[Expert consensus on late stage of critical care management].

We wished to establish an expert consensus on late stage of critical care (CC) management. The panel comprised 13 experts in CC medicine. Each statement was assessed based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) principle. Then, the Delphi method was adopted by 17 experts to reassess the following 28 statements. (1) ESCAPE has evolved from a strategy of delirium management to a strategy of late stage of CC management. (2) The new version of ESCAPE is a strategy for optimizing treatment and comprehensive care of critically ill patients (CIPs) after the rescue period, including early mobilization, early rehabilitation, nutritional support, sleep management, mental assessment, cognitive-function training, emotional support, and optimizing sedation and analgesia. (3) Disease assessment to determine the starting point of early mobilization, early rehabilitation, and early enteral nutrition. (4) Early mobilization has synergistic effects upon the recovery of organ function. (5) Early functional exercise and rehabilitation are important means to promote CIP recovery, and gives them a sense of future prospects. (6) Timely start of enteral nutrition is conducive to early mobilization and early rehabilitation. (7) The spontaneous breathing test should be started as soon as possible, and a weaning plan should be selected step-by-step. (8) The waking process of CIPs should be realized in a planned and purposeful way. (9) Establishment of a sleep-wake rhythm is the key to sleep management in post-CC management. (10) The spontaneous awakening trial, spontaneous breathing trial, and sleep management should be carried out together. (11) The depth of sedation should be adjusted dynamically in the late stage of CC period. (12) Standardized sedation assessment is the premise of rational sedation. (13) Appropriate sedative drugs should be selected according to the objectives of sedation and drug characteristics. (14) A goal-directed minimization strategy for sedation should be implemented. (15) The principle of analgesia must be mastered first. (16) Subjective assessment is preferred for analgesia assessment. (17) Opioid-based analgesic strategies should be selected step-by-step according to the characteristics of different drugs. (18) There must be rational use of non-opioid analgesics and non-drug-based analgesic measures. (19) Pay attention to evaluation of the psychological status of CIPs. (20) Cognitive function in CIPs cannot be ignored. (21) Delirium management should be based on non-drug-based measures and rational use of drugs. (22) Reset treatment can be considered for severe delirium. (23) Psychological assessment should be conducted as early as possible to screen-out high-risk groups with post-traumatic stress disorder. (24) Emotional support, flexible visiting, and environment management are important components of humanistic management in the intensive care unit (ICU). (25) Emotional support from medical teams and families should be promoted through"ICU diaries"and other forms. (26) Environmental management should be carried out by enriching environmental content, limiting environmental interference, and optimizing the environmental atmosphere. (27) Reasonable promotion of flexible visitation should be done on the basis of prevention of nosocomial infection. (28) ESCAPE is an excellent project for late stage of CC management.

Rectus abdominis muscle resection and fascial reconstruction for the treatment of uterine leiomyosarcoma invading the abdominal wall: a case report.

The authors present a case of intra-abdominal recurrent leiomyosarcoma invading a large area of the abdominal wall. The patient underwent cytoreductive surgery, including resection of the rectus abdominis muscle, followed by reconstruction of the defect using synthetic mesh. The tumor was surgically removed by en bloc resection, including most of the rectus abdominis muscle and ileum. The abdominal wall defect was repaired using synthetic mesh. The patient underwent radiotherapy and chemotherapy after the surgery and was healthy one year later.

[Clinical effects of free thinned deep inferior epigastric artery perforator flap in repairing extensive soft tissue defects in extremities].

Objective: To explore the feasibility and clinical effects of using free thinned deep inferior epigastric artery perforator flap to repair extensive soft tissue defects in extremities. Methods: From April 2010 to January 2014, 12 patients with extensive soft tissue defect in extremities after trauma, including 10 males and 2 females, aged 21 to 48 years, 6 patients with defect in the back of wrist and 6 patients with defect in ankle were admitted to the Department of Bone Microsurgery of Xi'an Honghui hospital. After debridement, the size of soft tissue defect ranged from 15.0 cm×4.5 cm to 28.0 cm×11.0 cm. The free thinned deep inferior epigastric artery perforator flap was designed, cut and transferred for reconstruction, with size of 15.0 cm×5.0 cm to 29.0 cm×12.0 cm. The flap thickness ranged from 4.0 to 6.5 cm before defatting, and was 0.6 to 0.9 cm after defatting. All the donor sites of flaps were closed directly by suturing. The flap survival and the appearance and function of flap and donor site were observed during follow-up. Results: All the flaps survived smoothly after surgery. During follow-up of 10 to 42 months, the flaps showed no bloat in appearance, no further flap revision or defatting procedures were required, the distance of static 2-point discrimination was 11 to 17 mm (14.5 mm on average). The abdominal function of patients was not affected, and no postoperative abdomen hernia or ulceration was noted. Conclusions: The free thinned deep inferior epigastric artery perforator flap is thin and suitable for repairing extensive soft tissue defects in extremities with very good outcomes.

[Clinical outcomes of COVID-19 cases and influencing factors in Guangdong province].

Objective: To analyze the clinical courses and outcomes of COVID-19 cases and the influencing factors in Guangdong province and provide basis for the formulation or adjustment of medical care and epidemic control strategy for COVID-19. Methods: We collected demographic data, medical histories, clinical courses and outcomes of 1 350 COVID-19 patients reported in Guangdong as of 4 March 2020 via epidemiological investigation and process tracking. Disease severity and clinical course characteristics of the patients and influencing factors of severe illness were analyzed in our study. Results: Among 1 350 cases of COVID-19 cases in Guangdong, 72 (5.3%) and 1 049 (77.7%) were mild and ordinary cases, 164 (12.1%) were severe cases, 58 (4.3%) were critical cases and 7 (0.5%) were fatal. The median duration of illness were 23 days (P(25), P(75): 18, 31 days) and the median length of hospitalization were 20 days (P(25), P(75): 15,27 days). For severe cases, the median time of showing severe manifestations was on the 12(th) day after onset (P(25), P(75): 9(th) to 15(th) days), and the median time of severe manifestation lasted for 8 days (P(25), P(75): 4, 14 days). Among 1 066 discharged/fetal cases, 36.4% (36/99) and 1.0% (1/99) of the mild cases developed to ordinary cases and severe cases respectively after admission; and 5.2% (50/968) and 0.6% (6/968) of the ordinary cases developed to severe cases, and critical cases respectively after admission. In severe cases, 11.4% developed to critical cases (10/88). The influencing factors for severe illness or worse included male (aHR=1.87, 95%CI: 1.43-2.46), older age (aHR=1.67, 95%CI: 1.51-1.85), seeking medical care on day 2-3 after onset (aHR=1.73, 95%CI: 1.20-2.50) pre-existing diabetes (aHR=1.75, 95%CI: 1.12-2.73) and hypertension (aHR=1.49, 95%CI: 1.06-2.09). Conclusions: The course of illness and length of hospitalization of COVID-19 cases were generally long and associated with severity of disease clinical outcomes. The severe cases were mainly occurred in populations at high risk. In the epidemic period, classified management of COVID-19 cases should be promoted according to needs for control and prevention of isolation and treatment for the purpose of rational allocation of medical resources.

[Comparison of two epidemic patterns of COVID-19 and evaluation of prevention and control effectiveness: an analysis based on Guangzhou and Wenzhou].

Objective: To compare the epidemiological characteristics of COVID-19 in Guangzhou and Wenzhou, and evaluate the effectiveness of their prevention and control measures. Methods: Data of COVID-19 cases reported in Guangzhou and Wenzhou as of February 29, 2020 were collected. The incidence curves of COVID-19 in two cities were constructed. The real time reproduction number (R(t)) of COVID-19 in two cities was calculated respectively. Results: A total of 346 and 465 confirmed COVID-19 cases were analysed in Guangzhou and Wenzhou, respectively. In two cities, most cases were aged 30-59 years (Guangzhou: 54.9%; Wenzhou: 70.3%). The incidence curve peaked on 27 January, 2020 in Guangzhou and on 26 January, 2020 in Wenzhou, then began to decline in both cities. The peaks of imported COVID-19 cases from Hubei occurred earlier than the peak of COVID-19 incidences in two cities, and the peak of imported cases from Hubei occurred earlier in Wenzhou than in Guangzhou. In early epidemic phase, imported cases were predominant in both cities, then the number of local cases increased and gradually took the dominance in Wenzhou. In Guangzhou, the imported cases was still predominant. Despite the different epidemic pattern, the R(t) and the number of COVID-19 cases declined after strict prevention and control measures were taken in Guangzhou and in Wenzhou. Conclusion: The time and scale specific differences of imported COVID-19 resulted in different epidemic patterns in two cities, but the spread of the disease were effectively controlled after taking strict prevention and control measures.

[The effects of closure to live poultry markets on Avian influenza A (H7N9) epidemics in China].

Since March 2013, China had experienced five seasonal epidemics related to Avian influenza A (H7N9). An unprecedented outbreak of H7N9 epidemic started from September 2016, with 730 cases reported till June 30(th) 2017, in mainland China that caused profound influences on both social development and health of the people. As an emerging infectious disease, information on pathogenic characteristics, transmission patterns and other epidemiological features of H7N9 virus somehow remained unclear. Data from previous studies suggested that the live poultry market (LPM) seemed to have served as main places where H7N9 virus got originated, mutated, spread and thus infected the human beings. Hence, closure of LPMs was suggested a major measure to control and prevent H7N9 epidemics in China. However, the effectiveness of different ways of LPM closures on H7N9 epidemics had been controversial. This study systemically summarized the effects of different ways of LPM closures on H7N epidemics from previous studies, aiming to provide references for developing a better program on H7N9 control and prevention in the country.

Use of vasopressin vs epinephrine to reduce haemorrhage during myomectomy: a randomized controlled trial.

OBJECTIVE: To compare the effectiveness and safety of vasopressin with epinephrine for reducing blood loss during laparoscopic myomectomy. STUDY DESIGN: Sixty patients undergoing laparoscopic myomectomy were allocated at random to receive either dilute vasopressin or epinephrine into the serosal and/or overlying myometrium, and just around the myoma. The surgeon was blinded to the group allocation. Blood loss, duration of surgery, degree of surgical difficulty, postoperative pain scores and complications were compared. RESULTS: Patient characteristics (e.g. age, body mass index, demographic data), number of myomas, and location and size of the largest myoma were similar between the two study groups. There were no differences in operative blood loss, operative time, subjective surgical difficulty or postoperative pain between the two groups. Transient and non-serious increases in systolic and diastolic blood pressure and heart rate following intra-operative intramyometrial and/or perimyometrial injection of the vasoconstrictive agent only occurred in the epinephrine group, but the difference between the groups was not significant (13% vs 0%, p=0.112). No significant postoperative complications were observed in either group. CONCLUSIONS: Injection of dilute epinephrine before laparoscopic myomectomy was comparable to injection of dilute vasopressin in terms of operative blood loss, operative time, subjective surgical difficulty, postoperative pain and complications.