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2019 Vol. 10, No. 5

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Editorials
Thirty Years of Clinical Hemodynamics
Da-wei LIU
2019, 10(5): 433-437. doi: 10.3969/j.issn.1674-9081.2019.05.001
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Tremendous development and progress in clinical hemodynamics have been made since 30 years ago when the first Swan-Ganz Cather was introduced to China. The emerging concept of clinical hemodynamic therapy (CHT) is enriched today in its theoretical system and clinical feasibility. CHT includes some new concepts, such as that hemodynamics is a discipline defining the state of both blood flow and blood component flowing inside and outside of the cardiovascular system. CHT is not as same as hemodynamic monitoring because of its characteristics and its control capability in clinical behavior, which include some key points like therapeutic timing and targeting, interventional therapy, and concomitant injury. The therapeutic target is at the interaction among organs and has changed from personalized therapy to organ-target directed therapy. CHT is a goal-directed, quantitative treatment process in accordance with the patient's real-time status and response to the intervention based on hemodynamic theories.
Rethink of the Definition and Classification of Shock
Xiang-dong GUAN, Xiang SI
2019, 10(5): 438-441. doi: 10.3969/j.issn.1674-9081.2019.05.002
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Shock, which has been clinically recognized and treated for many years, is a common life-threatening disorder. In recent years, with the development of hemodynamic theory, the assessment and understanding of shock have been progressing. Based on the latest knowledge, Chinese experts of critical care medicine attempted to define a Chinese definition of shock: an acute circulatory syndrome with insufficient perfusion to tissues and organs, which is due to changes in perfusion flow by various causes. According to the characteristics of hemodynamics and clinical application, shock is still classified into four groups: distributive, hypovolemic, obstructive, and cardiogenic. If different types of shock coexist, it is called "mixed shock". Therefore, it helps us to better understand, evaluate and manage this situation, so that more patients with shock can benefit from it.
Current Status of Clinical Infection of Candida Auris in China
Ying-chun XU, Jing-jing HUANG, Meng XIAO, Xin-fei CHEN, Ya-ting NING, Xin FAN, Yang YANG, Jia-jia FENG, Li-kai LIN
2019, 10(5): 442-445. doi: 10.3969/j.issn.1674-9081.2019.05.003
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Candida auris is an emerging pathogen in recent years that has developed resistance and caused nosocomial outbreaks in some countries especially in the United States. The term "super fungi" derived from "superbug", and it is rarely mentioned in the field of fungi. However, recently the articles with the definition that "Candida auris is a super fungi" are widely circulated on the internet. The situation of Candida auris in China differs from that in the United States according to existing reports and epidemiological surveillance data. The infection caused by it is still sporadic, and isolations of Candida auris are active to antifungal agents. Meanwhile, its pathogenicity is not stronger than the common non-albican Candida species. Therefore, the public should avoid excessive interpretation of the articles with unnecessary panic.
Specialist Forum
Dramatic Changes in Hemodynamics from the Changes of Surviving Sepsis Campaign Guidelines
Li LI, Jing YAN
2019, 10(5): 446-449. doi: 10.3969/j.issn.1674-9081.2019.05.004
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Hemodynamic therapy is an essential part of sepsis treatment. Since 2004, the Surviving Sepsis Campaign guideline for Management of Severe Sepsis and Septic Shock has undergone four changes, each of which is further improved. With the changes of Surviving Sepsis Campaign Guidelines, development and implementation of the strategies of hemodynamic therapy have also changed significantly. Clinical understanding of hemodynamic therapy in septic patients is more profound and the regulation is more accurate.
The Principles of Volume Management
Wei HUANG, Hong-min ZHANG, Xiao-ting WANG, Da-wei LIU
2019, 10(5): 450-455. doi: 10.3969/j.issn.1674-9081.2019.05.005
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Fluid management is one of the crucial interventions in critically ill patients, which runs through the whole process of hemodynamic therapy, and fluid resuscitation is the key part. Either too much or too little volume can have a negative impact on patient outcome. Only adequate volume status could improve prognosis. Early fluid resuscitation should be titrated carefully for each patient, reaching the target quickly and avoiding complications. Therefore, how to maintain an appropriate volume status is challenging. Nevertheless, the rules of fluid resuscitation are still controversial: when to start, how to proceed, when to finish? Even the type of fluid selected is far from a consensus. This article tends to summarize some experience in fluid management.
Maintenance of Perfusion Pressure: How to Choose the Vasoconstriction Drugs?
Xiang-dong GUAN, Zi-meng LIU
2019, 10(5): 456-460. doi: 10.3969/j.issn.1674-9081.2019.05.006
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Shock is a common critical condition of numerous diseases, resulting in multi-organ dysfunction and death. Vasopressors are the essential part of shock management. Catecholamines are the most commonly used vasopressors in the intensive care unit, among which norepinephrine is the first-line therapy in most clinical conditions. Vasopressin and angiotensin Ⅱ may be useful owing to their norepinephrine-sparing effects. Careful selection of vasoconstriction drugs based on desired pharmacologic effects that are matched to the patient's underlying pathophysiology of shock may optimize hemodynamics while reducing the potential for adverse effects.
Critical Ultrasonography: Hemodynamic Helper
Zhi-qun XING, Xiao-ting WANG, Da-wei LIU
2019, 10(5): 461-464. doi: 10.3969/j.issn.1674-9081.2019.05.007
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Recently, accompanying with more and more clinical and basic researches, our understanding of evaluating indexes of the diagnosis and treatment in critically ill patients has improved and developed. The treatment of critically ill patients has developed from group treatment and individual treatment to organ-based treatment. Treatments that directly evaluate blood flow of organs and aim at improving blood perfusion and function of organs are increasingly applied in critically ill patients. As an important monitoring and evaluating method for critically ill patients, critical ultrasonography plays an irreplaceable role in the treatment of critically ill patients, and constantly promotes physicians' understanding and evaluating diseases in the critical care. The application of critical ultrasonography revolutionized our understanding of systemic oxygen delivery, the heart, lungs, and other vital organs. At the same time, it promoted the clinical diagnosis and treatment of critically ill patients. How to better apply critical ultrasonography and evaluate organ hemodynamics is a very important problem for physicians of critical care. This article intends to systematically elaborate on the important role and application of critical ultrasonography in the assessment of systemic oxygen delivery and blood supply of organs, so as to provide a reference for clinicians.
2019, 10(5): 465-475. doi: 10.3969/j.issn.1674-9081.2019.05.008
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2019, 10(5): 551-552. doi: 10.3969/j.issn.1674-9081.2019.05.021
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Guideline Interpretation
Interpretation on the Update of American Diabetes Association Standards of Medical Care in Diabetes—2019
Na YANG, Hua-bing ZHANG, Yu-xiu LI
2019, 10(5): 476-480. doi: 10.3969/j.issn.1674-9081.2019.05.009
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Diabetes mellitus is one of the most common chronic non-infectious diseases. The American Diabetes Association publishes a new version of Diabetes Medical Standards every year that provides guidance for clinicians in the prevention, diagnosis, and treatment of diabetes. The latest version was released in December 2018. This article interprets some of the updated contents in this edition of the Standards for reference, including Diabetic medications especially for patients with arteriosclerosis cardiovascular disease, chronic kidney disease, or heart failure, choices of injectable hypoglycemic agents, goals of blood pressure control, and the use of aspirin.
Correlation of Cerebral Hemodynamics and Cerebral Oxygen Saturation with the Prognosis of Patients with Septic Shock: A Prospective Cohort Study
Qing FENG, Mei-lin AI, Li HUANG, Qian-yi PENG, Yu-hang AI, Li-na ZHANG
2019, 10(5): 481-488. doi: 10.3969/j.issn.1674-9081.2019.05.010
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  Objective  The aim of this study was to explore the correlation of the changes of cerebralhemodynamic indexes of the middle cerebral artery and cerebral oxygen saturation withthe prognosis of patients with septic shock.  Methods  The clinical data of patients with septic shock admitted to the department of Critical Care Medicine of Xiangya Hospital of Central South University from May 2018 to March 2019 were collected. Based on if dead or not within 28 days after the admission, the patients were divided into two groups, the death group and survival group. The general clinical information, arterial and central venous blood gas index immediately after admission into our department and after 6 hours of initial liquid resuscitation, critical cardiac ultrasound indicator, organ function index, indicator of sepsis biomarkers, middle cerebral artery blood flow velocity, dynamic cerebral perfusion index, brain transient congestion response ratio (THRR), and change of cerebral oxygen saturation after 6 hours of initial liquid resuscitation were compared.  Results  Totally 51 patients with septic shock meeting the inclusive and exclusive criteria were enrolled in this study, 31 male and 20 female, with an average age of (53±13) years and 28-day mortality of 43%. Compared with the survival group, the death group had a higher sequential organ failure assessment (SOFA) (P=0.007), acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) score (P=0.026), and peak APACHEⅡ score (P < 0.001). Patients in the death group had a lower oxygenation index (P=0.047) and a higher value of central venous-to-arterial carbon dioxide difference (Pcv-aCO2) (P=0.044). In addition, the death group showed more impaired dynamic cerebrovascular autoregulation (THRR < 1.09) (P=0.025), lower regional cerebral oxygen saturation (rSO2) mean (P=0.031), and more patients with mean rSO2 < 60% (P=0.010). Multivariable Logistic regression analysis showed that the peak APACHE Ⅱ score (OR=1.099, 95% CI: 1.009-1.196, P=0.030), the Pcv-aCO2 after 6 hours of initial liquid resuscitation (OR=1.320, 95% CI: 1.001-1.742, P=0.050), THRR < 1.09 (OR=4.952, 95% CI: 1.130-21.70, P=0.034), mean rSO2 < 60% (OR=4.817, 95% CI:1.392-16.663, P=0.013) were independently associated with the mortality.  Conclusions  The mortality of patients with septic shock is high; impaired dynamic cerebrovascular autoregulation (THRR < 1.09) and mean rSO2 < 60% among the cerebral hemodynamics and cerebral oxygen saturation indexes are the independent risk factors for predicting the death in 28 days.
Predictive Value of Ranson Score for Typing Moderately Severe and Severe Hyperlipidemic Acute Pancreatitis
Yan-meng QI, Ye-cheng LIU, Hua-dong ZHU
2019, 10(5): 489-493. doi: 10.3969/j.issn.1674-9081.2019.05.011
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  Objective  The aim of this study was to evaluate the predictive value of Ranson score for typing hyperlipidemic acute pancreatitis (HLAP).  Methods  The clinical data of HLAP patients in the department of Emergency Medicine of Peking Union Medical College Hospital from January 2014 to October 2018 were retrospectively collected, including age, sex, serum lipid, blood glucose, white blood cells, lactate dehydrogenase, aspartate aminotransferase, and hematocrit, urea nitrogen, blood calcium, alkali deficiency, fluid loss at the 48th hour after the admission. Ranson scores were evaluated and compared between the moderately severe and severe HLAP groups; the optimal cut-off value was obtained using the receiver operating characteristic (ROC) curve analysis, and its sensitivity and specificity were calculated. The chi-square test was used to verify the consistency.  Results  A total of 99 patients meeting the inclusive and exclusive criteria were enrolledin this study, including 45 with moderately severe HLAP and 54 with severe HLAP. Ranson score of the severe HLAP group was higher than that of the moderately severe group (5.19±1.33 vs. 3.09±1.35, P < 0.01). ROC curve analysis indicated that 4 was the cut-off value; its sensitivity and specificity were 75.9% and 84.4%, respectively. Using 4 as the cutting line, a Ranson score of 3-4 indicated the moderately severe HLAP, and > 4 indicated severe HLAP; Ranson scores of moderately severe and severe HLAP group were consistent with the disease classification (P < 0.01).  Conclusions  The Ranson score might be used to type the moderately severe and severe HLAP, with a score of 3-4 suggesting the moderately severe HLAP and > 4 suggesting the severe HLAP.
Relationship between Non-sustained Ventricular Tachycardia before Implantation and Appropriate Therapy in Patients with Implantable Cardioverter Defibrillator for Primary Prevention of Sudden Cardiac Death
Zhen WANG, Zhong-wei CHENG, Tai-bo CHEN, Peng GAO, Quan FANG
2019, 10(5): 494-498. doi: 10.3969/j.issn.1674-9081.2019.05.012
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  Objective  The aim of this study was to explore the relationship between non-sustained ventricular tachycardia (NSVT) recorded by Holter before implantation and appropriate therapy in patients with implantable cardioverter defibrillator (ICD) for primary prevention of sudden cardiac death.  Methods  A single-center retrospective cohort study was conducted. Consecutive inpatients who received ICD for primary prevention and finished Holter examination from January 2006 to December 2017 in Peking Union Medical College Hospital were enrolled. According to the results of Holter, the patients were divided into the NSVT group and the non-NSVT group. Clinic or telephone follow-ups were conducted until August 2018; the follow-up events included all-cause death, shock therapy, and anti-tachycardia pacing (ATP).  Results  Sixty patients meeting the inclusive and exclusive criteria were enrolled in this study. Median follow-up of all patients was 37 (14-61) months. Kaplan-Meier curve and Log-Rank test showed that there was no significant difference in mortality between the NSVT and the non-NSVT group (P=0.108), while the NSVT group had a significantly higher rate of appropriate therapy (P=0.033). Multivariate competitive risk regression analysis indicated that NSVT and left ventricular ejection fraction were independently correlated with the ICD appropriate therapy (NSVT: HR=5.099, 95% CI:1.399-18.588, P=0.014; left ventricular ejection fraction: HR=1.077, 95% CI:1.013-1.145, P=0.018).  Conclusion  NSVT in patients with ICD implantation for primary prevention suggests an increased risk of receiving appropriate therapy.
Diagnostic Value of Resistive Index of the Renal Interlobar Artery in Type 1 Cardiorenal Syndrome
Lin LIN, Kai GUO, Meng YANG, Guan-nan WANG
2019, 10(5): 499-504. doi: 10.3969/j.issn.1674-9081.2019.05.013
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  Objective  This study aimed to discuss the diagnostic value of the resistance index (RI) of the renal interlobar artery measured by color Doppler ultrasound in patients with type 1 cardiorenal syndrome(CRS).  Methods  Twenty patients with type 1 CRS diagnosed in emergency wards were defined as group CRS; 20 patients diagnosed as heart failure in the same period were defined as the control group. Clinical features, laboratory examination and medication of the two groups were analyzed. The RI of the two groups of patients was measured. The diagnostic value of RI in type 1 CRS was evaluated according to the receiver operat-ing characteristic(ROC) curve.  Results  There was no significant difference in age, left ventricular ejection fraction (LVEF), heart rate, pulse arterial pressure, and cardiac function classification between the two groups(all P>0.05). The level of N-terminal pro-brain natriuretic peptide, creatitine, and RI of CRS group were higher than those in the control group; the glomerular filtration rate in group CRS was lower than that in the control group, and the difference was statistically significant (all P < 0.05). The area under the ROC curve was 0.78 and the best cut-off point was 0.70. The sensitivity was 80% and the specificity was 80%.  Conclusions  As a new means, the RI of the renal interlobar artery can complement traditional methods and has a potential value in the diagnosis of type 1 CRS.
Reviews
Advances in Genomic Research of Cryptococcus Gattii
Xin-miao JIA, Meng XIAO, Tian-shu SUN, Ying-chun XU
2019, 10(5): 505-513. doi: 10.3969/j.issn.1674-9081.2019.05.014
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Cyptococcus gattii(C.gattii) belongs to the Cryptococcus neoformans complex and was previously considered to be a variant of the Cryptococcus neoformans complex (C. neoformans var. gattii) but eventually established as a separate species. Unlike C. neoformans, C. gattii predominantly infects immunocompetent persons. The pathogenic mechanism of C. gattii is not yet clear. The genomic research of C. gattii can not only comprehensively characterize the genetic composition, molecular evolution, virulence factors and pathogenic mechanisms, but also be used for the prediction of pathogenic genes and important proteins, which further facilitates the development of vaccines and new antibiotics and the construction of new effective treatments and prevention strategies against cryptococcosis. In this paper, the whole genome sequencing, genome features, genomic evolution, important virulence factors, and comparative genomic researches are reviewed.
The Significance of Early Intervention in Acute Pancreatitis
Han SUN, Xiao-yin BAI, Dong WU
2019, 10(5): 514-517. doi: 10.3969/j.issn.1674-9081.2019.05.015
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Acute pancreatitis is an inflammatory entity involving the pancreas and peri-pancreatic tissues. Severe acute pancreatitis leads to persistent organ failure and high mortality. Treatment in the first 24 hours of admission is crucial for the prognosis. Current evidence indicates that adequate fluid resuscitation with lactated Ringer's and early enteral nutrition may be effective, but prophylactic antibiotics and early ERCP should not be routinely used. The small sample size is a major limitation for current research. Large scale, multi-center randomized controlled trials are eagerly awaited.
Predictive Value of Preoperative Assessment Tools for Perioperative Major Adverse Cardiac Event in Patients Undergoing Noncardiac Surgery
Guang-yan XU, Li XU, Zi-jia LIU, Yu-guang HUANG
2019, 10(5): 518-523. doi: 10.3969/j.issn.1674-9081.2019.05.016
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The major adverse cardiac event (MACE) in patients undergoing noncardiac surgery is associated with a marked increase in morbidity and mortality. It is critical to use appropriate assessment tools preoperatively to assess the risk of major adverse cardiac event in patients undergoing noncardiac surgery. We already have guidelines and expert consensus to guide the risk stratification for perioperative major adverse cardiac events in patients undergoing noncardiac surgery. Revised Cardiac Risk Index, the American College of Surgeons' National Surgical Quality Improvement Program Myocardial Infarction or Cardiac Arrest Risk Calculator, and the American College of Surgeons' National Surgical Quality Improvement Program Surgical Risk Calculator are currently common assessment tools used for perioperative major adverse cardiac events in patients undergoing noncardiac surgery. Currently, we have no relevant research on analyzing the applicable conditions, evaluating the merits and demerits of those assessment tools, and comparing the predictive values on perioperative major adverse cardiac events in patients undergoing noncardiac surgery. In this article, we review some domestic and foreign literature in recent years, attempting to summarize the performance of these assessment toolsin patients undergoing noncardiac surgery. We also aim to provide a guide for doctors to find the most optimal preoperative assessment tool.
Clinical Practice Guidelines
Who Should Participate in the Development of Clinical Practice Guidelines?
Yao-long CHEN, Yan-fang MA, Qi ZHOU, Ying-feng ZHOU, Lan-ting LYU, Suo-di ZHAI, Chen YAO, Hong-cai SHANG, Ke-hu YANG, You-ping LI
2019, 10(5): 524-530. doi: 10.3969/j.issn.1674-9081.2019.05.017
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Clinical practice guidelines (CPG) are important tools for supporting evidence-based decision-making to clinicians. In recent years, with the increase in the number of CPGs, their quality has received more and more attention. However, for those who should participate in the development of CPGs and how to form a guideline-development group(GDG) scientifically and reasonably, the institutions and handbooks for guideline development have not yet given clear and unified requirements. Thus, we analyzed and compared the status quo of the GDG formation from the existing guidelines, the requirements and regulations for the GDG formation from different handbooks of guideline development, and the definitions and responsibilities of the guideline methodologists from different institutions. On this basis, we give our recommendations on how to form GDG.
Bacteria & Resistance
Management of Antimicrobial Agents: from the Experience of Peking Union Medical College Hospital to the National Standard
Dan MEI, Yang HU, Yang YANG
2019, 10(5): 531-538. doi: 10.3969/j.issn.1674-9081.2019.05.018
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Strengthening the scientific management of antimicrobial agents plus reducing bacterial resistance has become a worldwide urgency and one of the major challenges in public health. The National Special Project of Clinical Application and Management of Antimicrobials has been implemented for 8 years and it has achieved remarkable results. Antimicrobial stewardship program, combined with training, has been developed with the intention of reducing inappropriate and unnecessary use of antimicrobials while improving the quality of patient care and locally helping prevent the development of antimicrobial resistance. Based on data, the change from administrative intervention to a management mode of a long-term technology-supporting system will come true.
Breast Cancer
Prognostic Value of Progesterone Receptor and Ki-67 Combination in Hormone Receptor Positive Grade 2 Early-stage Breast Cancer
Yan-na ZHANG, Yi-dong ZHOU, Feng MAO, Ru YAO, Qiang SUN
2019, 10(5): 539-545. doi: 10.3969/j.issn.1674-9081.2019.05.019
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  Objective  To evaluate the prognostic value of the combination of progesterone receptor (PR) and Ki-67 index in grade 2 breast cancer with positive hormone receptor (HR) and negative axillary lymph node.  Methods  The clinical and pathological data of patients with grade 2 breast cancer who underwent surgical treatment and 21 genes' recurrence score (RS) testing in the department of Breast Surgery, Peking Union Medical College Hospital from May 2012 to May 2017 were retrospectively analyzed. According to the 21 genes' RS, patients were divided into RS low-risk group (RS < 18), RS intermediate-risk group (18≤RS < 31), and RS high-risk group (RS≥31). At the same time, the combination of PR and Ki-67 index (PK) was set according to the expression of PR and Ki-67 index. The patients were divided into PK low-risk group (PR≥10% and Ki-67≤20%), PK high-risk group (PR < 10% and Ki-67>20%), and PK intermediate-risk group (non-high or low-risk group). The consistency of the PK combination and 21 genes' RS was analyzed and compared.  Results  A total of 389 patients who met the inclusive and exclusive criteria were enrolled in this study, including 247 patients in RS low-risk group (63.5%, 247/389), 115 in RS intermediate risk group (29.6%, 115/389), 27 in RS high-risk group (6.9%, 27/389), 248 in PK low-risk group (63.8%, 248/389), 125 in PK intermediate risk group (32.1%, 125/389), 16 in PK high-risk group (4.1%, 16/389). The predictive sensitivity of the recommended PK combination for RS low risk and high-risk group was 75.3% and 37.0%, respectively, with the positive predictive values of 75.0% and 62.5%, and the inconsistency of 0.4% and 6.3%, respectively. After a median follow-up of 40 months, the total incidence of locoregional recurrence (LRR) and distant metastasis (DM) in PK low, intermediate, and high-risk group was 3.6%, 7.2%, and 12.5%, respectively. The total incidence of LRR and DM in RS low, intermediate, and high-risk groups was 3.2%, 8.7%, and 7.4%, respectively. There was no significant difference between PK combination and RS (P=0.655).  Conclusion  The prognostic value of PK combination for HR-positive grade 2 early-stage breast cancer with negative axillary lymph nodes is comparable to that of the 21 genes' RS.
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