2016 Vol. 7, No. 5

Original Contributions
Abstract:
  Objective  To prospectively evaluate the value of integrin αvβ3 receptor imaging approach basedon single photon emission computed tomography/computed tomography (SPECT/CT), using 99mTc-3PRGD2 as the tracer, in diagnosis and staging of non-small cell lung cancer (NSCLC) compared with 18F-FDG positron emisson tomography/computed tomography(PET/CT).  Methods  From February 2011 to December 2012, 65 patients with suspicious lung lesions were recruited with informed consent in Peking Union Medical College Hospital, including 41 males and 24 females, with a mean age of (60±11) years. The patients underwent both 99mTc-3PRGD2 SPECT/CT and 18F-FDG PET/CT within one week. After pathological diagnosis, all the patients were followed up until death or for at least two years. Receiver operating characteristic (ROC) curve, Z test, and Chi-square test were used to compare the diagnostic performance of the two imaging methods in assessing lung lesions and mediastinal lymph nodes.  Results  Sixty-five lung lesions in 53 patients were pathologically diagnosed as NSCLC, and 14 lung lesions in 12 patients were proved as benign. Based on the American Joint Committee on Cancer/Union for International Cancer Control(AJCC-UICC) standard, 248 regions of lymph nodes had metastasis and 56 were negative regions. 99mTc-3PRGD2 SPECT/CT was found to have higher specificity compared with 18F-FDG PET/CT in the per-region diagnosis of lymph node metastasis (94.6% vs. 75.0%, P=0.008), whereas the sensitivity of the two methods showed no statistically significant difference (88.3% vs. 90.7%, P=0.557). There was no significant difference between the two methods in diagnostic performance for lung lesion (Z=0.82, P=0.410).  Conclusion  99mTc-3PRGD2 SPECT/CT shows high specificity in the diagnosis of lymph node metastasis from NSCLC, which may complement 18F-FDG PET/CT in diagnosis and benefit surgical decision-making for patients with lung cancer.
Abstract:
  Objective  To investigate the antimicrobial resistance of clinical bacterial isolates in Peking Union Medical College Hospital (PUMCH) in 2015.  Methods  A total of 5746 non-duplicate clinical isolates from January 1 to December 31 2015 were collected. Disc diffusion test (Kirby-Bauer method) and automated systems were employed to detect the antimicrobial resistance. The data were analyzed by WHONET 5.6 software according to 2015 edition of antimicrobial susceptibility testing standards issued by The Clinical and Laboratory Standards Institute (CLSI) of the United States.  Results  Of the 5746 clinical isolates, the 10 most common bacteria were:Escherichia coli (19.4%), Pseudomonas aeruginosa (11.3%), Klebsiella pneumoniae (10.9%), Staphylococcus aureus (9.8%), Acinetobacter baumannii (9.6%), Enterococcus faecalis (6.5%), Streptococcus agalactiae (5.1%), Enterococcus faecium (4.6%), coagulase-negative Staphylococcus(2.7%), and Enterobacter cloacae(2.5%). Gram-negative bacilli and gram-positive cocci accounted for 67.5% and 32.5%, respectively. Among Staphylococcus aureus and Staphylococcus isolates, methicillin-resistant Staphyloccus aureus(MRSA) and methicillin-resistant coagulase-negative Staphylococcus (MRCNS) accounted for 22.9% and 77.6%, respectively. The resistance rates of MRSA and MRCNS strains to β-lactams and other antimicrobial agents were much higher than those in methicillin-susceptible Staphylococcus aureus (MSSA) and methicillin-susceptible coagulase-negatible Staphylococcus (MSCNS) strains. 88.8% of MRSA strains were still susceptible to trimethoprim-sulfamethoxazole, while 81.7% of MRCNS strains were susceptible to rifampin. No staphylococcal strain resistant to vancomycin, teicoplanin, or linezolid was detected. The resistance rate of E. faecalis strains to most of the antimicrobial agents tested (except Chloramphenicol) was much lower than that of E. faecium, while some strains resistant to vancomycin were found in both species. No linezolid-resistant Enterococcus strains was found. 90.8% of β-hemolytic streptococcus strains were susceptible to penicillin. Extended-spectrum β-lactamase (ESBL)-producing strains accounted for 52.3%(582/1112), 28.9%(200/692), and 26.2%(27/103) in E.coli, Klebsiella spp(K.pneumoniae and K.oxytoca), and P.mirabilis, respectively. Enterbacteriaceae strains were still highly susceptible to carbapenems, with an overall resistance rate of ≤ 4.3%. A few extensively-resistant strains of K.pneumoniae (3.0%, 19/630) were identified. About 76.5% and 74.8% of A.baumannii were resistant to imipenem and meropenem, while the resistant rates to cefoperazone-sulbactam (49.8%) and minocycline (21.8%) were the lowest. The resistance rates of P.aeruginosa to imipenem and meropenem were 16.6% and 11.9%, respectively, while the resistant rate (5.2%) to amikacin was the lowest. The prevalence of extensively-resistant strains in A.baumannii and P.aeruginosa were 20.8% (115/553) and 1.8% (12/650), respectively.  Conclusions  Antibiotic resistance may still pose a serious threat to clinical practice. Rational use of antibiotics should be required to prevent the spread of antimicrobial resistant strains.
Abstract:
  Objective  To investigate the value of ultrasonography in the diagnosis and differential diagnosis of lymphoma and stromal tumor of the small intestine.  Methods  The clinical characteristics and ultrasound findings of 36 patients with small intestine lymphoma and 69 patients with small intestine stromal tumor confirmed pathologically in Cancer Hospital of Chinese Academy of Medical Sciences between January 2009 and January 2016 were retrospectively analyzed and compared.  Results  There were statistically significant differences in echotexture, presence of echoless area, intratumoral gas, and ultrasonographic pattern between small intestine lymphoma and small intestine stromal tumor (all P < 0.001), whereas no statistically significant difference in clinical characteristics, lesion size, contour, or lobulated mass. On ultrasound, small intestine lymphoma mainlydemonstrated as infiltrative or mass-forming type, with homogeneous echotexture without cystic necrotic area; while small intestine stromal tumor demonstrated as mass-forming type with heterogeneous echotexture and cystic necrotic area.  Conclusions  Lymphoma and stromal tumor of the small intestine both have some characteristic ultrasound features, the difference between which may help in the diagnosis and differential diagnosis of these two conditions.
Abstract:
  Objective  To assess the effect of N, O-carboxymethyl chitosan (NOCC) in preventing postoperative adhesion in a rabbit model.  Methods  Double uterine horn model was established in 220 female rabbits to induce postoperative adhesion. The rabbits were randomized to receive either adhesion-inducing operation only (control group) or adhesion-inducing operation + intraperitoneal injection of NOCC before closure (NOCC group). All the operations were performed by one operator. Twenty-two rabbits from each group were euthanized at one of the five different time points (postoperative day 3, 7, 14, 28, and 42), and adhesion formation was scored both grossly (extent, type, and tenacity) and histopathologically (inflammation, fibrosis, and vascularization).  Results  The extent (P=0.0337) and tenacity of adhesion (P=0.0271) as well as inflammation(P < 0.0001) were lower in the NOCC group than in the control group on day 3. Fibrosis was less obvious in the NOCC group compared to the control group (P < 0.0005) before day 14. The tenacity scores of adhesion on day 14, 28, and 42 were significantly lower in the NOCC group than in the control group(all P < 0.05), while the type scores were obviously lower in the NOCC group on day 28 and 42(all P < 0.05).  Conclusions  Treatment with NOCC could reduce both gross and histopathological scores of surgery-induced abdominopelvic adhesions in rabbits. NOCC could be an effective therapy for preventing postoperative abdominopelvic adhesion.
Abstract:
  Objective  To develop a knowledge, attitude, and practice (KAP) questionnaire regarding clinical adverse event reporting and to evaluate its reliability and validity.  Methods  The questionnaire was developed following KAP theory, based on literature review and interview of experts and medical practitioners. Doctors and nurses in Peking Union Medical College Hospital were selected by random sampling and surveyed. Cronbach's α coefficient was used to test the internal consistency reliability, and intraclass correlation coefficient (ICC) to test retest reliability. Content validity index (CVI), exploratory factor analysis, and independent t-test between high-score and low-score groups were used to test the content validity, construct validity, and discrimination validity, respectively.  Results  130 questionnaires were collected. Cronbach's α coefficient of each dimension and total questionnaire was all > 0.6. ICC of each item was > 0.75 and CVI of each dimension was > 0.9. Five principal factors were extracted, the cumulative contribution rate was 61.8%, and the common variance of each item was > 0.4. There were statistically significant differences between the high-score and low-score groups(P < 0.01).  Conclusions  The KAP questionnaire regarding clinical adverse eventreporting is a reliable and valid tool for evaluating the status of adverse event reporting.
Rational Blood Use Column
Abstract:
  Objective  To investigate the clinical characteristics of patients with hemoglobin level higher than the recommended threshold by guidelines before receiving red blood cell (RBC) transfusion in non-surgical departments of Peking Union Medical College Hospital (PUMCH).  Methods  One thousand patients were randomly selected from hospitalized patients who received RBC transfusion at PUMCH between January and December in 2013. Among them, those in non-surgical departments and with hemoglobin ≥ 70 g/L before transfusion were identified, and their hemoglobin level before RBC transfusion, proportion in non-surgical patients receiving RBC transfusion, symptoms and signs related to anemia before transfusion were described.  Results  Of the 1000 patients, 270 were from non-surgical departments, and their average hemoglobin before RBC transfusion was (63.7±11.5)g/L. Seventy-four of the 270 (27.4%) patients had hemoglobin ≥ 70 g/L before RBC transfusion, including 60 (22.2%) patients with homoglobin ≥ 70 g/L and < 80 g/L, 10 (3.7%) patients with homoglobin ≥ 80 g/L and < 90 g/L, and 4 (1.5%) patients with hemoglobin ≥ 90 g/L. Among the 74 patients, symptoms and signs related to anemia and decision-making of the transfusion were identified in 59(79.7%) patients' medical records, the other 15(20.3%) patients with missing data were those with more severe conditions, multiple co-morbidities, multi-organ involvement, unstable conditions, or poor tolerance to decreasing hemoglobin level.  Conclusions  The hemoglobin threshold for RBC transfusion in non-surgical departments of PUMCH was consistent with the recommendations of both international and Chinese guidelines. Given specific conditions, RBC transfusion in those patients with hemoglobin level higher than the recommended threshold is clinically appropriate, but the decision-making process regrading RBC transfusion should be recorded in detail.
Abstract:
  Objective  To analyze red blood cell transfusion in the Department of Gastroenterology of Peking Union Medical College Hospital in 2015 in order to provide references for rational use of blood in clinical practice.  Methods  Medical records of patients hospitalized in Department of Gastroenterology of Peking Union Medical College Hospital who received red blood cell transfusion from January to October in 2014 and 2015 were reviewed. The clinical information including blood transfusion volume, transfusion case number, the cause of transfusion, and the hemoglobin level before transfusion were summarized.  Results  The red blood transfusion volume was 403 U in the Department of Gastroenterology in 2015, transfused in 76 person-times, accounted for 8.4% of the total red blood cell transfusion volume in all non-surgical departments. Gastrointestinal bleeding and inflammatory bowel disease were the two kinds of diseases which consumed the largest volume of blood both in 2014 and 2015. In 2015, the total transfusion volume of 37 gastraintestinal bleeding patients who needed blood transfusion was 204 U. The average transfusion volume was the highest in lymphoma (21.5 U per person). 9.2% of the patients needed emergency surgical hemostasis. The median hemoglobin level before red blood celltransfusion of in-patients in the Department of Gastroenterology was 65.5 g/L, meeting the recommended threshold of Chinese guidelines on blood transfusion.  Conclusions  The large volume of blood transfusion in the Department of Gastroenterology may be due to the type and severity of conditions treated in this department. Strengthening cooperation among departments and optimizing the schedule of surgery may help in reducing the volume of blood transfusion in Department of Gastroenterolgy.
Abstract:
  Objective  To assess the blood use in surgical patients with red blood cell(RBC) transfusion of over 20 U during single hospital stay in Peking Union Medical College Hospital (PUMCH) in order to help develop strategy for rational blood use.  Methods  We collected 27 surgical patients which received RBC transfusion of over 20 U during single hospital stay between January and October 2015 in PUMCH, and analyzed the data of these patients in aspects of baseline characteristics, blood use in perioperative period and during surgery, and treatment outcome.  Results  There were 22 males and 5 females in the 27 patients. A total of 867 U RBCs, 124 800 ml blood plasma, and 50 U platelets were transfused in them. Fifteen patients (55.6%) received 20~29 U RBCs in perioperative period, and the maximum volume of RBCs use per person was 92 U. Three hundred and thirty-four U RBCs were transfused during surgery, accounted for 38.5% of the total use; 32 000 ml blood plasma was transfused during surgery, accounted for 25.6% of the total volume used in perioperative period. The mean length of hospital stay was 43 days, with 1 patient hospitalized for less than 7 days (2.3%) and 3 for more than 60 days (11.1%). Sixteen patients (59.3%) were discharged after successful treatment, 5 patients (18.5%) gave up treatment, and 6 patients died (22.2%).  Conclusions  It is very important to perform preoperative assessment and cross-department consultation for rational blood transfusion strategy and disease severity evaluation. In order to reduce the volume of blood transfusion, conducting prompt hemostasis in the cases of major bleeding during surgery and seizing the appropriate timing for blood transfusion is essential. Management of blood use should also be strengthened for better use of blood product.
Abstract:
  Objective  To investigate the risk factors related to outcome of patients with severe massive hemorrhage in Intensive Care Unit (ICU).  Methods  Clinical data of all patients receiving transfusion of red blood cell (RBC) of >20 U for severe massive hemorrhage, who were hospitalized between January 2013 and December 2015 in ICU of Peking Union Medical College Hospital, were analyzed retrospectively. Comparisons were conducted between patients who died (death group) and those survived (survival group). Risk factors related to outcome were analyzed with Logistic regression.  Results  A total of 141 patients were identified, of whom 78 survived. In-hospital mortality was 44.7% (63/141). Among these patients with severe massive hemorrhage, there were 78 non-operation-related cases and 63 operation-related cases. The amount of RBC transfused in ICU (P=0.002), the proportion of non-operation-related cases (P=0.002), and the proportion of patients from emergency department (P=0.010) were all significantly higher in the death group than in the survival group, while the proportion of patients from surgical departments was lower in the death group than in the survival group (P=0.001). The baseline coagulation, renal, and liver function before RBC transfusion were significantly worse in the death group than in the survival group (all P < 0.05). Among the patients with non-operation-related severe massive hemorrhage, the death group had significantly higher proportion of severe massive hemorrhage due to infections (P=0.009), but significantly lower proportion of severe massive hemorrhage due to stress ulcer (P=0.048), baseline platelet level (P=0.003), and proportion of patients receiving surgical hemostasis (P=0.039). Among the patients with operation-related severe massive hemorrhage, the death group had higher volume of RBC transfusion in ICU (P=0.019), but higher proportions of patients with liver or renal function impairment before RBC transfusion (both P < 0.05). Logistic regression analysis showed that coagulation disorders (P=0.014, OR=3.594) and the presence of active massive hemorrhage after admission into ICU (P=0.025, OR=2.680) were risk factors for death in the patients with severe massive hemorrhage.  Conclusion  For all the patients with severe massive hemorrhage, coagulation disorders and the presence of active massive hemorrhage in ICU may be risk factors for death.
Abstract:
  Objective  To investigate blood management in perioperative period for patients using more than or equal to 20 units of blood.  Methods  Surgical patients using ≥ 20 units of blood in 2015 in Peking Union Medical College Hospital were included. Records regarding their perioperative period were collected, analyzed, and compared between the patients not receiving unplanned secondary surgery and those who received unplanned secondary surgery.  Results  Thirty-six patients were enrolled. The blood loss during the first surgery was significantly lower in the patients who did have unplanned secondary surgery (n=12) compared with those who did not(n=24) (1300 ml vs. 3000 ml, P < 0.05). Patients had higher American Society of Anesthesiology (ASA) grade in the unplanned secondary surgery compared with the primary surgery, with the number of cases classified as grade Ⅰ-Ⅴ being 0, 0, 4, 8, 0 and 2, 9, 1, 0, 0, respectively. Additionally, the average intraoperative blood loss (2250 ml vs. 1050 ml) and volume of blood transfusion (red blood cell, 8 U vs. 1 U; plasma, 400 ml vs. 100 ml) were higher in the unplanned secondary surgery than in the primary surgery (all P < 0.05). Eighteen patients were complicated with anemia before surgery.  Conclusions  For patients at high risk and receiving complex surgery, individualized treatment plan, therapy for anemia before selective surgery, careful hemostasis during operation, and perioperative monitoring of coagulation function may reduce the need for unplanned secondary surgery and improve patient outcome.
Abstract:
  Objective  To analyze the current situation of blood transfusion in Emergency Department of Peking Union Medical College Hospital(PUMCH) and to propose an appropriate strategy.  Methods  The data of blood transfusion in Emergency Department of PUMCH from January to October 2015 were analyzed and compared with the data of the corresponding period of 2014.  Results  Blood transfusion mainly concentrated in the therapeutic room of Emergency Department, in which red blood cells, plasma, and platelet transfusion accounted for 65%, 28%, and 78% of total volume of Emergency Department, respectively. Most of the patients receiving blood transfusion were patients with chronic diseases. Compared with the same period in 2014, the average amount of blood transfusion per capita (red blood cells, 6.02 U vs. 5.10 U; plasma, 8.26 U vs. 7.37 U; platelets, 2.48 U vs. 2.08U) and mean blood transfusion volume (red blood cells, 3.07 U vs. 3.04 U; plasma, 6.80 U vs.6.23 U; platelets, 1.21 U vs. 1.16 U) were both increased in 2015.  Conclusions  Many factors may cause large demand of blood transfusion in the therapeutic room in Emergency Department. We should follow the indications of blood transfusion strictly for appropriate use of blood tranfusion.
2016, 7(5): 321-326. doi: 10.3969/j.issn.1674-9081.2016.05.001
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