 mRNA (2-ΔΔCt): 6.66±0.65 vs. 5.27±0.69, CXCL-3 mRNA (2-ΔΔCt): 10.42±0.51 vs. 7.32±0.54, MCP-1 mRNA (2-ΔΔCt): 4.85±0.34 vs. 3.35±0.21, E-selectin mRNA (2-ΔΔCt): 8.42±0.47 vs. 7.28±0.73, ICAM-1 mRNA (2-ΔΔCt): 7.46±0.72 vs. 5.89±0.25, VCAM-1 mRNA (2-ΔΔCt): 4.35±0.26 vs. 2.92±0.33], aggravated trans-endothelial migration of PMNs (cells/HP: 348.40±22.68 vs. 290.20±16.48), enhanced the leakage of PMVECs monolayer [Pd (×10-6 cm/s): 39.65±2.69 vs. 32.55±2.13] and increased oxidative stress in PMVECs [reactive oxygen species (RFU): 847.04±29.26 vs. 781.45±64.59], with statistically significant difference (all P < 0.05).@*Conclusion@#Activation of endothelial Adora2b attenuates LPS-induced pulmonary microvascular inflammation by decreasing the release of early inflammatory factors, downregulating expressions of chemotactic factors and adhesion molecules, attenuating trans-endothelial migration of PMNs and oxidative stress in PMVECs, which suggest endothelial Adora2b is apotential anti-inflammatory target in the treatment of LPS-induced acute lung injury.

Risk factors associated with myocardial injury after non-cardiac major surgery in ICU admitted patients / 中华普通外科杂志

Objective@#To analyze the risk factors related to the myocardial injury after non-cardiac surgery (MINS) in patients who underwent major abdominal surgery.@*Methods@#The clinical data of all patients admitted in the surgical ICU of Peking University People′s Hospital from Jan 2016 to Dec 2018 were analyzed. Logistic multivariate analysis was performed to analyze the association of clinical characteristics with the incidence of MINS.@*Results@#A total of 322 patients were included, 48.4% (156/322) were diagnosed as with MINS. 97.4% (152/156) of MINS occurred during the first 72 h of admission. Multivariate analysis showed that independent predictive factors of MINS were age >65y (OR=1.747, P=0.021), body mass index (OR=1.085, P=0.008), acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ, OR=1.066; P=0.047), hypertension (OR=1.747, P=0.027), blood lactate (OR=1.393, P=0.001) and acute kidney injury (OR=2.065, P=0.047).@*Conclusions@#The incidence of MINS in patients who underwent major abdominal surgery was high. Age, body mass index, APACHE Ⅱ score, hypertension, blood lactate level and acute kidney injury after surgery were independent risk factors of MINS.

Risk factors associated with myocardial injury after non-cardiac major surgery in ICU admitted patients / 中华普通外科杂志

Objective To analyze the risk factors related to the myocardial injury after non-cardiac surgery (MINS) in patients who underwent major abdominal surgery.Methods The clinical data of all patients admitted in the surgical ICU of Peking University People's Hospital from Jan 2016 to Dec 2018 were analyzed.Logistic multivariate analysis was performed to analyze the association of clinical characteristics with the incidence of MINS.Results A total of 322 patients were included,48.4％ (156/322) were diagnosed as with MINS.97.4％ (152/156) of MINS occurred during the first 72 h of admission.Multivariate analysis showed that independent predictive factors of MINS were age ＞ 65y (OR =1.747,P =0.021),body mass index (OR =1.085,P =0.008),acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ,OR =1.066;P =0.047),hypertension (OR =1.747,P =0.027),blood lactate (OR =1.393,P=0.001) and acute kidney injury (OR=2.065,P=0.047).Conclusions The incidence ofMINS in patients who underwent major abdominal surgery was high.Age,body mass index,APACHE Ⅱ score,hypertension,blood lactate level and acute kidney injury after surgery were independent risk factors of MINS.

Clinical features and outcomes of patients with the cardio-renal syndrome admitting to a surgical intensive care unit / 中华危重病急救医学

Objective To investigate the clinical features and risk factors on outcomes of patients with cardio-renal syndrome (CRS) in surgical intensive care unit (SICU). Methods The clinical data of the patients admitted to SICU of Peking University People's Hospital from January 1st 2017 to December 31st 2017 were analyzed retrospectively, including gender, age, severity of the disease, underlying diseases, type of CRS, precipitating factors of CRS, cardiac and renal function [cardiac troponin I (cTnI), B-type natriuretic peptide (BNP), serum creatinine (SCr), glomerular filtration rate (eGFR)], outcomes [secondary outcomes, duration of mechanical ventilation, the length of ICU stay, the length of hospital stay, 28-day mortality and hospital mortality]. Patients were grouped according to CRS classification or hospitalization prognosis, the clinical features within different CRS types were analyzed, and risk factors on outcomes of the CRS patients were analysed by Logistic regression. Results 86 (7.3%) of the 1 172 patients during the study period had CRS. ①CRS clinical features: CRS 1-5 type patients accounted for 24.4% (21 cases), 1.2% (1 case), 20.9% (18 cases), 1.2% (1 case) and 52.3% (45 cases) respectively, CRS type 1, 3 and 5 were the main types (i.e. acute cardiac and renal dysfunction), while type 5 CRS was the highest (i.e. organ dysfunction caused by simultaneous involvement of cardiac and renal functions secondary to systemic diseases was the most common). Baseline BNP (Z = 11.365, P =0.023), SCr peak (Z = 13.405, P = 0.009) and baseline eGFR (F = 2.648, P = 0.037) were significantly different within the CRS 5 types. The basic cardiac function of type 1 CRS patients was significantly worse than that of type 3 and type 5 CRS patients [baseline BNP (μg/L): 434.2 (187.0, 1 252.0) vs. 154.9 (66.4, 272.5), 268.5 (124.1, 486.6), both P <0.05]. The basic renal function of type 3 CRS patients was significantly worse than that of type 5 CRS patients [baseline eGFR (mL/min): 71.0±30.3 vs. 88.3±29.0, P < 0.05]. The severity of acute kidney injury (AKI) in type 3 CRS patients was significantly higher than that in type 1 and type 5 CRS patients [SCr peak (μmol/L): 285.0 (171.5, 420.6) vs. 143.0 (99.5, 213.5), 189.0 (105.5, 280.5), both P < 0.01]. There were no significant differences in gender, age, department, acute physiology and chronic health evaluationⅡ (APACHEⅡ), intraoperative blood loss, basic cTnI and SCr levels, BNP peak, AKI staging and prognostic indicators among patients with various types of CRS. ② Death risk analysis:43 (50%) of the 86 CRS patients died during the hospital stay. Compared with the survival patients, CRS death patients were older [years old: 72 (57, 80) vs. 62 (50, 73)] and had higher APACHEⅡ score [22 (17, 29) vs. 18 (15, 21)], with higher proportion of cerebrovascular disease (9.3% vs. 0). Regarding to precipitating factors of CRS, sepsis/septic shock (41.9% vs. 18.6%) and surgery stress (9.3% vs. 0) were remarkably increased in death patients. Death patients had higher cTnI and SCr peak [cTnI peak (μg/L): 1.155 (0.192, 5.125) vs. 0.122 (0.045, 0.610), SCr peak (μmol/L): 208 (143, 295) vs. 146 (101, 289)] and also high proportion of AKI stage 3 (41.9% vs. 20.9%), higher rate of secondary infection (67.4% vs. 30.2%), prolonged duration of mechanical ventilation and the length of ICU stay [hours: 179 (61, 470) vs. 37 (7, 134);days: 10 (4, 24) vs. 5 (2, 11)], with statistically significant differences (all P < 0.05). Logistic regression analysis showed that the elderly [odds ratio (OR) = 1.053, 95% confidence interval (95%CI) = 1.003-1.094, P = 0.010], high APACHE Ⅱscore (OR = 1.165, 95%CI = 1.057-1.285, P = 0.002), sepsis/septic shock (OR = 4.561, 95%CI = 1.351-15.391, P = 0.014) and AKI stage 3 (OR = 5.468, 95%CI = 1.457-20.530, P = 0.012) were independent risk factors for hospital death in CRS patients. Conclusions Surgical ICU patients with CRS are characterized by acute cardiac and renal dysfunction. CRS type 5 is the most common and has a high fatality rate. Age, severity of illness, sepsis/septic shock and AKI stage 3 are independent risk factors of death.

Clinical characteristics and predictors of mortality in patients with candidemia in intensive care unit / 中华危重病急救医学

Objective To investigate the clinical characteristics and predictors of mortality in patients with candidemia in intensive care unit (ICU). Methods The patients with candidemia admitted to ICU of Peking University People's Hospital from January 2010 to December 2017 were enrolled. The general clinical data, indicators related to Candidia infection and prognosis were collected, and the clinical characteristics, infection characteristics and prognosis of patients with candidiasis were analyzed. Patients were divided into death group and survival group according to hospital survival status. The differences of each index were compared between two groups. The independent risk factors of mortality in patients with candidemia were analyzed by multivariate Logistic regression analysis. Results A total of 95 patients (55 males) with candidemia were included, with an average age of (69.3±16.5) years, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) was 24.7±3.6, sequential organ failure assessment (SOFA) was 6.6±2.7. Candida albicans accounted for the largest proportion of Candida infections (n = 56, 58.9%). Thirty-two (33.7%) patients received inadequate antifungal therapy and 38 (40.0%) patients received inadequate source control. Fifty-five (57.9%) patients were died in hospital. Compared with the survival group, patients in the death group was older (years: 72.5±14.6 vs. 64.9±18.0, P < 0.05), had higher APACHEⅡ and SOFA scores (26.6±2.2 vs. 22.1±3.6, 7.9±2.0 vs. 4.7±2.4, both P ﹤ 0.01), higher rate of glucocorticoid treatment (18.2% vs. 10.0%, P < 0.05), and higher proportion of Candida albicans and Candida glabrata (69.1% vs. 45.0%, 10.9% vs. 7.5%, both P < 0.05), the rate of multi-site Candida infection also significantly increased (47.3% vs. 17.5%, P < 0.05). Intra-abdominal infection was the primary infection site and more common in death group (49.1% vs. 35.0%, P < 0.05). The rates of sepsis (87.3% vs. 62.5%), inadequate antifungal therapy (49.1% vs. 10.0%), inadequate source control (60.0% vs. 12.5%) in death group were all higher than those in survival group (all P < 0.01). It was shown by multivariate Logistic regression analysis that APACHE Ⅱ[odds ratio (OR) = 1.605, P = 0.002, β = 0.473], SOFA (OR = 1.501, P = 0.029, β = 0.406), inadequate antifungal therapy (OR = 12.084, P = 0.006, β = 2.492) and inadequate source control (OR = 7.332, P = 0.024, β = 1.992) were independent risk factors for mortality in ICU patients with candidemia. Conclusions Candidemia patients were severe and had poor prognosis. APACHE Ⅱ, SOFA, inadequate antifungal therapy and inadequate source control were independent risk factors of mortality.

Activation of A2b adenosine receptor decreases lipopolysaccharide-induced pulmonary microvascular permeability / 中华危重病急救医学

Objective To explore the role of the A2b adenosine receptor (Adora2b) in lipopolysaccharide (LPS)-induced injury of human pulmonary microvascular endothelial cells (HPMECs), and its mechanism. Methods HPMECs were cultured in vitro. The LPS dose-effect experiment, time-effect experiment and the Adora2b agonist/antagonist intervention experiment were performed respectively. ① Dose-effect and time-effect experiments: HPMECs were stimulated with 1, 10, 100, 1 000 μg/L LPS for 24 hours, or 100 μg/L LPS for 4, 8, 12, 16, 24 hours. Cell viability was measured by cell counting kit-8 (CCK8). The protein and mRNA expressions of Adora2b were determined by Western Blot and real-time reverse transcription-polymerase chain reaction (RT-PCR) respectively. ② Adora2b agonist/antagonist intervention experiment: serum-starved HPMECs were pretreated with Adora2b specific agonist BAY60-6583 (0.1, 1, 10 μmol/L) or Adora2b specific antagonist PSB1115 (1 μmol/L) for 1 hour, respectively, and then incubated with 100 μg/L of LPS for 24 hours. The HPMECs without treatment were served as blank control group, and those treated with LPS, BAY60-6583 or PSB1115 alone were served as single challenge groups. The monolayer permeability of HPMECs was determined by fluorescein isothiocyanate (FITC)-dextran. Cell cycle was analyzed by flow cytometry. The mRNA expressions of VE-cadherin, occludin, vascular endothelial growth factor (VEGF) and angiopoietin-1 (ANGPT1) were determined by RT-PCR. Results ① Dose-effect and time-effect experiments: LPS induced the decreased cell viability of HPMECs in dose and time-dependent manner. Compared with the control group, the protein expression of Adora2b was sharply up-regulated after 100 μg/L or 1 000 μg/L LPS stimulation. Meanwhile, LPS was shown to cause a dose and time-dependent induction of Adora2b transcript level. ② Adora2b agonist/antagonist intervention experiments: compared with the control group, the monolayer permeability of HPMECs was rapidly enhanced after LPS treatment, and lower cell viability and proliferation, as well as the expression of cell junction and angiogenic factors were downregulated. Compared with LPS group, 0.1, 1, 10 μmol/L BAY 60-6583 pretreatment could decrease the endothelial cell barrier leakage in a dose-dependent manner [Pd: (203.06±15.24)%, (164.15± 17.82)%, (125.69±10.38)% vs. (218.53±12.05)%], and promote cell proliferation of HPMECs [the proportion of S and G2 phases: (24.36±1.40)%, (32.37±0.95)%, (40.05±2.99)% vs. (18.83±0.73)%]. Pretreatment of 10 μmol/L BAY60-6583 also upregulated the mRNA expressions of cell junction and angiogenic factors [VE-cadherin (2-ΔΔCt):2.17±0.23 vs. 0.56±0.10, occludin (2-ΔΔCt): 5.32±0.28 vs. 0.48±0.11, VEGF (2-ΔΔCt): 4.44±0.34 vs. 0.58±0.09, ANGPT-1 (2-ΔΔCt): 5.98±0.73 vs. 0.66±0.10, all P < 0.01]. PSB1115 pretreatment aggravated injury of microvascular endothelial cells after LPS incubation, with lower cell viability, slower proliferation and less expression of VEGF and ANGPT1. There was no influence of BAY 60-6583 or PSB1115 single treatment on cell viability, cell cycle and the expression of angiogenic factors in HPMECs. Conclusions In vitro studies of cultured HPMECs exposed to LPS are identified as dose and time-dependent induction of Adora2b transcript and corresponding protein induction. Activation of Adora2b attenuates LPS-induced pulmonary microvascular endothelial cell barrier enhancement by regulating intercellular junction and promoting angiogenesis, suggesting Adora2b as potential therapeutic target in the treatment of LPS-induced forms of acute lung injury.

New progress of nutrition for severe patients at home and abroad / 中国中西医结合急救杂志

In recent years, the researches on nutrition for critically ill patients had advanced quickly, especially the domestic severe illness nutritional studies. In this review, the risk of malnutrition in severe patients and the pros and cons of nutritional evaluation stool, illustration of the use of low calorie nutrition in critically ill patients, the comparison of the advantage and disadvantage between enteral nutrition and parenteral nutrition, and the immune nutritional method for treatment of critically ill patients were explained; the key point of this summary is on the advance of severe illness nutrition at home compared with that at abroad in order to make a suggestion to direct the future development of clinical nutrition.

Defects existing in sepsis clinical research / 中国中西医结合急救杂志

Sepsis has relatively high morbidity and mortality in patients at intensive care unit (ICU). With the study of sepsis having continued to develop in recent years, the defects existing in this research have unceasingly exposed. Because the lack of design process of international standardized clinical randomized controlled trials (RCT) for septic patients, the situation of incomplete data record exists in these clinical studies, that may further affect the interpretation of the research results, therefore it is in urgent need to have an international standardized RCT design process for septic patients.

Application of non opioids analgesic drugs in adult at intensive care unit / 中国中西医结合急救杂志

The majority of patients have experienced pain or discomfort associated with surgery or mechanical ventilation in intensive care unit (ICU), and the use of analgesic drugs can relieve patients' anxiety, improve sleep, promote the disease recovery, reduce the use of sedative drug dosage and the occurrence of delirium. Because of less adverse reactions of the non opioid analgesic drugs, in recent years gradually the doctors in ICU have paid attention to them. In this study, the related literatures have been reviewed to realize the present situation of applying non opioid analgesic drugs in ICU. It was found that nowadays the application of commonly used non opioid drugs in ICU (including ketamine, non-steroidal anti-inflammatory drugs, tramadol, lidocaine, tramadol and gabapentin) can all decrease the use of sedative drugs and opioids, reduce the incidence of adverse reactions, and gradually they will obtain more and more attention.