Volume 99 ·  Issue 35 ·  2019

Intensive care unit is a place for treating critically ill patients. It practices the most advanced medical technology and consumes huge personal and public costs. It is a place where many patients pass through the end of their lives or die. The accompanying medical ethics issues are also constantly emerging and being discussed.

With the rapid development of critical care medicine, more and more patients are treated. Due to the timeliness of rescue and the importance of organ support, it is easy to ignore the psychological feelings of patients, families and doctors, which often makes the recognition of critical care medicine by patients and society obviously low, and the sense of professional acquisition of medical staff in critical care medicine needs to be improved urgently. How to change the current dilemma has become an urgent problem to be solved. This article discusses how to make critically ill patients and ICU medical staff return to the essence of "human", so that the society can really feel the disciplinary temperature of critical care medicine.

The mortality rate of critically ill patients admitted to intensive care units is as high as 30%, and the proportion of critically ill patients admitted to intensive care units before dying is increasing year by year. This article will discuss the management of end-of-life patients from three aspects, such as end-of-life judgment, ineffective treatment and dignified death, and restriction and withdrawal of life support treatment.

Organ transplantation is a reliable or even the only effective treatment for multiple end-stage organ failures. Critical care medicine plays an important role in the initiation, evaluation, maintenance and publicity of organ donation due to its specialty characteristics of participating in and leading the treatment of acute and critically ill patients. This article focuses on the important role of critical care medicine in organ donation.

vascular cognitive impairment (VCI) is a clinical stroke or subclinical vascular brain injury caused by cerebrovascular disease and its risk factors. It involves a clinical syndrome with impaired at least one cognitive domain, ranging from mild cognitive impairment to dementia, and also includes varying degrees of cognitive impairment caused by mixed pathologies such as Alzheimer's disease (AD)^[1,2]。

To investigatea cellular/molecular mechanism of the CD40/TRAF1 signalling pathway involved in Rheumatoid arthritis (RA).

16 patients with active RA and 9 patients with Fractures who underwent total knee or hip replacement in The First Affiliated Hospital of Soochow University were included in the study. Synovial tissues (ST) and serum were obtained from each patient. The CD40, TRAF1, NF-κB p65 were detected by ELISA and Immunohistochemistry in serum and tissue respectively. Real time-PCR (RT-PCR) was applied to measure NF-κB-related gene expression.

CD40 and TRAF1 positive area (%) in RA patients were 28.7±5.4, 34.3±4.8 respectively, which were significantly higher (P<0.05) than Fracture controls (21.2±9.5, 21.6±8.7 respectively). The expression of total NF-κB p65, and phospho-NF-κB p65 proteins, as well as NF-κB-related gene expression, including cytokines (TNFα, IL-6), chemokines (MCP-1),and adhesion molecules (ICAM-1) were significantly higher in the ST of RA patients compared to Fracture controls.

It is thus possible that the CD40/TRAF1 pathway acted as a positive regulator through NF-κB activation and NF-κB-dependent proinflammatory genes in RA.

To assess whether acute-phase plasma PCSK9 levels predict recurrent cardiovascular (CV) events in acute myocardial infarction (AMI) patients without receiving reperfusion therapy.

Plasma PCSK9 levels were measured during the acute phase (≤24 hours) in 882 patients who did not undergo reperfusion therapy from the China PEACE-Prospective AMI Study (2012-2014). Associations of acute-phase PCSK9 tertiles with patient characteristics and recurrent CV events at 1 year were assessed using multivariable logistic and Cox proportional hazards regression models.

Female gender (odds ratio [OR] 2.86, 95% confidence interval [CI] 1.36-5.98), premature coronary heart disease (CHD) (OR 2.82, 95%CI 1.43-5.53), higher high-sensitivity C-reactive protein (OR 1.69, 95%CI 1.35-2.13), and higher triglycerides (OR 1.93, 95%CI 1.10-3.38) were associated with higher baseline PCSK9 levels. Patients with PCSK9 levels in the highest tertile (versus lowest) did not have an increased risk of 1-year recurrent CV events (HR 0.77, 95%CI 0.44-1.34).

Acute-phase plasma PCSK9 levels are associated with levels of inflammation and triglycerides, premature CHD, and gender in AMI patients without reperfusion therapy, however it do not predict recurrent CV events at 1 year.

To analyze the diagnostic value of diffusion-weighted imaging (DWI) signal pattern in renal lesions with T₂WI hypointensity.

Retrospective analysis was performed on DWI imaging datasets of 135 renal lesions with hypointentsity on T₂WI confirmed by surgery, biopsy, or follow-up in the First Medical Center of Chinese PLA General Hospital from February 2016 to February 2017.One hundred and thirty-five renal lesions,43 benign lesions(age from 28 to 70 years,mean age was 43.5 years, male 18 lesions and female 25 lesions) and 92 malignant lesions (age from 17 to 86 years, mean age was 54.1 years, male 62 lesions and female 30 lesions). DWI signal pattern was classified into six categories: homogeneously high signal, homogeneously low signal, heterogeneously high signal, high halo signal, high halo and nodular signal, and high nodular signal. The agreement between two observers were tested using kappa statistic. The statistical difference between DWI signal characteristics in benign and malignant lesions was analyzed with Chi-Square test. Diagnostic efficacy in differentiation of benign and malignant renal lesions using DWI signal pattern were calculated.

One hundred and thirty-five lesions were detected in 135 cases with T₂WI hypointensity. There were 43 benign lesions and 92 malignant lesions. The agreement between two observers was very good (kappa value=0.878 6). In renal T₂WI hypointensity lesions, the proportion of DWI homogeneous high signal, homogeneous low signal, heterogeneous high signal, high halo signal, high halo and nodular signal, high nodular signal was 4.7% (2/43), 25.6% (11/43), 30.2% (13/43), 18.6% (8/43), 11.6% (5/43), 9.3% (4/43), respectively. The proportion of malignant lesions was 10.9% (10/92), 0 (0/92), 17.4% (16/92), 13.0% (12/92), 56.5% (52/92) and 2.2% (2/92), respectively. The difference of high halo and nodules signal and homogeneous low signal was statistically significant (all P<0.01). The sensitivity, specificity, positive prediction value (PPV) and negative prediction value (NPV) of high halo and nodular signal for malignancy were 56.5% (52/92), 88.4%(38/43), 91.2% (52/57) and 48.7%(38/78), respectively and homogeneous low signal for benign lesions were 25.6% (11/43), 100.0% (92/92), 100.0% (11/11) and 74.2% (92/124), respectively.

DWI signal features may facilitated the accurate diagnosis of renal lesions with T₂WI hypointensity. Malignant lesions exhibit a higher propensity with high halo and nodular signal on DWI while benign lesions with homogeneous low signal.

To investigate the mechanisms of lncRNA on the occurrence and development of NOA by constructing ceRNA regulation network of lncRNA, miRNA and mRNA.

Samples of adult human testis were obtained from NOA patients and OA patients with normal spermatogenesis (controls), recruited from the Reproductive Medicine Center of Nanfang Hospital from June 2017 to June 2018. Differentially expressed lncRNAs and mRNAs in testicular tissues from patients with NOA were identified by microarray analysis in previous association study. In this study, differentially expressed lncRNAs and mRNA were used to construct the ceRNA regulatory network in NOA and clarify the interaction relationship among lncRNA, miRNA and mRNA. GeneMANIA database was used to construct Protein-Protein Interaction (PPI) of the mRNAs in ceRNA regulatory network. WebGestalt toolkit was employed to perform gene function and pathway enrichment analyses of those coding genes. Finally, qRT-PCR and dual luciferase reporter system were employed for further experimental validation.

The ceRNA regulatory network of lncRNA, miRNA and mRNA consists of 21 nodes and 26 edges, of which 4 lncRNAs, 13 miRNAs and 4 mRNAs. 19 proteins were found to interact with the mRNA coding proteins in ceRNA regulatory network by PPI analysis. Gene oncology and KEGG pathway enrichment analyses indicate these coding genes were significantly enriched in pentose metabolic process and pentose phosphate pathway. Furthermore, lncRNA ANXA2P3 was found binding with miR-613 and miR-206 to inhibit mRNA TKT expression.

lncRNAs exert an important role in the occurrence and development of NOA via ceRNA regulatory network, which could be used as new biomarkers for NOA treatment.

To explore the characteristics of serum D-dimer level before and after delivery in women with advanced maternal age (VTE), and to assess the value of the characteristics for the diagnosis of venous thromboembolic disease.

The objects were 785 puerperae with advanced maternal age (AMA) who experienced delivery in Women′s Hospital, Zhejiang University School of Medicine during 1^st Jan 2017 to 31^st Dec 2017, and 327 puerperae with appropriate maternal age as controls were randomly selected from puerperae who gave birth in the same period. Their serum D-dimer levels before and after delivery were evaluated, and AMAs with high-level postnatal serum D-dimer were specially observed for the prognosis. Besides, puerperae complicated with VTE were retrieved from the medical database during 2014-2018, and their clinical characteristics and dynamic variation of serum D-dimer levels were analyzed.

The significant difference of D-dimer levels neither before nor after delivery was not observed between AMAs and controls (antenatal: 1.64(1.19, 2.29) mg/L vs 1.53(1.04, 2.23) mg/L, and postnatal: 2.70(1.71, 2.97) mg/L vs 2.63(1.17, 4.13) mg/L, P<0.05 for both; None of AMAs with high-level serum D-dimer after delivery were complicated with VTE, and most of their serum D-dimer levels decreasedsharply with in four postnatal days (the average decrease was 9.2(7.69,12.74) mg/L, and 96.2% of the sepuerperae′s decrease was more than 50%). Eight puerperae complicated with VTE were found in the database from 2014 to 2018, among which five were AMAs. The eight puerperae all received a B ultrasound because of the discomfort of lower limbs or abnormal variation of serum D-dimer levels (a slow decrease or an increase trend), so that a diagnosis of VTE was established; besides, the diagnosis or symptoms all emerged in the 3^rd to 5^th day after caesarean.

The factor of advanced maternal age has little influence on the serum D-dimer level before or after delivery among pregnant women. It is not a single detection for serum D-dimer level, but the intensive monitoring of clinical symptoms and dynamic change of serum D-dimer level, that helps early diagnosis of VTE.

To investigate the brain activities of exercise addiction (EA) group people with the task-functional magnetic resonance image (task-fMRI).

A total of 29 exercise addicts (addiction group, average age 46±4 years) and 26 non-exercise addicts (control group, average age 46±6 years) matched by sex, age, average education level and sports dependence degree were selected by using exercise addiction index (EAI) through questionnaires to members of Jiangsu Local Fitness and Long-distance Running Association between January 2018 and June 2018. The participants were scanned with fMRI while watching sports pictures or non-sports pictures. The brain responses of the two groups under two stimulation tasks were analyzed and compared.

Compared with the control group, while watching sports pictures, the right fusiform gyrus (MNI:x=30, y=-87, z=0), left posterior central gyrus (MNI:x=-51, y=-21, z=54), left medial superior frontal gyrus (MNI:x=-9, y=54, z=30), and right middle occipital gyrus (MNI:x=42, y=-72, z=36) were significantly inhibited in the addiction group (t-test, all P<0.05). When watching non-sports pictures, the addictive group showed the left superior frontal gyrus (MNI:x=-12, y=54, z=30), left middle frontal gyrus (MNI:x=-30, y=18, z=45), right inferior frontal gyrus (MNI:x=42, y=33, z=-12), right occipital gyrus (MNI:x=42, y=-72, z=36), and they were more significantly inhibited than the control group (t-test, all P<0.05).

Compared to the control group, the EA group shows significant brain inhibition with visual stimulation, particularly with non-sports pictures.

To investigate the effect of intraoperative warming on the postoperative relaxation recovery of cisatracurium in patients undergoing gastrointestinal surgery.

Sixty ASA Ⅰ-Ⅱ patients, aged 20 to 60, undergoing elective gastrointestinal surgery in Cancer Hospital Chinese Academy of Medical Sciences from October, 2016 to March, 2019 were selected and they were randomly divided into two groups (n=30), N group and H group by random number table. N group was non-heat preserving group, and H group was heat preserving group. Tracheal intubation was induced by general anesthesia with cisatracurium 0.15 mg/kg, and the nasopharyngeal temperature were continuously monitored and recorded. Cisatracurium were infused 1-3 μg·kg ^-1·min^-1 by venous pump during operation with T1 at 1%-10% and stopped infusion 30 minutes before the end of surgery. The time when T1 recovered from 25% to 75%(muscle relaxation recovery index), and the time of T1 recovered to 25% to TOF ratios (TOFR, the ratio of the fourth muscle twitch height to T1 in TOF) recovery to 90% (full recovery time), cumulative drug use and surgery time were recorded.

There was no significant difference between the two groups in the cumulative drug dosage and operation time (P>0.05).The body temperature N group (35.7±0.2) ℃ was significantly lower than the H group (36.2±0.1) ℃ (t=13.940, P<0.01). The recovery index of N group (16.5±1.8) min was significantlyhigher than H group (10.5±2.1) min (t=12.094, P<0.01) and complete recovery time in N group (26.9±4.1) min was obviously longer than those in H group (15.0±2.9) (t=13.082, P<0.01).

Patients with open gastrointestinal surgery are prone to hypothermia during surgery and heat protection is helpful to muscle relaxation recovery of cisatracurium.

To explore the risk factors in HBV-associated hepatocellular carcinoma (HCC) patients with early recurrence after ablation and to establish predictive model.

A total of 81 patients with HBV-related HCC who underwent ablation from January 2016 to December 2016 were included in Beijing Youan Hospital, including 66 males and 15 females. Standard medical records were collected, which were summarized as follows: demographic data, liver function, the number and size of tumors and the modality of ablation. Univariate and multivariate analysis were performed to identify the independent risk factors.The ROC curve was used to determine prognostic value. Cox proportional hazards model was used to establish predictive model, and the scores of risk factors were assigned according to HR value. Patients were divided into high-risk group and low-risk group in accordance with scores.The analysis of early recurrence rate was performed by the Kaplan-Meier method.

Tumor number, fibrinogen (Fib) and platelet-lymphocyte rate (PLR) were independently correlated with recurrence-free survival (RFS). The AUCs of Fib, PLR and Fib-PLR were 72.9%, 71.5% and 81.8%. The recurrence rates of the low-risk group were 4.9%,7.3% and 29.3% at 6 months,12 months and 24 months while 14.6%,43.9% and 78.1% in high-risk group. Two groups revealed statistically significant differences (all P<0.05).

Tumor number, Fib, and PLR may be used as a set of predictive indicator of early recurrence in HBV-associated HCC patients after ablation.

To explore the risk factors and treatment of acute lower limb ischemia with catheter-directed thrombolysis combined with endovascular interventions.

Totally 191 patients (191 lower limbs) with acute lower limb ischemia in department of vascular surgery of the First Affiliated Hospital of Chongqing Medical University from June 2012 to June 2017 who underwent catheter-directed thrombolysis combined with endovascular interventions were collected. According to imaging findings and clinical characteristics, the patients were divided into acute arterial embolism group (n=36) and acute arterial thrombosis group (n=155). The treatment effect, long-term follow-up and the risk factors closely related to primary patency were analyzed.

Among the 191 patients, the immediate success rate of surgery was 100%, the amputation rate within 30 days was 8.4% (16/191), and the mortality rate within 30 days was 2.6% (5/191). The mean follow-up was 31.0 (1.0-60.0) months. The 1-year overall survival rate was 92.1% and the 5-year was 79.5%. The primary patency rate was 74.3% within 1 year and 61.5% within 5 years. Primary vascular patency rate within 1 year and 5 years was mainly affected by occlusion segment (OR=3.5, 2.9, P<0.05), outflow tract (OR=3.2, 2.8, P<0.05) and ischemia degree (OR=3.4, 3.6, P<0.05).

Catheter-directed thrombolysis combined with endovascular interventions for acute lower limb ischemia is a safe and effective method. Risk factors for primary patency at 1 and 5 years are occlusion segment, outflow tract and ischemia degree.

Wieacker-Wolff syndrome refers to X-linked congenital multiple joint contractures combined with intellectual disability, and other peripheral or central nervous, muscular, metabolic system damage. This article reports a case of Wieacker-Wolff syndrome in order to improve the awareness of the disease.

Mollaret's meningitis is a rare benign recurrent aseptic meningitis, and herpes simplex virus type 2 (HSV-2) is the main cause of Mollaret's meningitis. Second-generation cerebrospinal fluid sequencing (NGS) examination was performed in a patient with typical recurrent meningitis who was treated and followed up for 11 years. It was confirmed that it was caused by HSV-2 infection.

This paper reports 3 cases of anti-α-amino-3-hydroxy-5-methyl-4-isoAmong the patients with azolepropionate 2 receptor (AMPA2-R) antibody encephalitis, 2 cases onset with typical borderline encephalitis syndrome, and 1 case onset with limb movement disorder without consciousness, cognition and mental disorders. Brain MRI showed cerebral cortex involvement in 2 cases and normal in 1 case. The EEG of one case showed a large number of slow waves of medium and high amplitude in bilateral cerebral hemispheres, and the EEG of two cases was normal. The clinical symptoms of anti-AMPA2-R antibody encephalitis are diverse and lack of specificity, and it is easy to miss and misdiagnose in the early stage. Positive anti-AMPA receptor antibody in cerebrospinal fluid and/or blood can be diagnosed, and immunotherapy should be started as soon as possible.

This paper reports a case of congenital ectopic thoracic kidney with septal hernia in children treated by combined thoracoscopy and laparoscopy.

Due to the complex physiological and pathological anatomy, as well as fine neurological functions, the surgical treatment of gliomas in the central region is a difficult problem in the field of neurosurgery. In recent years, the surgical technique of glioma in the central region has also developed rapidly. This article reviews the progress of surgery for glioma in the central region from the aspects of preoperative imaging evaluation, intraoperative arousal anesthesia, intraoperative functional localization and brain functional remodeling.