Volume 98  ·  Issue 12  ·  2018

Extracorporeal life support (ECLS), also commonly referred to as extracorporeal membrane oxygenation (ECMO), originated from cardiopulmonary bypass and has become the most representative new treatment in the field of critical care and emergency medicine in recent years. ECMO can replace patients' heart and lung work, not only playing an important role in the treatment of heart and lung failure, but also helping many patients who have nearly died due to cardiopulmonary failure due to the primary disease to survive the most critical period, so that they can regain the opportunity to treat the primary disease. According to statistics, the number of ECMO cases nationwide reached 1,234 in 2016 (including 67 cases in Hong Kong Special Administrative Region)^[1]。 With the continuous development of ECMO technology and the continuous growth of personnel in related fields, the In Vitro Life Support Professional Committee of Chinese Medical Doctors Association was established in 2017 and immediately took the lead in formulating an expert consensus on ECMO assistance in adult circulatory failure^[2]。

According to domestic and foreign guidelines, the clinical diagnosis of community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) does not seem difficult. Several criteria can be added together to meet the requirements, and there are many methods for etiological diagnosis. Clinical treatment is also empirical or targeted selection of anti-infective drugs. If highly drug-resistant bacteria appear, choose a possible effective drug combination or off-label medication. However, this is not the case, and the etiological diagnosis rate of CAP under the experimental conditions is only 53.1%^[1]； The autopsy results confirmed that the coincidence rate of clinical diagnosis VAP was about 69%^[2]； Coupled with the problems of colonizing bacteria and contaminating bacteria, the accuracy of etiological diagnosis at ordinary times can be imagined. We often hear such complaints: We have done it strictly according to the guidelines, all the top experts that should be invited have been invited, and all the antibacterial drugs that can be used have been used, but they are still ineffective. What should we do? The current fast-food "evidence-based medicine" evidence and the endless, constantly updated diagnosis and treatment guidelines based on it appear to be of limited value.

extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support, as a mechanical circulation assistance technology that can be inserted percutaneously, has the advantages of convenient placement, no location restriction, simultaneous biventricular combined respiratory assistance and relatively low price. In recent years, it has been applied to various acute circulatory and/or respiratory failures where conventional life support is ineffective. With the accumulation of clinical experience of ECMO for circulatory and/or respiratory assistance and the advancement of biomedical engineering technology, more portable and more stable ECMO devices have entered the clinic, and more and more critically ill patients have benefited from it^[1,2]。 According to the International Extracorporeal Life Support Organization (ELSO), as of July 2017, a total of 16 561 adult patients with circulatory failure worldwide received ECMO adjuvant therapy^[3]。 In recent years, the number of ECMO cases in China has increased rapidly. According to the statistics of Extracorporeal Circulation Branch of Chinese Society of Biomedical Engineering, the number of ECMO cases nationwide reached 1,234 in 2016^[4]。

Genetic testing plays an important role in the auxiliary diagnosis and medication guidance of hereditary, infectious and tumor diseases. There are many detection methods in this field, and the advantages and disadvantages of different technologies are obvious. For example, fluorescence quantitative PCR detection speed is fast, but the throughput is limited, which cannot conveniently and quickly meet the clinical demand for the detection of dozens to hundreds of sites of multiple genes. Although high-throughput sequencing has extremely high throughput, its cost, time-consuming, personnel requirements, etc. are not suitable for such detection. Therefore, new technology platforms are urgently needed to fill this gap.

s To investigate the distributions of single nucleotide polymorphisms (SNPs) of tissue factor (TF) and its inhibitor tissue factor pathway inhibitor (TFPI) and analyze the association of the SNPs with venous thromboembolism (VTE) in lung cancer patients.

Between October 2009 and August 2013, a total of 152 hospitalized patients with newly diagnosed primary non-small cell lung cancer were enrolled from Beijing Chao Yang Hospital. Among them [male 105 cases, female 47 cases, with an age of (62.4±13.2) years old], 40 cases were lung cancer patients with VTE, 112 cases were lung cancer patients without VTE. In the same period, 79 healthy controls were included from the physical examination center. All patients′ blood specimens were collected and their DNA was isolated. The selected SNPs were TF+ 5466A/G, TFPI-287T/C and TFPI-33T/C and they were investigated by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) followed by validation of DNA sequence analysis.

Allelic frequencies of TF+ 5466G, TFPI-287C and TFPI-33C were 2.5%, 33.8% and 8.8%, respectively. There was no significant difference among the three groups in genotype or allele frequency distributions of TF+ 5466A/G, TFPI-287T/C and TFPI-33T/C polymorphisms (all P>0.05). There was no difference from different genders and ages in allele or genotype frequency distributions of TF+ 5466A/G, TFPI-287T/C and TFPI-33T/C polymorphisms among the three groups (allP>0.05). Meanwhile, the frequency distributions of genotype and allele of the three SNPs were not associated with lung cancer patients with VTE (allP>0.05). Still, no relationship was found between genotype or allele frequency distributions of the three SNPs with prognosis of lung cancer patients with VTE.

Genotype alterations in TF+ 5466A/G, TFPI-287T/C and TFPI-33T/C may be unrelated to the occurrence of VTE and the prognosis of lung cancer patients with VTE.

To analyze docetaxel (T) and carboplatin (C) combined with trastuzumab (H) -TCH regimen as neoadjuvant systemic therapy in early breast cancer patients with human epidermal growth factor receptor 2 (HER-2) positive.

From January 2008 to December 2014, the data of patients diagnosed as early breast cancer in Breast Disease Center of Peking University First Hospital were retrospective reviewed. The data of patients with HER-2 positive conducted TCH neoadjuvant therapy and surgery, and with the complete clinicopathological information were analyzed.

A total of 77 cases were enrolled in this study. We defined G2+ G3+ G4+ G5 as responsive group according to Miller-Payne grading system, the responsive rate was 84.4% (65/77). The rate of complete pathological remission (pCR) was 39.0% (30/77). The 5-year disease free survival (DFS) was 87.3%, and 5-year overall survival (OS) was 93.6%. There was a significant difference between DFS and OS in the responsive group and non-responsive group (DFS: χ ²=6.762, P=0.009; OS: χ ²=5.062, P=0.024).

TCH is an effective neoadjuvant therapy for patients with HER-2 positive breast cancer, and the toxic and side effects were under control.

To explore the level of resting energy expenditure (REE) estimated by bioelectrical impedance analysis and the association of resting metabolic rate (RMR) with clinical related factors, and provide new ideas for improving protein energy wasting (PEW) in maintenance hemodialysis (MHD) patients.

Seven hundred and sixty-five subjects receiving MHD between July 2015 and September 2016 in 11 hemodialysis centers in Guizhou province were enrolled in this cross-sectional study. Bioelectrical impedance analysis was used to measure RMR and body composition, such as lean body mass, fat mass and body cell mass (BCM). Baseline characteristics, routine blood test indexes and biochemical data of hemodialysis patients were collected. The level of RMR and body composition in hemodialysis patients was compared by gender grouping. Then the patients were divided into four groups according to the cutoff value of RMR quartile. Spearman correlation analysis and multiple linear regression analysis were used to analyze the relationships between RMR and clinical related factors.

The average age of MHD patients was (54.96±15.78) years and the duriation of dialysis was (42.3±9.0) months. The level of RMR in male patients (474 cases, 61.96%) was significantly higher than that in female patients [1 591(1 444, 1 764) kcal/d vs 1 226 (1 104, 1 354) kcal/d, P<0.001]. However, this significant difference of RMR between different genders disappeared after adjusting for lean body mass (P=0.193). Multiple linear regression analysis showed that RMR was positively correlated with body surface area (β=0.817) and lactate dehydrogenase (LDH) (β=0.198), and negatively correlated with age (β=-0.141), allP<0.05.

RMR levels in patients with maintenance hemodialysis are associated with lactate dehydrogenase level, which may become a new index to evaluate energy consumption.

While low anterior resection avoided a permanent stoma, it might also cause bowel dysfunction which can significantly impact patients′ quality of life. The objective of this study was to identify the incidence and risk factors for the development of bowel dysfunction following rectal surgery.

Patients undergoing anterior resection for rectal neoplasm between January 2010 and December 2015 were identified from a rectal cancer database at the Department of Gastrointestinal Surgery, Beijing Hospital. All patients were asked to fill in a low anterior resection syndrome (LARS) questionnaire. Clinical factors were compared between patients with major LARS and those with minor or no LARS using conditional logistic regression.

There was 254 patients enrolled in the study. One hundred and eleven (44.1%) had major LARS symptoms. Neoadjuvant radiotherapy (OR=2.814, 95%CI: 1.097-5.561, P<0.001), low tumor location (OR=3.568, 95%CI: 1.159-6.546, P<0.001) and anastomotic leakage (OR=6.574, 95%CI: 1.689-15.367, P<0.001) were independent risk factors for development of major LARS symptoms.

For patients with high risk of low anterior resection syndrome, the potential for long-term poor functional results should be discussed with patients and form a part of the decision-making in individual treatment plans. Sphincter-preserving surgery should be performed in highly selected patients to avoid major bowel dysfunction.

To evaluate the early results of fenestrated endovascular aortic repair (FEVAR) using physician-modified stent grafts (PMSGs) for the treatment of patients with thoracoabdominal pathologies.

Nineteen consecutive patients who underwent FEVAR using PMSGs between April 2012 and September 2017 were retrospectively reviewed. The modality of FEVAR technique was assessed, perioperative clinical data was recorded and the early results were evaluated.

Indications were thoracoabdominal aortic pathologies, including juxtarenal abdominal aortic aneurysm (JAAA) (n=12), chronic thoracoabdominal aortic dissection with aneurysmal dilatation (n=3), thoracoabdominal aortic aneurysm (TAAA) (n=1), infrarenal AAA with an accessory renal artery in the segment of the aneurysmal neck (n=2) and type Ⅰ endoleak after EVAR for AAA(n=1). Nineteen fenestrated stent grafts were deployed , including custom-made Cook Zenith fenestrated stent graft(n=1), home-made Cook Zenith TX2 fenestrated stent graft(n=6), home-made Cook Zenith TFFB fenestrated stent graft(n=9), home-made Cook Zenith Cuff fenestrated stent graft(n=2), home-made Gore C3 fenestrated stent graft(n=1). Mean duration for stent graft modification was 110 (90-140) min. Mean operative time was 268.0 (59.0-334.0) min, and fluoroscopy time was 66.0 (15.0-175.0) min. There were a total of 50 target vessels, of which 45 (95%) were stented. Bare metal stents were used in 28 vessels, and covered stents were used in 17 vessels. Technical success rate was 100%. No intraoperative target vessel loss was observed. Perioperative mortality was 5.3% (1/19). Endoleaks were persisted even after ballooning in five patients. A small type Ⅰ proximal endoleak and type Ⅲ endoleak were found in 2 and 1 patients, respectively. Type Ⅲ endoleak combined with type Ⅱ endoleak were observed in 2 patients. All the endoleaks were accepted and needed watching. In two patients, iliofemoral artery problems were resolved after local endarterectomy and stenting. Two patients presented renal deterioration postoperatively and recovered after the conservative therapy. Median length of stay was 6.6 (2.0-12.0)d. No early reintervention (<30 days) was performed. The mean duration of follow-up was 11.2 (2.0-41.0) months. One patient died 6 months after FEVAR due to advanced renal carcinoma. All target vessels remained patent except for one accessory artery occlusion.

FEVAR using PMSGs may be a viable alternative for high-risk patients with thoracoabdominal pathologies.

To explore the feasibility and effectiveness of the two-point traction with guidewire method to improve the safety of percutaneous transhepatic sinus tract dilation.

The clinical data of 18 patients underwent the two-point traction guided by percutaneous transhepatic sinus dilation between January 2013 and July 2017 in Shengjing Hospital of China Medical University were analyzed retrospectively. The operation time, volume of intraoperative blood loss and postoperative complications were recorded.

All of the 18 patients were treated successfully. The mean size of the percutaneous transhepatic sinus tract was (18.6±2.3) Fr. The operation time was 15-45 min, with an average of 30 minutes, and the average intraoperative blood loss was about 11.7 ml. The incidence of postoperative complications was 22.2% (4/18), including cholangitis in 3 patients, pancreatitis in 1 case. All the complications were relieved after symptomatic treatment, no severe complications (biliary tract perforation or severe haemorrhage) occurred. A total of (3.3 ± 2.6) times cholangioscopic explorations for stone extraction were performed, with a overall clearance rate of 64.7% (11/17).

From the results of limited patient data in this group, the two-point traction with guidewire can provide the exact guidance for percutaneous transhepatic sinus tract dilation, which is effective and easily conducted, but still need further clinical study to confirm.

To discuss the feasibility, effect and safety of lower abdominal aorta balloon occlusion technique by ultrasound guiding during caesarean section in patients with pernicious placenta previa.

The clinical data of 40 patients with pernicious placenta previa complicated with placenta accreta from January 2015 to August 2017 in Liuzhou workers hospital were analyzed retrospectively. The study group included 20 cases, which were operated in the way of cesarean section combined lower abdominal aorta balloon occlusion technique by ultrasound guiding, while the control group also included 20 cases, which were operated in the way of the conventional cesarean section without balloon occlusion technique. The bleeding amount, blood transfusion volume, operative total time, hysterectomy and complications of the two groups were compared.

The bleeding amount and blood transfusion volume in study group were(850±100)ml and (400±50)ml, which were lower than that of the control group[(2 500±230)ml and (1 500±100)ml], the difference was statistically significant(t=35.624, 16.523, all P<0.05). In addition, the hysterectomy rate in study group was 5%, which was lower than that in the control group(30%), the difference was statistically significant(χ²=8.672, P<0.05). And the total time of operation was (2.0±0.5)h in the study group, which was shorter than that in the control group[(3.5±0.4)h]. The difference was statistically significant(t=11.362, P<0.05). No postoperative complications took place in the study group.The blood pressure, heart rate and blood oxygen fluctuated significantly, and the postoperative renal function was significantly reduced in the control group.

The lower abdominal aorta balloon occlusion technique by ultrasound guiding during a caesarean section in patients with pernicious placenta previa can effectively control the bleeding during operation, and preserve reproductive function to the utmost degree.Therefore, the technique is safe, feasible, convenient and cheaper, and worthy of being widely applied in clinic.

To investigate the effects of intermittent hypoxia (IH) exposure on renal tubular epithelial cell injury and autophagy in rats.

A total of 12 Sprague Dawley (SD) rats were randomly divided into two groups: normal control (NC) group and IH group, with 6 rats in each group. An IH animal model was established to observe the effects of IH on renal tubular epithelial cell damage and autophagy in rats. Microalbumin (mAlb) was detected by immunoturbidimetry. Neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule-1(KIM-1)in urine were assessed by enzyme-linked immunosorbent assay (ELISA) test. The pathological damage of renal tubules was observed by hematoxylin-eosin (HE) staining. The expression of autophagy marker protein light chain 3 (LC3) and Beclin-1 were detected by immunohistochemistry and immunoblotting.

At the end of the test, the levels of mAlb [(34.7±6.7) mg/L vs (11.1±3.3) mg/L, P=0.011], NGAL [(17.3±3.9) ng/ml vs(4.0±1.7)ng/ml, P=0.011] and KIM-1 [ (10.8±2.7) ng/ml vs (2.6±1.0) ng/ml, P=0.016] in urine of IH group were higher than those of control group, and the differences were statistically significant (all P<0.05). Pathological injury was showed by HE staining in IH group. The increase of autophagy in IH group was more obvious than that in NC group. Besides, the expression level of autophagy markers (protein LC3 and Beclin-1) was significantly higher in IH group than that in NC group (P<0.05).

IH can not only cause renal tubular injury, but also induce increased autophagy in renal tubular epithelial cells. Autophagy activation might participate in renal tubular epithelial cell injury induced by IH.

To investigate the relationship between the radioresistance of pancreatic cancer cell SW1990 and the induction of the Epithelial-Mesenchymal Transition (EMT).

The radio-resistant pancreatic cancer cell SW1990-R were established by using the method of radiating pancreatic cancer cell SW1990 step by step and repeatedly. Then the changes of the morphology of the cell was observed by inverted phase contrast microscope, the radioresistance of SW1990-R was detected by colony-forming assay, and the apoptosis rate of the two cell lines after radiation were measured by flow cytometry. Then invasiveness and EMT-related genes was measured by trans-well test and qRT-PCR. Finally, the model of transplanted tumor on nude mouse was used to confirm the relationship between the radioresistance of pancreatic cancer cell SW1990 and the induction of EMT.

Compared with SW1990, SW1990-R had a lower radiosensitivity (survival fraction in 2 Gy, SF₂: 0.326 3±0.007 3 vs 0.840 8±0.001 9, P<0.05) and lower apoptosis rate[(6.12±1.27) % vs (16.87±1.73)%,P<0.05]. Meanwhile, the invasive ability of SW1990-R were significant higher than that of SW1990 cell. According to the result of both in vivo and in vitro experiment, SW1990-R had a higher expression level of Vimentin and Snail, and lower expression level of E-cadherin when compared with SW1990.

Compared with SW1990, the radio-resistant pancreatic cancer cell SW1990-R can induce the Epithelial-mesenchymal transition.

The reports of abdominal aortic aneurysm (AAA) complicated with malignant tumors are uncommon, but its incidence is on the rise in recent years. The proportion of patients with AAA or malignant tumors found to be complicated with both diseases before or during operation is about 3% ~13%^[1,2]。 In the preoperative examination of AAA, it was found that about 9% to 13% of patients had abdominal malignancy^[3,4]。 Among them, colorectal cancer is the most common. Studies have shown^[5], 1.3% of patients with AAA had concomitant colorectal cancer, while 0.9% of patients with colorectal cancer had concomitant AAA. The purpose of this study was to analyze the surgical treatment strategies of AAA combined with digestive malignancies.

Bronchial fistula refers to the pathological condition of abnormal passages (fistula or fistula) between the bronchus and the cavity organs or cavities such as the thoracic cavity, thoracic cavity, stomach, esophagus and even bile duct^[1]。 Pulmonary cavity is a cavity-type lesion of the lung, which refers to an air-containing space located in a mass, parenchyma or nodule of the lung. Liquefaction necrosis of lung tissue due to different reasons is the pathological basis of lung cavity formation after air entry after bronchial elimination. It is common in tuberculosis and lung cancer^[2]。 If a pathological channel in the segment and above is directly connected to the cavitary lesion of the lung, we call it a "bronchopulmonary cavitary fistula (bronchial pulmonary cavity fistula, BPCF) ". The fistula of BPCF can be seen directly under the microscope during bronchoscopy, which can be directly accessed into the lung cavity. The data of 6 patients with BPCF complicated with fungal infection are reported as follows.

A 19-year-old male was admitted for "intermittent urination pain with hematuria for 1 year, recurrent and aggravated for 1 month". Blood routine: white blood cells 15.66 (normal reference value 3.5~9.5) ×10⁹/L. Urine routine: urine protein + (normal reference value-), white blood cell + + + (normal reference value-), occult blood test + + + (normal reference value-), white blood cell count 954.6 (normal reference value 0-28) /μ L, red blood cell count 381.3 (normal reference value 0-28) /μ L. The serum tumor markers were all within the normal range. Abdominal color ultrasound showed solid retroperitoneal echo (pancreatic head occupied space was not excluded). 18 Fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) (GE Discovery VCT, USA) examination showed: irregular mass in the pancreatic head area with a small number of punctate calcifications, increased radioactivity uptake, SUV_max17.38, considering the possibility of pancreatic neuroendocrine tumors (FIG. 1A，FIG. 1B)。 Abdominal CT scan showed a round soft tissue shadow at the head of the pancreas, with a CT value of about 45 HU (FIG. 2A)； After enhancement, the arterial phase was significantly enhanced, and the CT value was about 128 HU (Figure 2B)； The degree of enhancement decreased in the venous phase, and the CT value was about 107 HU (Figure 2C)； The size is about 3.8 cm ×3.4 cm ×5.0 cm, the border is clear, and the adjacent blood vessels are shifted. Consider the possibility of pancreatic head cancer. Pancreaticoduodenectomy was performed, and pancreaticoduodenectomy tissue specimens were taken. Microscopically, adenoid structures were seen in the proliferating fibrous tissue, and the cells were atypical and disordered (Figure 3) Immunohistochemistry showed: CD56 (+), CK19 (+), CK8/18 (+), Ki67 (~5%), P53 (scattered +), SYN (+), Villin (scattered +), AACT (±), AAT (±); Special staining results showed: AB/PAS (loose +). Consistent with pancreatic acinar cell carcinoma (PACC).

A 21-year-old male was admitted on 30 December 2013 with "paroxysmal left epigastric pain and vomiting after eating for 13 d". Physical examination: Mild tenderness in the left upper abdomen and weakened breathing sounds in the left middle and lower lungs. Auxiliary examination: Urinary amylase: 1 013 U/L. Gastroscopy showed that the gastric cavity was torsed, and the gastric antrum was deformed and narrowed. After further imaging examination (including chest X-ray, total abdominal three-phase enhanced CT, and upper gastrointestinal tract angiography, seeFigure 1,Figure 2,Figure 3,Figure 4) The diagnosis was: left diaphragm swelling, gastric volvulus and splenic volvulus. Treatment: Abdominal pain was significantly relieved after conservative treatment after admission, but vomiting was not relieved, and the vomit did not contain bile; Endoscopic volvulus reduction was performed on the third day after admission, which ended in failure; On the 7th day of admission, surgical exploration was performed. During the operation, the left diaphragm was relaxed and swollen, the cardia moved down, the pylorus was located in the area adjacent to the esophageal hiatus in the left upper abdomen, the great curvature of the stomach was turned forward and upward and located above the small curvature of the stomach, the transverse colon was pulled upward, the spleen was located in the left middle abdomen, the spleen hilum faced outward, and the spleen rotated 180 ° clockwise, but there was no blood supply disorder. During the operation, the diagnosis of left diaphragm swollen, gastric torsion and splenic torsion was clear. Intraoperative gastroscopy after reduction showed that the gastric cavity was patent, and liquid diet began on the second day after operation. Upper gastrointestinal angiography on the sixth day after operation showed that the left diaphragm and gastric anatomical position returned to normal (Figure 5), the patient was successfully discharged on the 7th postoperative day and was followed up for 3 years without recurrence.

Non-invasive positive pressure ventilation (NPPV) is a common and usual respiratory support for patients with acute and chronic respiratory failure^[1,2]Provide positive pressure ventilation assistance to patients through non-invasive connection methods such as nasal mask, mouth and nose mask or full face mask. Because there is no artificial airway to close the respiratory circuit, NPPV is essentially a "leaky" ventilation mode. In order to achieve the ideal therapeutic effect, on the one hand, it is required that NPPV ventilator can solve how to achieve good man-machine synchronization and effective alveolar ventilation in the case of circuit leakage, that is, it is required that "the air blows well"; On the other hand, in the absence of artificial airway, how to maintain the patency of natural airway and implement effective airway maintenance is the basis, condition and prerequisite to ensure the success of NPPV treatment, that is, it is required that "the breath is clear". The problem of airway maintenance for NPPV patients is described below.

Autophagy is a survival mechanism of cells under stress. It exists in eukaryotic cells, which is mediated by lysosomes to degrade damaged organelles and long-acting proteins in cells, realize cell metabolism and renewal of organelles, promote cell survival and maintain homeostasis; However, excessive autophagy is harmful to the body, and proper autophagy regulation is a necessary condition for the formation of intracellular homeostasis^[1]。 Abnormal regulation of autophagy activity has been elucidated in a number of diseases, including malignancies, neurodegenerative diseases, infections, and inflammation. However, there are relatively few studies on autophagy in burns. This article will briefly introduce the general characteristics of autophagy and complications of severe burns, sort out the current articles on autophagy in burns, and summarize the characteristics and regularities of autophagy in burn environment, so as to provide more comprehensive theoretical support for a deeper understanding of the mechanism of autophagy after severe burns and its role in burn treatment in the future, and finally achieve reducing burn complications and improving treatment efficiency.