2017 Vol. 8, No. 6

2017, 8(6): 321-321.
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2017, 8(6): 352-358. doi: 10.3969/j.issn.1674-9081.2017.06.007
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2017, 8(6): 358-358, 363.
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2017, 8(6): 387-390. doi: 10.3969/j.issn.1674-9081.2017.06.013
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2017, 8(6): 394-394.
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2017, 8(6): 395-399. doi: 10.3969/j.issn.1674-9081.2017.06.015
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2017, 8(6): 400-400.
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Editorials
Abstract:
Shock, which has been recognized and treated in clinic for a long time, however, is a commonly seen lethal morbid state. The development of hemodynamics in critical care provides specific guidance and novel inspirations. Hemodynamics is a discipline defining the movement of blood flow and blood components inside and outside of cardiovascular system. Hemodynamic treatment in critical care is a quantitatively goal-oriented approach based on the theories of hemodynamics, according to the patient's real-time status and response to the intervention. Hemodynamic principles and concepts influence the choice and performance of treatment on shock. Firstly, flow indicator should be ensured the top priority at selecting feedback parameters for treatment. Meanwhile, be aware that, every hemodynamic indicator, so long as it is correctly measured, is of value in clinical practice. Secondly, the change of right heart function is of great importance in shock. Managing the right heart function has become an indispensible part in the treatment. Thirdly, the central venous pressure needs to be kept as low as possible in shock patients. Central venous pressure, which is different from the traditionally used pressure parameter instead of flow, is of significance in definitely guiding the treatment. Fourthly, critical hemodynamic therapy is not merely limited to supportive treatment, but encompasses the whole set of management of shock from etiology to prognosis.
Abstract:
Sepsis is life-threatening multi-organ dysfunction caused by a dysregulated host response to infections, and it is one of the most common and thorny diseases in critically ill patients. With the complement and refinement of sepsis bundles, the mortality rate of sepsis has decreased. However, due to population aging, lifestyle changes, and increasing prevalence of coexisting chronic diseases, its incidence increases significantly, and the pathological process is more complicated, causing the number of annual deaths to rise. Sepsis has become a heavy global burden, which is particularly obvious in poorly resourced settings. The effects of health resource allocation on the epidemic of sepsis, the level of the diagnosis and treatment, and costs of care in sepsis will be discussed in this article. Moreover, it put forward proposals on how to reduce negative effects of poor resource on the occurrence and development of sepsis, and improve compliance of Surviving Sepsis Campaign guidelines.
Specialist Forum
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Poor tissue perfusion and cellular hypoxia could be persistent even when macro-circulation has been restored, which has become a great challenge for physicians in performing resuscitation on patients with circulatory shock. Hereby, we introduced the concept of resuscitation coherence (RC) to evaluate the interaction of macro-circulatory alteration with the corresponding change of microcirculatory perfusion and cellular oxygen metabolism in resuscitation. Early identification of the loss of RC might be helpful to avoid over-resuscitation and determine the next therapeutic direction.
Abstract:
Septic acute kidney injury(SAKI) is the leading type of acute kidney injury in critically ill patients. We reviewed currently hot topics including:The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), big data, precision medicine, novel biomarkers, hemodynamic treatment and critical care blood purification, and deeply explored how to understand those topics correctly, so as to promote the study on SAKI, and apply them into clinical practice properly.
Abstract:
Surgery is the preferred treatment for most lateral skull base lesions. Due to the complexity of the anatomical structure of lateral skull base and its close adjacency to important blood vessels, cranial nerves and the brain, surgery prones to induce deadly or disabling complications, which limit the implementation of the surgery. Brain function, low cranial nerves, facial nerve and hearing are the priorities that should be taken care of during surgery. The key points for functional protection of organs include:a good balance between preservation of functions and resection of lesions, skillful surgical technique, and new instruments or equipment such as image navigation and interventional therapy.
Abstract:
The anatomy of the lateral skull base is very complicated, which supports the brain upwards and connects the neck downwards with a large number of crucial structures passing through, including important blood vessels, nerves, and vestibular and auditory apparatuses. The basic principle of lateral skull base surgery is resecting the lesion and meanwhile preserving the function of important tissue and organs. With the development of interventional medicine, neuromedicine and facial nerve surgery, protection of important nerves and blood vessels of the skull base has made significant progress, and fatal complications and neurological defects have been greatly reduced. However, the protection of auditory function is not ideal, which has gradually become a research hotspot. The selection of appropriate treatment and surgical approach, the usage of endoscopic techniques, intra-operative auditory electrophysiology monitoring, and intraoperative reconstruction of the auditory function are all very critical for hearing protection.
Original Contributions
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  Objective  To explore neuroprotective effects of p66Shc knock-out on hypoxic-ischemic brain injury in mice and possible underlining mechanisms.  Methods  C57 mice were divided into 3 groups:sham-operation group (SO, wild type), hypoxic-ischemic wild type group (HIWT) and hypoxic-ischemic p66Shc knock-out group (HIKO), 20 mice each group. HIBI model making:ligation of the right common carotid artery and then exposure to a hypoxic environment. The neurological dysfunction score, HIBI lesion volume, serum neuron specific enolase (NSE) level and interleukin (IL)-1β level in brain tissue were measured and compared.  Results  Twenty-four hours after HIBI, the neurological function of HIKO mice was better than that of HIWT mice, the HIBI lesion volume of HIKO mice was smaller than that of HIWT mice, the serum NSE level of HIKO mice was much lower than that of HIWT mice, IL-1β level in the brain tissue of HIKO mice was much lower than that of HIWT mice (all P < 0.05).  Conclusion  p66Shc knock-out plays an important role in neuroprotective effects on HIBI of mice, possibly through attenuating IL-1β expression in the brain tissue after HIBI.
Abstract:
  Objective  To investigate the antimicrobial resistance of clinical bacterial isolates in Peking Union Medical College Hospital (PUMCH) in 2016.  Methods  A total of 11 721 non-duplicate clinical isolates were collected from January 1 to December 31 2016. Disc diffusion test (Kirby-Bauer method) and automated systems were employed to detect antimicrobial resistance. The data were analyzed by WHONET 5.6 software according to the 2016 edition of Performance Standards for Antimicrobial Susceptibility Testing issued by The Clinical and Laboratory Standards Institute (CLSI) of the United States.  Results  Of the 11 721 clinical isolates, the 10 most common bacteria were:Escherichia coli (16.3%), Klebsiella pneumoniae (11.4%), Pseudomonas aeruginosa (9.3%), Acinetobacter baumannii (9.0%), Staphylococcus aureus (7.4%), coagulase-negative Staphylococcus (7.3%), Enterococcus faecalis (6.1%), Enterococcus faecium (3.9%), Streptococcus agalactiae (3.4%) and Enterobacter cloacae (3.3%). Gram-negative bacilli and gram-positive cocci accounted for 62.7% and 37.3%, respectively. Methicillin-resistant strains in S. aureus (MRSA) and coagulase-negative Staphylococcus (MRCNS) accounted for 27.0% and 68.9%, respectively. The resistance rates of MRSA and MRCNS strains to β-lactams and other antimicrobial agents were much higher than those of methicillin-susceptible Staphylococcus aureus (MSSA) and methicillin-susceptive coagulase-negative Staphylococcus (MSCNS) strains. 93.9% of MRSA strains were still susceptible to trimethoprim-sulfamethoxazole, while 85.0% of MRCNS strains were susceptible to rifampin. No staphylococcal strains resistant to vancomycin, teicoplanin, and linezolid were 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. 97.4% of β-hemolytic streptococcus strains were susceptible to penicillin. Extended-spectrum β-lactamase (ESBL)-producing strains accounted for 50.7%(969/1913), 33.9%(488/1439) and 32.1%(59/184) 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 ≤ 7.3%. A few extensively resistant strains of K. pneumoniae (6.5%, 87/1331) were identified. The resistance rates of K. pneumoniae to imipenem and meropenem were 18.0% and 16.6%, respectively. About 76.7% of A. baumannii were resistant to imipenem, and 74.4% to meropenem, while the resistant rates to tigecycline (9.3%) and minocycline (26.9%) were the lowest. The resistance rates of P. aeruginosa to imipenem and meropenem were 26.3% and 18.5%, respectively, while the resistant rate (8.2%) to amikacin was the lowest. The prevalence of extensively resistant strains in A. baumannii and P. aeruginosa was 24.8% (260/1049) and 3.1% (34/1095), respectively.  Conclusions  The prevalence of carbapenem-resistant K. pneumonia is still higher. Infections due to carbapenem-resistant strains pose a huge challenge for clinicians.
Complicated and Rare Disease
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We reported a case of lumbar spinal stenosis, whose symptoms improved temporarily after surgery, but 4 weeks later, the symptoms worsened again, in addition to fever and bilateral foot drop. The patient was diagnosed with POEMS syndrome after multidisciplinary consultation, the symptoms improved with chemotherapy and autologous stem cell transplantation. Although POEMS syndrome is a rare disease, and the combination with lumbar spinal stenosis is an even rarer condition, if we stick to following the diagnostic protocol for neurological diseases to find the location first and then the etiology, without neglectingdoubtful points, we will be able to avoid misdiagnosis in such cases.
Continued Medical Education
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The discipline of critical care blood purification(CCBP) is a branch of science that aims at studying changes of the internal environment in critically ill patients and relating principles, and exploring the methodology of blood purification with the guidance of theories of critical care medicine. Because of the complexity and variability of the conditions of critically ill patients, we should select different blood purification techniques according to the state of the illness, which makes integration as one of main characteristics of CCBP. There are two forms of integration:sequential integration and concurrent integration. This article will elaborate on the integration feature and main integration techniques of CCBP.
Clinical Research and Evidence Based Medicine
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Researches, especially population studies and clinical studies, need to be repeated. However, repeated studies on the same question may produce conflict results. Therefore, a systematic review, a timely comprehensive analysis of individual studies on the same question, is the basis of evidence-based decision making. Meta-analysis of systematic review, which is regarded as the method for producing the evidence of top level, has been widely used in more and more fields. However, there are some methodological limitations for meta-analysis. It is controversial whether meta-analysis could be applicable to all type of researches. In view of this fact, we introduced the procedure of systematic review, the basic principle and the statistical formula of meta-analysis, and further explored the sources of error in meta-analysis and explained the difference between the random effect model and the fixed effect model in order to understand the methodological limitations of meta-analysis and perform it deliberately. At the same time, we recommended that clinicians should carefully interpret the pooled results of a meta-analysis, especially of the one using the random effect model, when they are going to make a clinical decision.
Case Report
Abstract:
We reported one patient with rare malformation, congenital lower vaginal atresia with vesico-vaginal fistula, and introduced the characteristics of this case encompassing clinical symptoms, examinations, diagnosis and management. Meanwhile, we reviewed previously reported similar cases to help clinical physicians better understand urogenital system malformation. When periodic hematuria without vaginal menstrual bleeding occurs in puberty, congenital vaginal atresia with vesico-vaginal fistula should be suspected. Imaging examinations and cystoscopy are important adjuvant diagnostic methods. The only treatment of this disease is surgical incision of the vaginal atresia for drainage and repair of the fistula tract.