2018 Vol. 9, No. 5

Editorial
Abstract:
Infection or shock is such a disease or syndrome that everybody seems to know, and is confronting every clinician because any patient has the opportunity to get it and even worse into septic shock. Infection may induce dysregulated host response to cause life-threatening organ dysfunction. Shock may represent profound circulatory and cellular metabolic abnormalities, and increase mortality substantially. It is very important for every clinician to keep abreast of advances in understanding and managing infection, shock, and septic shock correctly. Septic shock is a common lethal syndrome but is curable and preventable if you and I just do the right things from the beginning.
Specialist Forum
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Sepsis and septic shock continue to be a devastating syndrome that is associated with morbidity and mortality. Sepsis and septic shock are time-critical conditions. Emergency department(ED) plays a vital role in the identification, risk stratification, and resuscitation for patients with sepsis or septic shock. The "sepsis bundle" has been reported to improve the outcome of sepsis. In April 2018, the Surviving Sepsis Campaign issued an " hour-1 bundle" for patients with suspected sepsis. Getting this" hour-1 bundle" done in less than 1 hour will be a challenge for emergency physicians.The aim of this review was to discuss the process, management, and possible future policies to improve the compliance to the bundle and quality metrics so that encourage a rapid and high-quality care of sepsis and septic shock in the ED.
Abstract:
he medical development brought about by the progress of science and technology has made great contributions to the improvement of diagnosis and treatment of many diseases including infection. However, it is undeniable that infection is still an important disease threatening human beings. Even the most advanced technique of pathogen identification still cannot change the model of empirical treatment and comprehensive judgment, which is the main module of early diagnosis and treatment of infectious diseases (ID). Therefore, how to improve the comprehensive diagnosis and treatment of ID by clinicians is very important in the early diagnosis and treatment, especially in the current situation of general lack of ID specialists in our country. This article is to combine basic skills of clinical practice and international advanced experience to sort out the diagnosis and treatment of ID, in order to provide a feasible reference for clinicians.
Abstract:
Infectious diseases are still the main diseases that threaten human health. Traditional diagnostic technology has been unable to meet the clinical needs. The development of pathogenic diagnosis technology is of vital importance to the diagnosis and treatment of infectious diseases. In recent years, non-cultured new diagnostic technologies have been rapidly developing, especially the real-time detection based on lateral flow immunoassay and real-time polymerase chain reaction. The continuous application of proteomics mass-spectrometry and high-throughput sequencing technology in clinical practice makes the clinical diagnosis of infectious diseases more convenient, faster and more accurate. However, it is necessary to correctly handle the problems in the clinical application of new diagnostic technology. Diagnostic tests should be assessed from the angle of evidence-based medicine and the applied crowds to gather the best evidence, so that they can be applied to the appropriate people and achieve the best effect, making the application of new technology in etiologic diagnosis really solve the problem of clinical diagnosis and eventually provide the basis for scientific decision-making about the clinical diagnosis and treatment of infectious diseases.
Abstract:
Recognizing a critical scenario and its etiology is the key point of the therapeutic direction. Critical ultrasonography is now more and more comprehensively used in monitoring organ function and predicting pathogenesis, and is recognized as a fundamental component of critical care. Respiratory and circulatory failure is the core part of a critical scenario, analysis of which is the advantage of critical ultrasonography. Furthermore, evaluation of the precursor disease is also of great significance, indicating the wide range application of critical ultrasonography.
Guideline Interpretation
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Consensus on the Management of the Right Heart Function in Critically Ill Patients is the first consensus on the management of right heart function in the field of critical care medicine, which could be used to guide clinical practice. The consensus described pathophysiology of the right heart, right heart dysfunction related diseases, and the management of right heart function, and gave a clear description of the relationship of the preload, afterload, diastolic function, and systolic function of the right heart, and the relationship between right heart and the macrocirculation, microcirculation, pulmonary circulation, and the left heart. The consensus fully addressed the importance of the right heart function in the critical hemodynamic management theory and could guide the clinical practice of each right heart function related step, i.e., to monitor and manage the right heart function.
Point/Counterpoint
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Sepsis is not equal to infection. It is defined as life-threatening organ-dysfunction caused by a dysregulated host response to infection. Sepsis focuses on organ dysfunction instead of the infection, which is the main difference of opinion between Infectious Disease Society of America(IDSA) and Surviving Sepsis Campaign(SSC). Screening is the most important thing for sepsis in order to initialize the sepsis therapy-bundles to improve the patients' outcome. The definition and concept of sepsis originate from the evidence-based medicine and big data study. The methodology of sepsis keeps its development potential. This article interpreted the essence of sepsis to support SSC and disprove the opinions of IDSA.
Abstract:
Sepsis is one of the leading causes of morbidity and mortality in critically ill patients. With the development of understanding in the definition, diagnosis, and treatment of sepsis, the mortality rate is significantly reduced. The Surviving Sepsis Campaign Guideline: International Guidelines for Management of Sepsis and Septic Shock, which is released every four years, has received an extensive international attention. Based on big changes in the definition and diagnosis of sepsis and septic shock, the 2016 version of the SSC guideline was formally released in January 2017. However, just in November 2017, Infectious Disease Society of America (IDSA)issued a public statement in its official journal, Clinical Infectious Diseases, to question the recommendations of the 2016 SSC guidelines on the diagnosis and treatment of infection. Why did such a heated disagreement break out between the international medical authoritative societies over sepsis and infection? According to the concept, diagnosis, and treatment of sepsis, this article attempts to stand in the position of IDSA to interpret the IDSA statement and discuss the topic of "sepsis" and "infection".
Abstract:
Sepsis and septic shock are among the leading causes of death in critically ill patients. Since considerable advances have been made in understanding their pathophysiology and clinical management, the Surviving Sepsis Campaign(SSC) guideline for sepsis and septic shock is updated every four years since 2004, which aims at standardizing the clinical practice. The mortality of sepsis was significantly decreased based on the data from the last decades. The recent update of SSC was released in 2016, but it was argued against by Infectious Disease Society of America(IDSA) regarding antimicrobial therapy. IDSA published a statement on its official journal, Clinical Infectious Diseases, claiming they did not endorse the SSC guideline, which caused some confusion in clinical references and applications. So it is important to understand the essence of the controversy between these two societies. The guidelines of SSC and IDSA can better instruct the clinical practice for sepsis and septic shock only after the core of the contradiction between them is fully understood.
Original Contributions
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  Objective  The aim of this study was to investigate the prognostic value of mitral regurgitation for patients with septic shock in the department of critical care medicine.  Methods  General clinical information and cardiac valves function of patients with septic shock from April to August 2016 in the Department of Critical Care Medicine, West China Hospital of Sichuan University were collected and analyzed retrospectively from the database of SHOCK-ICU(NCT03082326). All the patients were divided into the survival group and the death group based on whether they died in 28 days after enrollment. The effects of regurgitation of the mitral valve and other valves on the prognosis were compared by the Logistic regression model. The effect of mitral regurgitation on the survival of 28 days in patients with septic shock was analyzed.  Results  Totally 111 cases met the inclusion and exclusion criteria, including 67 males and 44 females with the average age of (57.5±18.5) years. The score of Acute Physiology and Chronic Health Evaluation Ⅱ(APACHE Ⅱ) and the 28-day mortality were 23.6±8.6 and 46.8% (52/111), respectively. The univariate analysis showed that mitral regurgitation and the lung ultrasound aeration loss score (LUSS) of the death group were higher than those of the survival group (P=0.039 and P=0.020). Mitral regurgitation and LUSS were independent risk factors for the 28-day mortality (P=0.015 and P=0.020) by Logistic multivariate analysis. The 28-day survival rate of patients with mitral regurgitation (38.2%, 13/34) was significantly lower than that of the non-mitral regurgitation group (59.7%, 46/77) (P=0.039) by the survival analysis.  Conclusions  Mitral regurgitation is associated with a worse prognosis in patients with septic shock.
Abstract:
  Objective  The aim was to study the clinical characteristics and therapeutic strategies of cryptococcal meningitis and provide further evidence for clinical diagnosis and therapy.  Methods  Data of the inpatients with cryptococcal meningitis who were admitted in the Department of Infectious Diseases, Peking Union Medical College Hospital from January 2000 to December 2016, including clinical data (age, gender, comorbidity, history of avian contact), clinical manifestations, laboratory examination, CT and magnetic resonance imaging findings, therapy, and prognosis, were analyzed retrospectively.  Results  The age of the 62 enrolled inpatients ranged from 16 to 68 years (median 39). 41 patients were male and 21 were female. There were 37 patients (59.7%, 37/62) with comorbidity and 23 patients (37.1%, 23/62) had contacted with pigeons or poultries. The number of cases misdiagnosed with tubercular meningitis or virus meningitis was 20 (32.3%, 20/62) and 9 (14.5%, 9/62), respectively. The main clinical symptoms included headache (98.4%, 61/62) and fever (82.3%, 51/62); 19 (30.6%, 19/62) patients had blurred vision; 13(21.0%, 13/62) had organ involvement beyond the central nervous system. The intracranial pressure increased in 55 patients (88.7%, 55/62) and 34 (61.8%, 34/55) had an opening pressure of more than 330 mm H2O. The white blood cell count of cerebrospinal fluid had a median of 71×106 cells/L(range 0-408×106 cells/L), dominated by mononuclear cells in 55 patients (88.7%, 55/62). Fifty-three (85.5%) of the 62 cases were positive of cryptococcus by India ink stain of cerebrospinal fluid; latex coagulate test was performed in 55 cases with 51 (92.7%, 51/55) positive; cerebrospinal fluid culture was positive in 28 cases (49.1%, 28/57). Twenty-five patients with a dilated ventricle received brain ventricular drainage. Only 4 cases used fluconazole monotherapy; 7 patients received intravenous amphotericin B (AmB) and flucytosine combined therapy; 16 patients took AmB and fluconazole combined therapy; 35 patients received AmB, flucytosine, and fluconazole combined therapy. The average dosage of AmB was 4139 mg; the median treatment duration was 19.6 weeks (range 2-42 weeks). In general, 10 of the 62 cases were cured, 44 improved, 6 no response, and 2 died; the total effective rate was 87.1% (54/62).  Conclusions  Cryptococcal meningitis might occur in immunocompetent patients with a high misdiagnosis rate. India ink stain and cryptococcal antigen test of cerebrospinal fluid are useful assays for early diagnosis of cryptococcal meningitis and therapeutic effect evaluation. We recommend the combination of amphotericin B with flucytosine and fluconazole as the standard therapy for cryptococcal meningitis. Early ventricular drainage is the key point to improve the treatment success for cryptococcal meningitis.
Abstract:
  Objective  The purpose of this study was to investigate the evaluating value of the modified critical care ultrasonic examination (M-CCUE) protocol for those patients unplanned admission to the ICU and to analyze whether it could influence the management decision and predict the outcome.  Methods  The clinical data of patients unplanned admission to the department of critical care medicine of Peking Union Medical College Hospital from December 2015 to June 2016 were collected and analyzed retrospectively, including the hemodynamic index, organ and tissue perfusion index, and prognosis evaluating index. All the enrolled patients received the M-CCUE within 30 minutes after admission to our department and were scored according to the M-CCUE scoring system (MCS). The correlation between MCS and the prognosis and its effect on the management decision were analyzed.  Results  A total of 272 patients who met the inclusion and exclusion criteria were enrolled in this study. Only 3 patients (1.1%, 3/272)did not show any anomaly in M-CCUE; the management decision of 138 patients (50.7%, 138/272), was adjusted; 81 patients (29.8%, 81/272) underwent additional invasive diagnostic procedures or treatment. The univariate analysis revealed that MCS correlated positively with the 28-day mortality (r=0.432, P=0.020), 48-hour mortality (r=0.594, P=0.008), ventilator time (r=0.454, P=0.040), and length of ICU stay (r=0.563, P=0.003). The multivariate analysis demonstrated that age, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ), MCS, and sequential organ failure assessment score were the independent risk factors for the 28-day mortality, while age, MCS, and sequential organ failure assessment score were the independent risk factors for the 48-hour mortality.  Conclusions  M-CCUE protocol can achieve the early bedside cardiopulmonary function assessment; its quantitative assessment results are associated with the prognosis and might improve the clinical management decision.
Review
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With the increasing importance of the prevention and treatment of infectious diseases in health care and the increasing social concern caused by infectious diseases, new technologies are crucial for preventing and controlling the spread of pathogens. The microbiology laboratory has always being playing a significant role as the first line of pathogen detection in infection control by carrying on smear microscopy, culture, identification, and susceptibility testing. Information provided by traditional molecular diagnostics and genotyping methods is limited, which can not satisfy the requirement of epidemiologic investigation on the outbreak and spread of communicable diseases. Next-generation sequencing determines the DNA sequence of a complete bacterial genome in a single sequencing run, from which information on resistance, virulence and typing is obtained. It is useful for investigation into the outbreak. The obtained genome data can be further used for developing an outbreak-specific screening test. In this review, a general introduction to next-generation sequencing and its applications in clinical microbiology including outbreak management, identification of unknown pathogens, taxonomy, and research on resistant genomes are presented.
Abstract:
As deep learning brings a series of revolutionary change, artificial intelligence has become a focus in various fields again in recent years. With the transition from computer vision to deep learning and the progress in hardware and big data, artificial intelligence, has demonstrated broader prospects for the development of image recognition. Image algorithm exploiting deep learning model has achieved better identification accuracy than the naked eye, which offers the possibility of making breakthrough in medical imaging field. Ultrasonography is a main branch of medical imaging. An increasing number of papers on research of the application of artificial intelligence-related algorithms into analyzing ultrasonographic images provide new insights into clinical research. Meanwhile, specific software is able to compensate for the practitioner's deficiency in experience and improve diagnostic accuracy as well.
Clinical Research and Evidence Based Medicine
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A clinical research project of high quality cannot be carried out without standard data management and quality control. Data management and quality control of clinical research should be started from the design of the study and performed throughout the whole process of study. The process of data management includes planning, the design of case reporting form, data dictionary and coding specification, construction of the database, data collection and monitoring, data input, data auditing and cleaning, generation of new key variables, medical coding, deidentification, data review and data lock. Strict data management and quality control can improve the integrity and accuracy of clinical research, and further improve the quality of the overall clinical research project.
Clinical Case Analysis
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The aim of this article was to explore the diagnostic approach and treatment of persistent hypotension in postoperative patients with severe acute pancreatitis(SAP). The diagnostic approach and treatment were summarized through retrospectively analyzing the clinical data of one SAP patient with persistent postoperative hypotension. This was a 61 years old male SAP patient and was transferred to the department of critical care medicine after surgery. Hypovolemic shock and infection, the initial features of this patient, were controlled after resuscitation and anti-infective therapy. But the patient still had persistent hypotension. All types of shock were distinguished and hormone examination was performed. The patient was finally diagnosed as critical illness-related corticosteroid insufficiency(CIRCI). The symptom of persistent hypotension was significantly improved after hormone replacement. At the one-month follow-up, the patient's blood pressure returned to normal and then hormone therapy was stopped. The possibility of CIRCI should be taken into account when a SAP patient with unexplained persistent postoperative hypotension after the successful control for infection. Early diagnosis and glucocorticoid replacement therapy is helpful for the recovery of the patients.
Conference Express
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The 28th European Conference on Clinical Microbiology and Infectious Diseases (ECCMID) opened with a great ceremony from 21st to 24th, April 2018 in Madrid, Spain. This meeting focused on several hot topics concerning clinical microbiology and infectious diseases,including the breakpoints update of the European Committee on Antimicrobial Susceptibility Testing (EUCAST), EUCAST rapid antimicrobial susceptibility testing by disk diffusion directly from blood culture bottles, HeIP as a new prognostic biomarker for patients with bloodstream infection of Pseudomonas aeruginosa, the comparable effect of 7-day versus 14-day antimicrobial therapy for gram-negative bacteremia, reemergence of West Nile Virus infection in humans in Southern Greece, the implementation of the infection-risk scan in a Dutch hospital resulting in standardization, transparency and substantial improvement, novel mechanisms of fosfomycin resistance in Escherichia coli, the outbreak of Candida auris infection in a UK intensive care unit, mazEF bacterial toxin-antitoxin systems as targets for novel antimicrobials, and so on. Besides, China also showed its stories in the conference, including the first introduction of China Antimicrobial Resistance Surveillance System, the successful hosting of the second work meeting of Chinese Committee on Antimicrobial Susceptibility Testing, and China-Europe Forum of Global Chinese Association of Clinical Microbiology and Infectious Diseases.
2018, 9(5): 445-447. doi: 10.3969/j.issn.1674-9081.2018.05.013
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2018, 9(5): 467-473. doi: 10.3969/j.issn.1674-9081.2018.05.018
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2018, 9(5): 479-480. doi: 10.3969/j.issn.1674-9081.2018.05.020
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