The 492nd case: recurrent thrombosis, thrombocytopenia / 中华内科杂志

A 43-year-old female patient was admitted with recurrent thrombosis for more than 2 years and thrombocytopenia for more than 1 year. Both arterial and venous thromboses developed especially at rare sites even during anticoagulation therapy such as cerebral venous sinus thrombosis. Antinuclear antibody, anti-ENA antibody and antiphospholipid antibody were all negative. Platelet count elevated to normal after high dose glucocorticoid and intravenous immunoglobulin (IVIG). Immune thrombocytopenia was suspected. When 4 grade thrombocytopenia recurred, intravenous heparin, rituximab 600 mg, IVIG and eltrombopag were administrated. After 3 weeks, thrombocytopenia did not improve, and new thrombosis developed instead. Screening of thrombophilia related genes revealed PROS1 gene heterozygous mutation and MTHFR TT genotype. Low amount of serum IgG κ monoclonal protein was detected. Heparin-induced thrombocytopenia was differentiated and excluded. Finally, serum negative antiphospholipid syndrome was considered the most likely diagnosis. Dexamethasone 20 mg/day × 4 days combined with sirolimus 2 mg/day was prescribed. The patient was discharged with low molecular weight heparin. At one month, her headache was greatly relieved. The platelet count raised to 20-30×10 9/L, and no new thrombosis or bleeding was reported.

Prediction of emergency difficult airway by airway evaluation based on CHANNEL process / 中华急诊医学杂志

Objective:To evaluate the accuracy of CHANNEL process in predicting difficult airway of patients in emergency department.Methods:From July 2016 to December 2019, we selected patients who underwent airway management in the emergency department of Peking Union Medical College Hospital. They were evaluated by CHANNEL and improved Mallampati (modified Mallampati test, MMT) classification at the same time. After completion, the glottis was exposed under direct laryngoscope, and then Cormack Lehane classification was performed. Difficult airway was defined as Cormack-Lehane grade Ⅲ or Ⅳ. The receiver-operating characteristics curve was used to evaluate the accuracy of MMT and CHANNEL in predicting difficult airway.Results:122 of 312 patients who underwent emergency airway management were included in the study. The sensitivity of CHANNEL in predicting difficult airway was 100%, the specificity was 90.1%, the area under the curve(95% confidence interval) was 0.948(0.907~0.988).Compared with MMT, the area under the curve of CHANNEL in predicting difficult airway was significantly increased( P<0.05). Conclusion:CHANNEL can accurately predict difficult airway of patients in the emergency department.

Risk factors of acute kindey injury in critical patients in emergency department / 中华急诊医学杂志

Objective:To investigate the incidence and risk factors of acute kidney injury in patients admitted to the resuscitation room of the Emergency Department.Methods:Patients were enrolled from the resuscitation room of our hospital from September to December 2018 by a retrospective cohort study. Patients were divided into AKI group and non-AKI group according to whether AKI occurred within seven days after admission. Demographic characteristics, APACHEⅡ score, whether to use nephrotoxic drugs,24-hour fluid volume, and patients survival time were collected. Multivariate regression analysis was used to explore the risk factors for AKI. Cox regression was used to study the effect of the occurrence of AKI on survival and to analyze the influence of AKI severity on the death risk of patients in the resuscitation room.Results:Among 238 critical patients who were finally included, 108 patients developed AKI(45.4%), 83 patients were in AKI stage 1 (34.9%), and 25 patients were in AKI stage 2-3 ( 10.5%).APACHEⅡ score>13( OR=1.11, 95% CI (1.08-1.16), P <0.01), vasoactive drugs ( OR=2.20, c95% CI (1.08-4.49), P=0.03), diabetes mellitus ( OR=2.33, 95% CI (1.23-4.42), P=0.01), and fluid load> 3 L( OR=3.10, 95% CI (1.17-8.25). P=0.02) were independent risk factors for AKI. After adjustment for APACHEⅡ score and age by multivariate COX regression, AKI remained an independent risk factor for death in emergency patients, and the severity of AKI significantly increased the risk of death in these patients(AKI 1: HR=1.45, 95% CI (1.08-2.03), P =0.04; AKI 2~3: HR=3.15, 95% CI (1.49-4.81), P=0.03). Conclusions:AKI occurred commonly in the resuscitation room of the emergency department. APACHE Ⅱ score>13, vasoactive drugs, diabetes, and fluid load>3 L were independent risk factors for AKI. The risk of death increased with the aggravation of AKI severity.

The predictive value of mean arterial pressure and end expiratory carbon dioxide on severe cardiovascular collapse in early stage after emergency endotracheal intubation / 中华急诊医学杂志

Objective:To analyze the changes of mean arterial pressure (MAP) and end expiratory carbon dioxide (ETCO 2) in patients after emergency endotracheal intubation (ETI). To explore the values of MAP and ETCO 2 monitoring in early prediction of severe cardiovascular collapse (CVC) after emergency ETI. Methods:The clinical data of adult patients who underwent ETI from March 2015 to May 2020 were collected consecutively in the emergency departments of Peking Union Medical College Hospital. The values of MAP and ETCO 2 were observed and recorded at 5, 10, 30, 60 and 120 min after intubation. According to whether severe CVC occurred after ETI, the patients were divided into the severe CVC group and non-severe CVC group. The values of MAP and ETCO 2 were compared at the same time points between the two groups and the adjacent time points within the groups. The correlation between MAP and ETCO 2 after ETI was also analyzed. ROC curve was used to analyze the ability of MAP and ETCO 2 at 5 min and 10 min after ETI to predict severe CVC. Results:Totally 116 patients were enrolled in this study, among them 75 (64.7%) cases had severe CVC after ETI. The majority were male and elderly patients in the severe CVC group. The values of MAP and ETCO 2 in 5, 10, 30, 60 and 120 min after ETI in severe CVC group were significantly lower than those in the non-severe CVC group. The values of MAP and ETCO 2 in the two groups showed simultaneous decrease from 5 min to 30 min after ETI, reached the lowest value at 30 min after ETI, and appeared the synchronous recover from then to 120 min after ETI. After ETI, the changes of MAP was correlated with that of ETCO 2 ( rs = 0.653, P<0.01). At 5 min after ETI, MAP could predict severe CVC (AUC=0.86, P<0.01), MAP≤72 mmHg was the best cutoff value (sensitivity 78.7%, specificity 87.8%); ETCO 2 could also predict severe CVC (AUC=0.85, P<0.01), and ETCO 2≤35 mmHg was the best cutoff value (sensitivity 77.3%, specificity 85.4%). At 10 min after ETI, MAP could predict severe CVC (AUC = 0.90, P<0.01), MAP≤67 mmHg was the best cutoff value (sensitivity 89.3%, specificity 85.4%), ETCO 2 could also predict severe CVC (AUC=0.87, P<0.01), and ETCO 2≤33 mmHg was the best cutoff value (sensitivity 81.3%, specificity 78.0%). There was no significant difference in the ability of prediction between any two indexes of the MAP and ETCO 2 at 5 min and 10 min after ETI ( P>0.05). Conclusions:Patients with severe CVC after ETI have early signs of decreased MAP and ETCO 2, but the delayed recognition and insufficient intervention may be related to the occurrence and development of severe CVC. MAP and ETCO 2 at the early stage after ETI have high accuracy in predicting severe CVC. MAP≤72 mmHg, ETCO 2≤35 mmHg at 5 min after intubation, MAP≤67 mmHg and ETCO 2≤33 mmHg at 10 minutes after intubation all suggest the possibility of severe CVC.

Preliminary exploration on training of emergency airway management course guided by clinical procedure / 中华医学教育探索杂志

Objective:To promote emergency airway management from the perspective of training and to explore the training mode of emergency airway management based on clinical procedures.Methods:Airway management training courses were designed according to the clinical treatment principle centered on patient safety in combination with actual clinical procedures. The course took the CHANNEL process of airway management as the main line and focused on artificial ventilation, oxygen therapy and rapid induction of intubation techniques. During the teaching, we took the clinical handling process as the main line, and adopted methods of equipment display, video presentation and on-site explanation. Courses were freely registered or oriental enrollment. Online questionnaires were used to collect feedback from the students after class and were then analyzed.Results:A total of 15 training sessions were held in 13 cities across the country, with 566 participants, and 185 questionnaire responses were received. About the content of single course, participants thought that the first three parts were difficult to understand, including oxygen therapy (48, 25.9%), CHANNEL process explanation and practice (48, 25.9%) and rapid induction of intubation process (47, 25.4%). After class, 41 participants (22.2%) changed work procedures of emergency airway management, 140 (75.7%) partially changed work procedures of emergency airway management, and 4 (2.2%) still used the original work procedure.Conclusion:The course of emergency airway management based on clinical procedures meets the current clinical needs and can better improve the training of clinical competency.

Research experiences on laparoscopic high ligation of hernia / 国际外科学杂志

Objective To investigate the advantages of treating pediatric indirect inguinal hernia by laparoscopic high ligation of hernia.Methods Two hundred and forty-four pediatric indirect inguinal hernia cases were admitted from August 2012 to May 2014,and were divided into conventional surgery group and laparoscopic surgery group according to the operation methods,with 122 cases in each group.The differences between the two groups regarding operation time,bleeding volume,postoperative pain,surgical scars,complications and recurrence were compared.Results Contralateral recessive hernia was observed in 52 cases (46.4％) of laparoscopic surgery group.The differences in operation time [unilateral hernia:(16.1 ± 5.3) min vs (14.3 ±4.4) min],[bilateral hernia:(29.2 ± 6.4) min vs (31.4 ± 5.2) min],bleeding volume [(2.2 ± 1.1) mL vs (2.9 ± 1.4) mL],surgical scars and recurrence between the two groups were not statistically significant,and no scrotal hematoma and latrogenic cryptorchidism were observed in both groups.But the differences regarding post-operative pain,time to ambulation,scrotal swelling were statistically significant (P ＜ 0.05).Conclusions Laparoscopic surgery showed advantages in small operation wound,rapid recover,less complications and possibility of exploration of contralateral processus vaginalis,so it is much more secure and reliable.

Modulation of dendritic cells phenotype by Astragalus polysaccharides in experimental colitis in rats / 中华临床营养杂志

Objective To investigate the effect of Astragalus polysaccharides (APS) on 2,4,6-trinitrobenzenesulfonic acid (TNBS)-induced colitis in rats and on dendritic cells (DCs) in mesenteric lymph nodes.Methods Forty-four male Sprague-Dawley rats were randomly divided into four groups (n = 11) using simple random sampling: normal control group, TNBS group, APS group, and 5-aminosalicylic acid (5-ASA) group.Experimental colitis was induced in rats by TNBS enema in the last three groups.Rats in APS and 5-ASA groups were treated by gavage with APS (0.75 g ? kg-1 ? d-1) and 5-ASA (100 mg ? kg-1 ? d-1) on the 10 consecutive days following TNBS administration.The rats were then sacrificed and the colonic inflammatory scores of rats were measured, including the scores of disease activity index ( DAI) , macroscopic lesions, and histological damages,as well as the activity of myeloperoxidase (MPO).The expressions of major histocompatibility complex class Ⅱ(MHC Ⅱ ) and costimulatory molecule CD86 on DCs were determined by flow cytometry.Results Compared with the TNBS group, APS group had significantly decreased scores of DAI ( P = 0.007 ) , macroscopic lesions (P =0.017), and histological damages (P = 0.016).Moreover, its level of the activity of MPO dropped but without statistical significance (P =0.183).TNBS group had significantly higher expressions of MHC Ⅱand CD86 molecules on DCs than the normal control group (P = 0.005, P = 0.008), APS group (P = 0.023, P = 0.018), and 5-ASA group (P = 0.017, P=0.013).Conclusion APS may attenuate TNBS-induced colitis in rats and downregulate the activation of DCs in mesenteric lymph nodes.

Role of dendritic cells in inflammatory bowel diseases / 中华临床营养杂志

Inflammatory bowel diseases (IBD) possibly lie in a dysregulated response of the intestinal mucosal immune system towards intestinal microflora under a combined action of genetic and environmental factors.Mucosal dendritic cells are assumed to play key roles in regulating immune responses in the antigen-riched intestinal environment, either by initiating immune responses or by maintaining tolerance. Defects in this regulation are supposed to lead to IBD. This paper reviews the recent research advances in the relationship between IBD and dendritic cells.