Volume 92  ·   Issue 45  ·  2012

Septic shock is one of the main causes of death in critically ill patients, and the pathophysiological basis of this high mortality rate is organ insufficiency caused by microcirculation disorders. In the complex pathophysiological process, the activation and dysfunction of endothelial cells are the main factors leading to microcirculation dysfunction. Recently, it has been found that the widespread polysaccharide coating (glycocalyx) on the luminal side of vascular endothelial cells can be used as a new biomarker of endothelial cell injury, and can be used to evaluate the severity of septic shock and guide fluid resuscitation. At the same time, the destruction of polysaccharide coating by ischemia-reperfusion injury and heparinase and the protective effect of glucocorticoids on it have also become new research hotspots.

In recent years, critical care medicine has developed rapidly in China, and the number of intensive treatment wards (ICUs) in China has increased exponentially. Especially since the establishment of Critical Care Medicine Branch of Chinese Medical Association in 2005, the department of critical care medicine has become more and more standardized and has become an important base for the treatment of critical patients. The content of critical care medicine is all-encompassing, but the fundamental idea of treatment is to provide strong organ support for critical patients, so that they have the opportunity to recover and improve step by step. Among them, critical blood purification technology is one of the most commonly used organ support technologies in critical care medicine, and it is called "ICU Three Treasures" together with respiratory support technology and circulation support technology.

Patients with severe acute pancreatitis (SAP) are often complicated with abdominal hypertension, and its incidence rate can be as high as 60% ~80% [1]. It is generally believed that the causes of its occurrence include: edema, exudation and even hemorrhage of pancreatic and retroperitoneal tissues caused by pancreatic and retroperitoneal inflammation; Gastrointestinal paralysis, high gastrointestinal flatulence, intestinal wall edema and peritoneal effusion can lead to a sharp increase in abdominal pressure. At the same time, improper fluid resuscitation often aggravates the edema of abdominal organs and further increases the abdominal pressure. When SAP patients are complicated with abdominal hypertension or abdominal compartment syndrome, the rapid aggravation often brings special difficulties to the maintenance of organ function in these patients.

Acute pancreatitis is a clinical emergency characterized by local inflammatory reaction of pancreatic tissue, with or without changes in other organ functions. About 80% of acute pancreatitis is mild or edematous in clinic, and can generally be cured within 1 week; The remaining 20% can develop severe acute pancreatitis (SAP) with persistent multiple organ dysfunction or local complications. At present, the mortality rate of SAP with multiple organ dysfunction is still as high as 40%. The main causes of early death of SAP patients are shock, toxemia, systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS) caused by the release of inflammatory factors.

China is a big country with liver cancer, and the statistics of the World Health Organization show that about 55% of liver cancer patients in the world occur in China; Half of the new cases of liver cancer every year are in our country [1]. This phenomenon is mainly attributed to the large number of hepatitis B virus carriers and hepatitis B patients in our country. Data released by the Ministry of Health in April 2008 showed [2] that although the number of hepatitis B virus carriers in China has decreased significantly compared with before, it still remains at the level of 7.18%. Nearly 10% of these hepatitis B carriers will eventually develop liver fibrosis and cirrhosis in their lives, and some of them will progress to liver cancer.

capillary leak syndrome (CLS) is a common group of pathophysiological changes in critically ill patients, and it has been a hot topic in critical care medicine for a long time. Since the concept was put forward in the early 1960s [1], various clinical and basic studies have been carried out in this field for more than half a century, with different results and different opinions. However, the capillary wall itself has the physiological function of exchanging blood and extracellular fluid, and the relationship between physiological permeability and "leak" and its change mechanism are still not clearly analyzed.

1. sepsis treatment is in trouble: it has been 10 years since the campaign to save sepsis (SSC) was launched. How the progress of sepsis treatment can be seen by benevolent and wise people, but two points are certain: (1) The goal of reducing the mortality rate of sepsis by 25% within 5 years set out in the Barcelona Declaration has not been achieved; (2) The five most influential new methods for the treatment of sepsis proposed at the beginning of this century, which form the foundation of the confidence of the Barcelona Declaration, have been frequently questioned in subsequent studies, or have been greatly modified, or have been dropped, and few remain so far. These circumstances show that the treatment of sepsis is far more difficult and complicated than people think [1].

Severe infection is a complex clinical syndrome characterized by systemic infection causing organ function damage, and its incidence is increasing year by year. In the United States, severe infection is the 10th cause of death, and 25 people die of severe infection or septic shock every hour. A multicenter study in China showed that the incidence of severe infection is similar to that in foreign countries, which is 8.68% [1]. Although the treatment measures such as liquid resuscitation and anti-infection have made great progress, the mortality rate of severe infection is still high [2]. In recent years, people have noticed that immune dysfunction is an important cause of the development of severe infection and multiple organ dysfunction (MODS). Moreover, studies have shown that this immune dysfunction is mainly manifested by the high activity of innate immunity and the suppression of acquired immunity. Therefore, attaching importance to immunomodulation treatment of severe infection may open up a new way to improve the prognosis of patients with severe infection.

Objective To explore the causative factors of lower limb deep vein thrombosis complicated with pulmonary artery embolism in orthopedics patients.Methods The clinical manifestations and causes of thrombosis defluxion of pulmonary artery embolism patients whose diagnosis were confirmed by computed tomography pulmonary angiography(CTPA)during May 2009-May 2012 were retrospectively analyzed.Results Among 45 cases of CTPA-confirmed pulmonary artery embolism patients,5 patients had no obvious clinical manifestation.The initial symptoms included chest stuffiness and dyspnea(n =9)and cough(n =8).And the major causes of thrombosis defluxion were early postoperative mobilization(n =11),postoperative functional exercise(n =9),rollover or defecation in bed(n =7),sneezing(n =2)and unknown causes(n =14).Conclusion The patients with lower limb deep vein thrombosis have a high risk of thrombosis defluxion during unstable period.Despite adequate anticoagulation,early mobilization and functional exercise are likely to cause thrombosis defluxion and lead to pulmonary artery embolism.

Objective To explore the possible brain mechanism of online game addiction(OGA)in terms of brain morphology through voxel-based morphometric(VBM)analysis.Methods Seventeen subjects with OGA and 17 age-and gender-matched healthy controls(HC group)were recruited from Department of Psychology at our hospital during February-December 2011.The internet addiction scale (IAS)was used to measure the degree of OGA tendency.Magnetic resonance imaging(MRI)scans were performed to acquire 3-demensional T1-weighted images.And FSL 4.1 software was employed to confirm regional gray matter volume changes.For the regions where OGA subjects showed significantly different gray matter volumes from the controls,the gray matter volumes of these areas were extracted,averaged and regressed against the scores of IAS.Results The OGA group had lower gray matter volume in left orbitofrontal cortex(OFC),left medial prefrontal cortex(mPFC),bilateral insula(INS),left posterior cingnlate cortex(PCC)and left supplementary motor area(SMA).Gray matter volumes of left OFC and bilateral INS showed a negative correlation with the scores of IAS(r =-0.65,r =-0.78,P ＜0.05).Conclusion Gray matter volume changes are present in online game addicts and they may be correlated with the occurrence and maintenance of OGA.

Objective To detect the expressions of matrix metalloproteinase-9(MMP-9),progesterone receptor(PR),Ki-67 and Survivin in the multiple meningiomas(MMs)and explore its genesis,diagnosis and bionomics features.Methods A total of 66 cases with histological sections of meningiomas retrieved from the archives of Department of Pathology of our hospital,including 30 cases of solitary meningiomas(SMs)and 36 cases MMs,were regrouped as benign,atypical and malignant by hematoxylin and eosin staining according to the World Health Organization classification of nervous system tumors.Immunohistochemistry was performed to detect the expressions of MMP-9,PR,Ki-67 and Survivin in 36 cases of MMs and 30 cases of SMs.And normal brain tissue was selected as a control group.The staining intensity was analyzed quantitatively for the differential expressions of MMP-9,PR,Ki-67 and Survivin between SMs and MMs.Results No expression of MMP-9,PR,Ki-67 and Survivin was detected in 5 normal brain tissues,but the expression rates were 100％,53％,23％ and 88％ respectively for significant difference comparing with normal tissue.The result of statistical analysis showed that there was significant difference in the expression intensity of MMP-9 and PR between two groups.The expression intensity MMP-9 in multiple group was significantly higher in MMs than that in SMs(P ＜ 0.01)while PR was lower in MMs than that in SMs(P ＜ 0.05).But no significant difference was found for the expression of Ki-67 or Survivin between two groups.Conclusion The detections of MMP-9,PR,Ki-67 and Survivin are helpful in the clinical diagnosis and early detection of meningioma.

Objective To investigate the genetic feature of Schnyder corneal dystrophy identified in a four-generation Chinese family.Method Ophthalmologic examinations were performed in 3 affected members and 2 unaffected members of a family with Schnyder corneal dystrophy and controls.Genomic DNA was extracted from peripheral blood.The coding regions,3′UTR and 5′UTR of UBIAD1 gene from all samples were screened by polymerase chain reaction(PCR)and direct DNA sequencing using the primers designed according to the sequence of UBIAD1,and comparatively analyzed with data from Genebank.Result The family has 15 members over 4 generations with similar signs and symptoms among proband and affected members.All affected members of the family demonstrated central discoid crystalline deposition with arcus lipoides.Confocal microscopy examination showed multiple depositions of crystalline materials in anterior stroma.OCT showed the high reflective material localized within the anterior stroma.A missense mutation c.305A ＞ G in 1 exon of UBIAD1 gene resulting in a substitution of Asparagine to Serine at codon 102(p.Asnl02Ser)was found in all affected members of the family who were clinically diagnosed as Schnyder corneal dystrophy while not in the unaffected members of the family and controls.Conclusion The missense mutation c.305A ＞ G(p.Asn102Ser)of UBIAD1 gene may cause the disease of the family.Gene screen can assist clinicians in making definitive diagnosis,presymptomatic diagnosis and prenatal diagnosis.

Objective To explore the prognostic effects of ultra-early,early,medium-term and late treatments of poor-grade aneurysm patients.Methods A total of 119 patients of WFNS Ⅳ and Ⅴ,including WFNS Ⅳ grade(n =73)and Ⅴgrade(n =46),were analyzed.There were 51 males and 68 female with a mean age of 55.2 years.Among them,57 cases underwent surgical clipping,including ultra-early treatment(n =2),early treatment(n =14),medium-term treatment(n =28)and late treatment (n =13);40 cases underwent interventional embolization,including ultra-early treatment(n =14),early treatment(n =16),medium-term treatment(n =8),late treatment(n =2)and conservative treatment (n =22).The outcomes were assessed according to the Glasgow outcome score during a 3-month follow-up.Results There was 0 case of a good prognosis in surgical clipping group with ultra-early treatment versus 13 of good prognosis in interventional embolization group;poor prognosis 2 vs 0 and death 0 vs 1 in two groups respectively.Early treatment:good prognosis 5 vs 13;poor prognosis 9 vs 0;death 0 vs 3;Medium-term treatment:good prognosis 17 vs 0;poor prognosis 10 vs 0;death 1 vs 8;Late treatment:good prognosis 0 vs 0;poor prognosis 9 vs 1;death 4 vs 1.Conclusion For patients of WFNS Ⅳ grade,the treatment should be performed as soon as possible.For patients in WFNS Ⅴ grade,ultra-early and early treatments fare better than medium-term and late treatments.The mortality of medium-term treatment is the highest.Overall prognosis of late treatment has the worst outcome.Regardless of treatment period,conservative treatment shows the worst prognosis and the highest mortality.

Objective To explore the methods of detecting and defining the biological boosting target volume(BBTV)in patients with locally advanced nasopharyngeal carcinoma(NPC).Methods Ten patients with locally advanced NPC treated at our center during September to December 2010 were enrolled.The following factors were used to define and contour BBTV,including dose-deficient area locating at skull-base of gross tumor volume in conventional irradiation,hypoxia area detected by 99mTc-HL91 Single-photon emission computed tomography/computed tomography(SPET/CT)imaging and tumor-burdened area evaluated by comparing the pre-treatment and 36 Gy irradiation's CT images scanning at the same treatment position.Results The volume of BBTV was(17 ± 7)cm3,accounting for 51％ ± 19％ of gross tumor volume.In BBTV,the volumes and proportion of skull base dose-deficient,hypoxia and tumor-burdened area were(5.8 ± 2.5)cm3,(7.7 ± 3.6)cm3,(9.0 ± 5.8)cm3 and 34.4％,45.7％ and 53.3％respectively.However,the proportion of overlapping volume between three areas was only 33.1％.Conclusion BBTV may be composed of skull base dose-deficient,hypoxia and tumor-burdened volume.It provides a new reference for individualized radiotherapy in locally advanced NPC.

Objective To investigate the feasibility for judging the postoperative lymph node metastasis of esophagus cancer patients with pN0 stage by detecting the protein expression of metastasis-associated protein 1(MTA1).Methods Immunohistochemistry was used to detect the expression of MTA1 protein in lymph node of esophageal squamous cell carcinoma(ESCC).with pN0 stage.Results(1)There were no significant differences in age,gender and differentiation among the lymph node metastasis(P ＞0.05),but not with pT stage(P ＜ 0.05;x2 =13.29).(2)There were no significant differences among the expression of MTA1 protein and age,gender and differentiation(P ＞ 0.05),but not with differentiation and pT stage(P ＜0.05;x2 =18.61).Both stages pT1b and pT3 had higher expression of MTA1 protein than stage pT1 a(P ＜ 0.05;x2 =25.54).(3)The curve of lymph node metastasis showed that the patients with no/lower MTA1 protein expression had a lower metastasis rate than those a higher MTA1 protein expression (P ＜ 0.05;x2 =16.63).(4)The results of multivariate analysis confirmed that T status and MTA1 protein over-expression were independent risk factors for pN0 stage ESCC.Conclusion Detecting MTA1 protein expression is helpful for judging the lymph node metastasis of ESCC patients with pN0 stage.And its over-expression may used as a guide in the decision-making of postoperative adjuvant therapy.

Objective To explore the efficacy and safety of whole brain radiation therapy(WBRT)plus temozolomide(TMZ)versus WBRT alone in the treatment of brain metastases from non-small cell lung cancer(NSCLC)through a meta-analysis.Methods All previously published and some unpublished studies were comprehensively searched from the databases of MEDLINE,EMBASE,Cochrane Library and CBM,etc.The meta-analysis included all randomized controlled trials(RCTs)to compare WBRT plus TMZ with WBRT alone in treatment of brain metastases from NSCLC.The primary meta-analysis was based upon objective remission(OR)and toxicity and the second overall survival(OS).Results Four RCTs identified by two reviewers were included.There was significant improvement for the WBRT + TMZ group in OR rate (RR =1.55,P =0.003);but without significant improvement in OS(P =0.69).Meanwhile,WHO grade Ⅲ/Ⅳ hematologic toxicity of myelosuppression increased in the WBRT + TMZ group(RR =2.47,P =0.008),but without significant difference in gastrointestinal toxicity(P =0.14).Conclusions For the treatment of brain metastases from NSCLC,the combined therapy of WBRT plus TMZ improves OR,but without significant improvement in OS.And the incidence of myelosuppression is elevated.Future large-scale,high-quality and prospective phase Ⅲ RCTs are needed to confirm the clinical efficacy and safety of WBRT plus TMZ.

Objective To explore the changes in serum protein levels of schizophrenics before and after treatment of risperidone and identify the potential markers of diagnosis,treatment and drug side effects of schizophrenia.Methods Eighty first-episode schizophrenics without other concurrent diseases and with positive and negative symptom scale(PANSS)score greater than or equal to 60 were recruited.And 15 of them were measured by proteomics.Different serum levels of proteins were obtained from these patients and were separated by two-dimensional electrophoresis(2-DE)before and after a single risperidone treatment for 8 weeks.These proteins were then identified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry(MALDI-TOF-MS)and peptide mass fingerprinting.Enzyme-linked immunosorbent assay (ELISA)was used to verify the results.Results Almost 1400 spots were detected by 2-DE in each gel.Of these proteins,23 protein spots showed significant differences in abundance before and after risperidone treatment.After MALDI-TOF peptide mass fingerprinting,9 up-regulated proteins and 8 down-regulated proteins were validated after treatment.Of these proteins,the schizophrenics showed a significantly higher content of apolipoprotein A-1(APOA-1)than those before treatment and haptoglobin(HP)protein was down-regulated after treatment.The results of ELISA were parallel with those of proteomic(P ＜ 0.01).Conclusion The serum proteins correlated with blood glucose and lipid metabolism are altered in schizophrenia after treatment of risperidone.A clinician should monitor the side effects of antipsychotic drugs according to the changes of serum proteins.

Objective To explore the expression of hypoxia-inducible factor 1 alpha(HIF-1a)in rat lower limb skeletal muscle with acute ischemia.Methods Acute lower limb ischemia was established in 25 male or female SD rats of 200-250 g by ligating left iliac artery with microsurgical techniques.Gastrocnemius of lower limb was harvest at the timepoints of sham(0h),4,8,12 and 24 h respectively.Immunohistochemistry,Western blot and real-time polymerase chain reaction(PCR)were used to detect the expression of HIF-1a in lower limb gastrocnemius.Results There was a low expression of HIF-1a in normal gastrocnemius,but it was highly expressed in lower limb ischemia.With the elongation of ischemia time,its expression increased(P ＜ 0.05),peaked at 4 h and 8 h(P ＜ 0.05)and then declined gradually.Conclusion With a characteristic trend during acute limb ischemia,HIF-1 a may play an important role in the adaptive response to acute limb ischemia.

Objective To explore the stress responses and protective effects of neuregulin-1β1 (NRG-1β1)on astrocytes after oxygen-glucose deprivation(OGD).Methods Rat cerebral cortical astrocytes from 3-day-old newborn SD rats were propagated.They were divided into control,OGD,10 ng/ml NRG-1β1 and 20 ng/ml NRG-1β1 groups.Immunohistochemical results of GFAP,S100β and CD44 markers were analyzed to observe their changes before and after OGD.Enzyme-linked immunosorbent assay (ELISA)was used to evaluate the secretion of tumor necrosis factor-alpha(TNF-α)and interleukin-1 β(IL-1 β)in different groups before and after OGD.Results Under OGD,NRG-1 β1 showed no protective effects on maintenance of cell morphology.Expression and distribution of GFAP and S100β did not change while there was no expression of CD44 in any group before and after OGD.Secretion of TNF-α and IL-1β significantly decreased in the 20 ng/ml NRG-1 β1 protection group(P ＜ 0.05).Conclusion The morphological changes of astrocytes undergo swelling to shrinking.NRG-1 β1 has no protective effects on maintenance of cell morphology under OGD.And it can significantly decrease the secretion of TNF-α and IL-1β.Thus the reduction of TNF-α and IL-1β may explain the mechanism of protective effects of NRG-1β1 on astrocytes under stress.

Before the 1960s, all patients who urgently needed cranial drilling for exploration, ventriculography and extracorporeal ventricular drainage adopted Dandy's skull drilling technique in 1918. However, this operation must be performed in the operating room, with at least 20 operating procedures, and time-consuming, which made many endangered patients lose their lives because they missed the best rescue time. In 1963, Zhang Qinglin of the Department of Neurosurgery of Qilu Hospital of Shandong University and others put forward the original idea and design, and in 1964, a pistol-type rapid fine-hole cranial drill sample completely different from Dandy's cranial drill was developed [1]. The cranial drill only has three operating procedures, no scalp incision, no suction device, no electrocoagulation and shadowless lamp; It can be completed within 3~5 min in emergency room, treatment room or ward. In 1970s, it was named as rapid fine-hole cranial drilling device, which was packaged and supplied separately. In 1993, it was added to the A-type instrument package of war wound surgery, so that it was quickly popularized and applied nationwide, and has applied for national invention patent; This cranial drilling device has been popularized in county hospitals and some township hospitals in Shandong Province in 1980s. The clinical application of this device for 50 years is summarized as follows.

Patients with acute Stroke, especially after cerebral hemorrhage, often have ocular gaze paralysis (CED), which is caused by damage to the frontal gaze center and/or its subcortical white matter. A team led by Japanese scholar Dr. Shoichiro Sato conducted a series of studies on the risk factors of cerebral hemorrhage, one of which was the discovery of the relationship between ocular gaze paralysis and the prognosis of cerebral hemorrhage. The research results were published in the journal Stroke in November 2012 (Stroke, 2012, 43:2898-2903).

In recent years, there are many irregularities in the use of antimicrobial drugs in China.Neurosurgery is one of the special departments in surgical system.Once the infection occurs in perioperative patients, it will seriously affect the prognosis and even endanger the life.Therefore,the neurosurgery emphasizes strict aseptic operation norms and strict antibacterial drug use strategies.Therefore,referring to relevant data at home and abroad [1-2], we formulated the principles and strategies for the use of antimicrobial drugs in neurosurgery, so as to standardize and guide the use of antimicrobial drugs in neurosurgery specialty, so that the clinical work should not only effectively prevent and treat neurosurgical infection, but also prevent the abuse of antimicrobial drugs.This principle was discussed and formulated by experts from neurosurgery, neurology, infectious diseases, microbiology and critical care medicine.

A 37-year-old female was admitted to the hospital on December 20, 2011 due to "sleep disorder for 55 days, epileptic seizures and abnormal mental behavior for 20 days". 55 days ago, the patient developed low mood, poor sleep, dreamy at night and easy to wake up due to family changes. 20 days ago, she developed epileptic seizures and abnormal mental behavior, could not distinguish between day and night, questions and answers were not relevant, and her condition progressively worsened. 5 days ago, she went to another hospital, and the head magnetic resonance (MRI) showed "abnormal signal in the right hippocampus", and the electroencephalogram (EEG) showed "3~4 Hz slow activity in the frontotemporal region and center, with right side". 1 day ago, the patient was transferred to the emergency department of Xuanwu Hospital due to "status epilepticus" in another hospital after treatment with lumina and diazepam, and was admitted to the hospital. Since the onset of the disease, the patient has no fever, limb weakness, poor sleep, urination difficulty, constipation, and his weight has lost about 5 kg in the past month. Physical examination at admission: body temperature 36.5℃, pulse 80 beats/min, clear mind, indifference and little speech, and no abnormalities were found in the physical examination of the rest of the nervous system.