[A comparison of clinical characteristics between acute fatty liver of pregnancy and hemolysis, elevated liver enzymes and low platelets syndrome].

OBJECTIVE: To compare and analyze the clinical characteristics between acute fatty liver of pregnancy (AFLP) and the hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome. METHODS: This is a retrospective cohort study. The clinical data of 13 cases with AFLP and 34 cases with HELLP syndrome were collected from three tertiary referral centers in Yunnan (the First Affiliated Hospital of Kunming Medical University, the Second Affiliated Hospital of Kunming Medical University, and Yan'an Hospital of Kunming City) from January 2016 to December 2021. The patients were diagnosed to AFLP and HELLP syndrome according to the Swansea criteria and the Tennessee classification system. The general characteristics, clinical features, laboratory results within 24 hours after admission, complications, maternal and neonatal outcomes were compared to analysis the differences between the two groups. RESULTS: (1) Maternal characteristics: compared with HELLP syndrome group, AFLP group had lower body mass index (BMI) and blood pressure at admission (both P < 0.01). (2) Clinical features: the most common symptoms in AFLP patients were skin jaundice, abdominal pain, nausea and vomiting, edema. The main manifestations of patients with HELLP syndrome were albuminuria, hypertension, edema, headache. Some patients had multiple symptoms concurrently. (3) Laboratory results: compared with HELLP syndrome group, the levels of platelet count (PLT), total bilirubin (TBil), direct bilirubin (DBil), γ-glutamyl transferase (γ-GGT), alkaline phosphatase (ALP), total bile acid (TBA), serum creatinine (SCr) and international standardized ratio (INR) in AFLP group were significantly increased within 24 hours after admission [PLT (×109/L): 107.69±51.13 vs.76.71±43.25,TBil (µmol/L): 121.60 (83.20, 170.00) vs.15.25 (7.22, 29.05), DBil (µmol/L): 86.50 (58.60, 104.00) vs. 4.30 (2.22,10.10), γ-GGT (U/L): 87.00 (37.00, 127.00) vs. 41.00 (19.00,64.42), ALP (U/L): 199.10 (109.00, 349.20) vs. 125.50 (90.50, 155.25), TBA (µmol/L): 51.50 (16.20, 117.40) vs. 4.15 (2.02, 6.95), SCr (µmol/L): 155.80 (129.00, 237.00) vs. 79.00 (65.43, 113.70), INR: 1.28 (1.17, 1.63) vs. 0.94 (0.88, 1.08), all P < 0.05], prothrombin time (PT) was significantly prolonged [seconds: 16.10 (14.50, 19.20) vs. 12.40 (11.43, 13.40), P < 0.05]. The level of blood glucose (GLU), fibrinogen (FIB) and the activity of antithrombin III (AT III) decreased significantly [GLU (mmol/L): 5.18±1.33 vs. 6.33±1.19, FIB (g/L): 1.96±1.46 vs. 3.81±1.58, AT III (%): 40.61±25.84 vs. 66.39±24.11, all P < 0.05]; (4) Complications: compared with HELLP syndrome group, the incidence of patients with hypoglycemia [30.77% (4/13) vs. 0% (0/34)], acute liver failure [53.85% (7/13) vs. 5.88% (2/34)], acute renal insufficiency [69.23% (9/13) vs. 8.82% (3/34)], coagulopathy [76.92% (10/13) vs. 38.24% (13/34)], disseminated intravascular coagulation (DIC) [53.85% (7/13) vs. 5.88% (2/34)], and multiple organ dysfunction syndrome (MODS) [53.85% (7/13) vs. 5.88% (2/34)] were significantly higher in AFLP group (all P <0.05). (5) Maternal and neonatal outcome: all patients delivered after admission. The total length of hospital and intensive care unit stay were significantly longer in the AFLP group than in the HELLP syndrome group [days: 17.00 (11.00, 25.00) vs. 9.00 (7.00, 12.00), 12.00 (4.00, 22.00) vs. 3.91 (0, 7.00), both P < 0.01]. Two AFLP patients died, including one due to intracranial venous thrombosis and one due to multiple organ failure and cardiopulmonary arrest. There were no deaths in the HELLP syndrome group. CONCLUSIONS: There are significant differences in maternal characteristics, laboratory results and complications between AFLP and HELLP syndrome. TBil, γ-GGT, SCr, FIB, INR and AT III activity may help to distinguish the two diseases.

Adjunctive sepsis therapy with aminophylline (STAP): a randomized controlled trial.

BACKGROUND: Sepsis is a serious disease caused by infection. Aminophylline has anti-asthma and anti-inflammatory effects. We aimed to explore the safety and effect of aminophylline in sepsis. METHODS: We conducted a clinical randomized controlled trial involving 100 patients diagnosed with sepsis within 48 h after intensive care unit (ICU) admission in two sites. All patients were randomized in a 1:1 ratio to receive standard therapy with or without aminophylline. The primary clinical outcome was all-cause mortality at 28 days. RESULTS: From September 27, 2018 to February 12, 2020, we screened 277 septic patients and eventually enrolled 100 patients, with 50 assigned to the aminophylline group and 50 to the usual-care group. At 28 days, 7 of 50 patients (14.0%) in the aminophylline group had died, compared with 16 of 50 (32.0%) in the usual-care group ( P  = 0.032). Cox regression showed that the aminophylline group had a lower hazard of death (hazard ratio = 0.312, 95% confidence interval: 0.129-0.753). Compared with the usual-care group, patients in the aminophylline group had a longer survival time ( P  = 0.039 by the log-rank test). The effects of aminophylline on vasopressor dose, oxygenation index, and sequential organ failure assessment score were time-dependent with treatment. There were no significant differences in total hospitalization days, ICU hospitalization days, and rates of serious adverse events (all P > 0.05). No adverse events were observed in the trial. CONCLUSIONS: Aminophylline as an adjunct therapy could significantly reduce the risk of death and prolong the survival time of patients with sepsis. TRIAL REGISTRATION: ChiCTR.org.cn, ChiCTR1800019173.

[Comparison of pulse oxygen saturation/fraction of inhaled oxygen and arterial partial pressure of oxygen/fraction of inhaled oxygen in the assessment of oxygenation in acute respiratory distress syndrome patients at different high altitudes in Yunnan Province].

OBJECTIVE: To investigate and evaluate if pulse oxygen saturation/fraction of inhaled oxygen (SpO2/FiO2) can be used, as replacement of arterial partial pressure of oxygen/fraction of inhaled oxygen (PaO2/FiO2), to assess oxygenation in acute respiratory distress syndrome (ARDS) patients at different high altitudes in Yunnan Province, and to find a rapid and non-invasive method for the diagnosis of ARDS at different altitudes. METHODS: Patients with ARDS at different high altitudes in Yunnan Province from January 2019 to December 2020 were enrolled. The patients were divided into three groups according to different altitudes, and received different oxygen therapies according to their respective medical conditions. Group 1 consisted of patients with moderate to severe ARDS from the department of critical care medicine of the First Affiliated Hospital of Kunming Medical University (average altitude approximately 1 800 m), and received mechanical ventilation to maintain SpO2 of 0.90-0.96 with a low FiO2 for more than 30 minutes, and SpO2, FiO2, PaO2 were recorded. Group 2 consisted of patients with moderate to severe ARDS at the department of critical care medicine of People's Hospital of Diqing Tibetan Autonomous Prefecture (mean altitude about 3 200 m), and received oxygen with an attached reservoir mask to maintain SpO2 of 0.90-0.96 for 10 minutes, and then SpO2, FiO2, and PaO2 were recorded. Group 3 consisted of patients with mild to moderate-severe ARDS who admitted to the emergency department of the People's Hospital of Lijiang (average altitude approximately 2 200 m); when SpO2 < 0.90, patients received oxygen with the oxygen storage mask, and the FiO2 required to maintain SpO2 ≥ 0.90 was recorded, and SpO2, FiO2, PaO2 were recorded after oxygen inhalation for 10 minutes. Spearman coefficient was used to analyze the correlation between SpO2/FiO2 and PaO2/FiO2 in each group. Linear analysis was used to derive the linear equation between SpO2/FiO2 and PaO2/FiO2, and to evaluate arterial pH, arterial partial pressure of carbon dioxide (PaCO2), FiO2, tidal volume (VT), positive end-expiratory pressure (PEEP) and other related factors which would change the correlation between SpO2/FiO2 and PaO2/FiO2. The receiver operator characteristic curve (ROC curve) was plotted to calculate the sensitivity and specificity of using SpO2/FiO2 instead of PaO2/FiO2 to assess oxygenation of ARDS patients. RESULTS: Group 1 consisted of 24 ARDS patients from whom 271 blood gas analysis results were collected; group 2 consisted of 14 ARDS patients from whom a total of 47 blood gas analysis results were collected; group 3 consisted of 76 ARDS patients, and a total of 76 blood gas analysis results were collected. The PaO2/FiO2 (mmHg, 1 mmHg = 0.133 kPa) in groups 1, 2 and 3 were 103 (79, 130), 168 (98, 195) and 232 (146, 271) respectively, while SpO2/FiO2 were 157 (128, 190), 419 (190, 445) and 319 (228, 446) respectively. Among the three groups, patients in group 1 had the lowest PaO2/FiO2 and SpO2/FiO2, while patients in group 3 had the highest. Spearman correlation analysis showed that PaO2/FiO2 was highly correlated with SpO2/FiO2 in groups 1, 2 and 3 (r values were 0.830, 0.951, 0.828, all P < 0.05). Regression equation was fitted according to linear analysis: in group 1 SpO2/FiO2 = 58+0.97×PaO2/FiO2 (R2 = 0.548, P < 0.001); in group 2 SpO2/FiO2 = 6+2.13×PaO2/FiO2 (R2 = 0.938, P < 0.001); in group 3 SpO2/FiO2 = 53+1.33×PaO2/FiO2 (R2 = 0.828, P < 0.001). Further analysis revealed that PEEP, FiO2, and arterial blood pH could affect the correlation between SpO2/FiO2 and PaO2/FiO2. ROC curve analysis showed that the area under ROC curve (AUC) was 0.848 and 0.916 in group 1 with moderate to severe ARDS; based on the regression equation, the corresponding SpO2/FiO2 cut-off values at a PaO2/FiO2 of 100 mmHg and 200 mmHg were 155, 252 with a sensitivity of 84.9% and 100%, specificity of 87.2% and 70.6%, respectively. Patients with moderate to severe ARDS in group 2 (AUC was 0.945 and 0.977), the corresponding SpO2/FiO2 cut-off values at PaO2/FiO2 of 100 mmHg and 200 mmHg were 219 and 432 with the sensitivity of 100% and 85.2%, specificity of 82.5% and 100%, respectively. Patients with mild to moderate-severe ARDS in group 3 (AUC was 0.903 and 0.936), the corresponding SpO2/FiO2 cut-off values at a PaO2/FiO2 of 200 mmHg and 300 mmHg were 319 and 452 with the sensitivity of 100% and 100%, specificity of 80.9% and 86.2%, respectively. CONCLUSIONS: SpO2/FiO2 and PaO2/FiO2 in ARDS patients at different high altitudes in Yunnan Province have a good correlation, and non-invasive SpO2/FiO2 can be used to replace PaO2/FiO2 to assess the oxygenation in ARDS patients.

[Clinical observation of extremely elevated erythrocyte sedimentation rate].

OBJECTIVE: To analyze the clinical features of adult patients with extremely elevated erythrocyte sedimentation rate (ESR, ESR ≥ 100 mm/1 h), so as improve the ability of clinicians to use erythrocyte sedimentation rate to assist in the diagnosis and treatment of diseases. METHODS: A retrospective cohort study was conducted to examine the clinical data of patients with ESR ≥ 100 mm/1 h admitted to the First Affiliated Hospital of Kunming Medical University from January 1st 2019 to December 31st 2019. The age, gender, clinical diagnosis, first ESR level after admission, blood routine, liver function, renal function, coagulation function and C-reactive protein (CRP) within 24 hours after admission were collected. Patient cohorts were divided into youth group (18-65 years old), middle-aged group (66-79 years old) and elderly group (≥ 80 years old) according to the new standards of human age classification of World Health Organization (WHO) 2019. Patient cohorts were also divided into infectious disease group, hematological disease group, autoimmune disease group, renal failure group and others according to their respective clinical diagnosis. The distribution of extremely elevated ESR in each group, and the correlation between ESR and various laboratory indicators were analyzed. RESULTS: (1) Among 429 patients with ESR ≥ 100 mm/1 h, there were 236 males and 193 females. There was no significant difference in ESR levels between males and females [mm/1 h: 108.00 (103.00, 119.75) vs. 117.00 (105.50, 140.00), P = 0.234]. (2) The age of 429 patients ranged from 18 to 98 years old, the average age was (53.70±18.70) years old. There were 310 cases in the youth group, 87 cases in the middle-aged group and 32 cases in the elderly group. The ESR level of the young group was significantly lower than that of the middle-aged group and the elderly group [mm/1 h: 108.00 (103.00, 120.00) vs. 119.00 (107.00, 140.00), 120.00 (110.25, 140.00), both P < 0.01]. (3) The main diagnoses associated with extremely elevated ESR were infectious diseases [157 cases (36.6%)], hematological system diseases [127 cases (29.6%)], autoimmune diseases [74 cases (17.2%)]. Pulmonary infection accounted for 58.0% (91/157) of infectious diseases. Hematopoietic stem cell diseases accounted for 45.7% (58/127), lymphocyte and plasma cell diseases accounted for [37.0% (47/127)] and erythrocyte diseases accounted for [11.0% (14/127)] of the hematological system diseases. Diffuse connective tissue diseases accounted for 75.7% (56/74) of autoimmune diseases. (4) Spearman correlation analysis showed that the extremely elevated ESR in all patients was significantly negatively correlated with the levels of red blood cell count (RBC), hemoglobin (HB) and hematocrit (HCT) (ρ value was -0.395, -0.381 and -0.383, respectively, all P < 0.01), the ESR was significantly positively correlated with the level of fibrinogen (FIB; ρ = 0.345, P < 0.01). A total of 266 patients were tested for both ESR and CRP, and there was no significantly correlation between ESR and CRP level (ρ = -0.019, P = 0.756). CONCLUSIONS: The extremely elevated ESR was more common in pulmonary infections diseases, hematopoietic stem cell diseases, lymphocyte and plasma cell diseases, erythrocyte diseases and diffuse connective tissue diseases. The extremely elevated ESR was significantly correlated with the levels of RBC, HB, HCT and FIB.

[Feasibility of pulse oxygen saturation for the condition evaluation of acute respiratory distress syndrome patients in the Lijiang region].

OBJECTIVE: To explore the feasibility of using pulse oxygen saturation (SpO2) to evaluate the condition of patients with acute respiratory distress syndrome (ARDS) in the Lijiang region. METHODS: Patients with ARDS who visited the department of emergency of People's Hospital of Lijiang from August to December 2020 were selected as study subjects. Patients were divided by severity into mild ARDS group [200 mmHg (1 mmHg = 0.133 kPa) ≤ oxygenation index (PaO2/FiO2, P/F) ≤ 300 mmHg] and moderate to severe ARDS group (P/F ≤ 200 mmHg). The general condition, clinical diagnosis, arterial blood gas analysis results of the patients were recorded, and the differences of the above indexes between the two groups of ARDS were compared. Spearman correlation analysis was used to analyze the correlation between SpO2 and arterial oxygen saturation (SaO2). SpO2 was carried into the Ellis equation and the Rice equation to calculate the derived P/F and analyze the correlation between the derived P/F and the P/F measured in arterial blood gas analysis; receiver operator characteristic curve (ROC curves) were plotted, the sensitivity and specificity of SpO2/fraction of inspiration oxygen (SpO2/FiO2, S/F) instead of P/F to assess oxygenation in patients with ARDS was calculated. To evaluate the feasibility of SpO2 for the condition evaluation of patients with ARDS in the Lijiang region. RESULTS: Compared with the mild ARDS group, the arterial partial pressure of oxygen (PaO2), SaO2 and hemoglobin (Hb) were significantly decreased in the moderate to severe ARDS group [PaO2 (mmHg): 50.5 (39.3, 56.5) vs. 60.0 (55.0, 67.5), SaO2: 0.86 (0.73, 0.91) vs. 0. 93 (0.90, 0.96), Hb (g/L): 142±27 vs. 156±24, respectively, all P < 0.05]. Correlation analysis revealed a significant positive correlation between SpO2 and SaO2 in ARDS patients residing at high altitude (R = 0.650, P = 0.000). The P/F derived by the Rice formula was significantly and positively correlated with the P/F derived from arterial blood gas analysis (R = 0.802, P = 0.000). The deduced P/F in mild and moderate to severe ARDS groups were all significantly correlated with the measured P/F (R values were 0.562, 0.647, both P = 0.000). The P/F derived using the Ellis formula showed a significant positive correlation with the P/F derived from arterial blood gas analysis (R = 0.822, P = 0.000). The deduced P/F of mild ARDS group and moderate to severe ARDS group were all positively correlated with the measured P/F (R values were 0.556, 0.589, P values were 0.000, 0.010). There was a significant positive correlation between S/F and P/F in ARDS patients (R = 0.828, P = 0.000), and the regression equation was S/F = 1.33 P/F+52.41. ROC curve analysis showed that S/F had some predictive value for patients with mild and moderate to severe ARDS, and area under ROC curve (AUC) and 95% confidence interval (95%CI) were 0.903 (0.829-0.977), 0.936 (0.870-1.000), both P = 0.000. When the cut-off value was 452 mmHg, S/F had a sensitivity of 100% and a specificity of 80.9% for predicting mild ARDS. When the cut-off value was 319 mmHg, S/F predicted moderate to severe ARDS with 95.1% sensitivity and 86.2% specificity. CONCLUSIONS: At high altitude, SpO2 and SaO2 have been correlated in patients with ARDS, and P/F derived using SpO2 and measured P/F were significantly correlated in patients with ARDS, especially in those with moderate to severe ARDS. SpO2 may be useful in the assessment of severity of illness in patients with ARDS at high altitude.

[Clinical analysis of 32 adult patients with infection-associated hemophagocytic syndrome].

OBJECTIVE: To analyze the clinical feature of adult patients with infection-associated hemophagocytic syndrome (IAHS), and to improve the ability of clinicians to diagnose and treat IAHS. METHODS: A retrospectively study was performed. The clinical data of 32 adult patients with IAHS admitted to the intensive care unit (ICU) of the First Affiliated Hospital of Kunming Medical University from July 2014 to November 2019 were analyzed. The general data, clinical manifestations, laboratory results, imaging findings, pathogen and clinical outcomes were collected, and the patients were divided into survival group and death group according to the 28-day prognosis. The clinical data between the two groups were compared, and multivariate Logistic regression analysis was used to analyze the variables with statistical significance in univariate analysis. The receiver operating characteristic (ROC) curve was drawn to analyze the predictive value of variables with statistical significance in univariate analysis for 28-day prognosis of adult patients with IAHS. RESULTS: Among 32 adult patients with IAHS, there were 17 males (53.1%) and 15 females (46.9%). Eighteen patients were bacterial infection, most of which were Acinetobacter baumannii and Escherichia coli; 14 patients were viral infection, mainly EB virus; and the overall 28-day mortality was 62.5% (20/32). (1) Compared with the survival group (n = 12), the levels of white blood cell (WBC), neutrocyte (NEU), lymphocyte (LYM), platelet (PLT) and oxygenation index (OI) in the death group (n = 20) were lower, while the levels of aspartate aminotransferase (AST), K+, serum ferritin (SF) and lactate dehydrogenase (LDH) were higher [WBC (×109/L): 3.90±3.36 vs. 9.57±6.48, NEU (×109/L): 2.69±2.09 vs. 7.01±6.34, LYM (×109/L): 0.36 (0.23, 0.84) vs. 1.24 (0.61, 2.36), PLT (×109/L): 51.15±27.60 vs. 108.42±80.26, OI (mmHg, 1 mmHg = 0.133 kPa): 134.0 (77.5, 192.0) vs. 292.0 (187.0, 329.0), AST (U/L): 254.00 (67.80, 452.50) vs. 85.50 (38.38, 111.25), K+ (mmol/L): 4.06 (3.65, 4.51) vs. 3.52 (3.26, 3.76), SF (µg/L): 6 290.0 (1 851.0, 13 904.8) vs. 1 777.1 (1 228.5, 3 486.3), LDH (µmol×s-1×L-1): 19.3 (11.9, 27.0) vs. 9.8 (6.9, 11.1), all P < 0.05]. In death group, duration of having a fever after admission was prolonged [days: 13.5 (9.0, 17.2) vs. 6.0 (2.5, 8.0), P < 0.05] and the incidence of cyanosis was higher (40.0% vs. 0%, P < 0.05). There was no significant difference in other indicators between the two groups. (2) Multivariate Logistic regression analysis showed that low OI combined with high LDH were risk factors for 28-day mortality of adult patients with IAHS [odds ratio (OR) was 0.967 and 1.007, respectively, both P < 0.05]. (3) It was shown by ROC curve analysis that WBC, NEU, AST, SF, LDH and OI had predictive value for 28-day prognosis of adult patients with IAHS (both P < 0.05), and the area under ROC curve (AUC) of OI and LDH was higher, that was both 0.847. When the best cut-off of OI was 145.5 mmHg, the sensitivity was 63.2%, and the specificity was 100%. When the best cut-off of LDH was 13.4 µmol×s-1×L-1, the sensitivity was 72.2%, and the specificity was 91.7%. CONCLUSIONS: OI < 145.5 mmHg, and LDH > 13.4 µmol×s-1×L-1 were significant predictors for poor 28-day prognosis of adult patients with IAHS.

Difference in hematocrit and plasma albumin levels as an additional biomarker in the diagnosis of infectious disease.

INTRODUCTION: In clinical practice, it has been observed that patients with severe infections show changes to their hematocrit (HCT) and serum albumin (ALB) levels. This study aimed to evaluate whether the difference of HCT and ALB (HCT-ALB) levels can be used as an additional biomarker for fast diagnosis of severe infections. MATERIAL AND METHODS: This was a retrospective case-control study which included adult patients with severe infections, patients with non-infective conditions and healthy individuals. A total of 7,117 individuals were recruited in Yunnan Province, China, from January 2012 to January 2018, and were divided into three groups: 1,033 patients with severe infections (group 1); 1,081 patients with non-infective conditions (group 2); and 5,003 healthy individuals from the general population (group 3). The potential diagnostic threshold of HCT-ALB for severe infectious patients was determined by the receiver operating characteristic (ROC) curve analysis. Group 3 was used as the reference to draw the ROC curves of the HCT-ALB value in group 1 or group 2. RESULTS: HCT-ALB values in each group were significantly different. We found that the area under the ROC curve (AUC) of group 1 reached 0.87 (95% CI: 0.86-0.89), whereas the AUC of group 2 was 0.60 (95% CI: 0.58-0.62). To reach a higher specificity of 99.0% (95% CI: 98.8-99.3%, and with sensitivity of 37.5%, 95% CI: 34.5-40.5%), a HCT-ALB value of 10.25 was recommended as the standard for diagnosis of severe infection. CONCLUSIONS: The HCT-ALB value was increased in patients with infectious disease. The measurement of the HCT-ALB value (> 10.25) might be useful in the fast diagnosis of infectious disease.

[Analysis of the clinical characteristics of severe tsutsugamushi disease in Yunnan Province from 2017 to 2018].

OBJECTIVE: To analyze the clinical characteristics of severe tsutsugamushi disease, and to improve the ability of clinicians to recognize severe cases. METHODS: The clinical data of patients with tsutsugamushi disease from January 1st, 2017 to December 31st, 2018 in hospitals of Yunnan Province were retrospectively collected by the Case Report Form (CRF). The age, gender, clinical symptoms at admission; white blood cell (WBC), eosinophil count (EO), red blood cell (RBC), platelet count (PLT), hemoglobin (Hb), hematocrit (HCT), albumin (ALB), alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBil), lactate dehydrogenase (LDH), blood urea nitrogen (BUN), serum creatinine (SCr), uric acid (UA) on the first day of admission; and clinical outcomes were recorded. The patients were divided into the non-critical group and the critical group according to the diagnostic criteria, the data of clinical manifestation, laboratory examination, imaging examination and prognosis were compared between the two groups. Multivariate Logistic regression analysis was performed on the variables with statistical significance. The receiver operating characteristic (ROC) curve of LDH and UA for differential diagnosis of severe tsutsugamushi disease were drawn. RESULTS: From January 1st, 2017 to December 31st, 2018, 408 patients with tsutsugamushi disease were enrolled in 37 hospitals in 15 prefectures and municipalities of Yunnan Province. 385 cases were clinically diagnosed and 23 cases were laboratory diagnosed. There were 265 cases in non-critical group and 143 cases in critical group. A total of 8 cases died and the remaining 400 cases were discharged from hospital. (1) Compared with the non-critical group, age of the critical group was older, the incidence of dizziness, cough, expectoration, general soreness, dyspnea, palpitation, abdominal pain, diarrhea, bulbar conjunctival congestion, pleural effusion, peritoneal effusion, pericardial effusion, hepatomegaly, splenomegaly, and the levels of WBC, ALT, AST, LDH, TBil, BUN, SCr, UA were significantly increased, the incidence of lymph node enlargement and the levels of EO, PLT and ALB were significantly decreased, and there was no significant difference in other indicators between the two groups. (2) Multivariate Logistic regression analysis showed that age, dyspnea, palpitations, LDH, UA, ALB were risk factors for severe tsutsugamushi disease, ß value was 0.040, -2.147, -1.414, 0.002, 0.005 and -0.132 respectively, and the odds ratio (OR) was 1.041, 0.117, 0.243, 1.002, 1.005 and 0.877 respectively (all P < 0.01). (3) ROC curve analysis showed that UA and LDH had better accuracy in differential diagnosis of severe tsutsugamushi disease (both P < 0.01), and the area under ROC curve (AUC) was 0.693 [95% confidence interval (95%CI) = 0.633-0.754], 0.819 (95%CI = 0.776-0.862), respectively. When the cut-off of UA was 306.2 µmol/L, the sensitivity was 60.8%, and the specificity was 77.4%. When the cut-off of LDH was 485.5 U/L, the sensitivity was 74.8%, and the specificity was 74.7%. The diagnostic value of UA combined with LDH was higher, AUC was 0.832, the sensitivity was 69.9%, and the specificity was 85.3%. CONCLUSIONS: Severe tsutsugamushi disease can be diagnosed at an early stage according to age, respiratory distress, palpitations, hypoalbuminemia, UA > 306.2 µmol/L, and LDH > 485.5 U/L.

[Feasibility of difference between hematocrit and albumin for identifying severity of scrub typhus disease].

OBJECTIVE: To explore the feasibility of difference between hematocrit and albumin (HCT-ALB) to evaluate the severity in patients with severe scrub typhus (Tsutsugamushi disease). METHODS: The clinical data of 408 patients with scrub typhus in 37 hospitals located in 15 prefectures of Yunnan Province from January 1st, 2017 to December 31st, 2018 were retrospectively collected. The patients were divided into the non-severe scrub typhus disease group (n = 265) and the severe scrub typhus disease group (n = 143) according to the diagnostic criteria. Volunteers attending Kunming City Medical Center in Yunnan Province for routine physical examination were enrolled as healthy control group (n = 230). HCT, ALB, lactate dehydrogenase (LDH), uric acid (UA), and acute physiology and chronic health evaluations II (APACHE II) and sequential organ failure assessment (SOFA) within 24 hours after admission were collected. HCT-ALB difference was calculated. Pearson method was used to analyze the correlation between HCT-ALB difference and LDH, UA, APACHE II and SOFA scores in patients with severe scrub typhus disease; the receiver operating characteristic (ROC) curve was used to analyze the value of HCT-ALB difference in the diagnosis of severe scrub typhus disease. RESULTS: (1) There was no significant difference in gender composition between patients with non-severe scrub typhus disease group and severe scrub typhus disease group, but the age of the severe scrub typhus disease group was significantly higher than that of the non-severe scrub typhus disease group (years old: 53.57±15.23 vs. 35.03±23.47, P < 0.01). (2) Compared with the healthy control group, the HCT, ALB of the non-severe scrub typhus disease group and severe scrub typhus disease group were significantly decreased [HCT: (36.54±6.82)%, (38.13±7.60)% vs. (46.20±4.42)%; ALB (g/L): 35.53±5.87, 26.90±6.10 vs. 47.75±4.28, all P < 0.01], and the HCT-ALB difference was significantly increased (5.28±3.90, 11.26±6.62 vs. 1.55±5.32, both P < 0.01). Compared with the non-severe scrub typhus disease group, the HCT of the severe scrub typhus disease group was significantly increased [(38.13±7.60)% vs. (36.54±6.82)%, P < 0.01], the ALB was significantly decreased (g/L: 26.90±6.10 vs. 35.53±5.87, P < 0.01), and the HCT-ALB difference was significantly increased (11.26±6.62 vs. 5.28±3.90, P < 0.01). (3) Pearson correlation analysis showed that HCT-ALB difference was positively correlated with LDH and UA in patients with severe scrub typhus disease (r values were 0.316 and 0.284, respectively, both P < 0.01), and negatively correlated with APACHE II score and SOFA score (r values were -0.229 and -0.198, respectively, both P < 0.05). (4) ROC curve analysis showed that the area under the curve (AUC) of HCT-ALB difference in the diagnosis of severe scrub typhus disease was 0.786, standard error was 0.024, P = 0.000, and 95% confidence interval (95%CI) was 0.739-0.832. When the best diagnostic value was 8.56, the sensitivity was 81.1%, the specificity was 60.8%, and the Youden index was 0.419. CONCLUSIONS: HCT-ALB difference is an indicator to evaluate the severe scrub typhus disease. When HCT-ALB difference is above 8.56, it can be used as an indicator to identify severe scrub typhus disease.

[Feasibility study of the difference between hematocrit and albumin for identifying hemorrhagic shock and septic shock].

OBJECTIVE: To observe the difference between hematocrit (Hct) and albumin (Alb) levels (Hct-Alb) in hemorrhagic shock and septic shock, and to provide a quick and simple method for differentiating hemorrhagic shock from septic shock. METHODS: 270 shock patients admitted to intensive care unit (ICU) of the First Affiliated Hospital of Kunming Medical University from August 2012 to August 2018, including 124 patients with hemorrhagic shock and 148 patients with septic shock, were enrolled. 148 patients underwent routine physical examination served as a control healthy group. General information such as gender, age, and body mass index (BMI) of the patient were collected. Hct and serum Alb levels on the day of physical examination or onset before blood products transfusion were recorded, and the Hct-Alb difference was calculated. The Hct-Alb differences among the three groups were compared. The receiver operating characteristic (ROC) curve was plotted to analyze the differential diagnosis value of Hct-Alb difference for shock type. RESULTS: All patients were enrolled in the final analysis. Compared with the healthy control group, the patients with hemorrhagic and septic shock were older (years: 50.0±19.8, 59.9±16.9 vs. 42.5±13.6, both P < 0.01), and those patients with septic shock was significantly older than those with hemorrhagic shock (years: 59.9±16.9 vs. 50.0±19.8, P < 0.01). There were no significant differences in gender or BMI among the three groups. Compared with the healthy control group, Hct and Alb values in hemorrhagic shock group and septic shock group were significantly decreased [Hct: (27.9±8.4)%, (35.5±7.1)% vs. (47.0±4.4)%, Alb (g/L): 28.9±7.1, 23.3±5.8 vs. 45.4±4.3, all P < 0.01]. The Hct-Alb difference in the septic shock group was significantly higher than that in the healthy control group (12.1±7.5 vs. 1.6±5.9, P < 0.01), but no significant difference was found between hemorrhagic shock group and healthy control group (-0.9±5.3 vs. 1.6±5.9, P > 0.05). Compared with hemorrhagic shock group, the Alb level in septic shock group was significantly decreased (g/L: 23.3±5.8 vs. 28.9±7.1, P < 0.01), and Hct and Hct-Alb difference were significantly increased [Hct: (35.5±7.1)% vs. (27.9±8.4)%, Hct-Alb difference: 12.1±7.5 vs. -0.9±5.3, both P < 0.01]. It was shown by ROC curve analysis that the area under the ROC curve (AUC) for diagnosing hemorrhagic shock and septic shock was 0.366 and 0.867, indicating that Hct-Alb difference had diagnostic value only for septic shock. When the best cut-off value of Hct-Alb difference was 6.8, the sensitivity was 79.5% for diagnosing septic shock, and the specificity was 79.7%, the positive predict value was 0.80, the negative predict value was 0.80, the positive likelihood ratio was 3.916, the negative likelihood ratio was 0.257. CONCLUSIONS: The Hct-Alb difference in patients with septic shock is higher than that in patients with hemorrhagic shock. The Hct-Alb difference is highly accurate in diagnosing septic shock. When the Hct-Alb difference is greater than 6.8, it can be used for differential diagnosis of hemorrhagic shock and septic shock.

[The difference between hematocrit and plasma albumin in the course of systemic capillary leak syndrome: a systematic review].

OBJECTIVE: To investigate the changes of the difference between hematocrit (Hct) and plasma albumin (Alb) in the course of patients with systemic capillary leak syndrome (SCLS). METHODS: 281 case reports on human vascular leaking from the PubMed database from January 1st, 1996 to September 30th, 2015 were screened by systematic review method. Studies related to intracranial vascular leakage or intraocular vascular leakage were excluded. 213 articles related to SCLS were identified (164 in English, 16 in French, 8 in Japanese, 7 in German, 7 in Spanish, 4 in Italian, 2 in Chinese, 2 in Danish, 2 in Dutch, and 1 in Swedish). Due to the unavailable full text, 40 articles were excluded. A total of 173 articles related to SCLS were screened, of which 84 patients were enrolled. The data of Alb, Hct, age, gender, weight change, the length of hospital stay and 24-hour fluid infusion volume in SCLS patients were recorded, and the difference between Hct and plasma Alb (Hct-Alb) was calculated. According to the time when accurate Hct and Alb data were collected, they were divided into three groups: basic value group before onset, value group at onset and value group at recovery/discharge after onset. The levels of Hct and Alb and Hct-Alb at different time points in the course of the disease were compared. Pearson test was used to analyze the correlation between Hct-Alb and 24-hour fluid infusion volume. RESULTS: (1) A total of 12 cases with both exact values of Alb and Hct [or hemoglobin (Hb)] at the time of onset and recovery after treatment were selected from 84 cases of SCLS. It was shown that the Hct-Alb at the time of onset was significantly higher than that after treatment (26.33±16.36 vs. 0.55±8.81, P < 0.001). (2) A total of 17 cases with both the pre-onset baseline value and the exact values of Alb and Hct (or Hb) at the time of onset were selected from 84 cases of SCLS. It was shown that the Hct-Alb at the time of onset was significantly higher than that of the pre-onset basic value (15.83±11.37 vs. 1.82±7.97, P < 0.001). (3) A total of 14 cases with both exact values of Alb, Hct and 24-hour fluid infusion volume at the time of onset were selected from 84 cases of SCLS. It was shown that the Hct-Alb was 35.45±19.58 at the time of onset. The average 24-hour fluid infusion volume was (9.82±4.95) L, and the maximum volume of fluid infusion was 20 L. Pearson correlation analysis showed that the Hct-Alb at the time of onset was significantly positively correlated with 24-hour fluid infusion volume (r = 0.578, P < 0.05). CONCLUSIONS: In the analysis of SCLS cases published with adequate data available from 1996 to 2015, it was revealed that: (1) the difference in Hct-Alb levels at the onset of SCLS was 32.06±17.41. (2) The greater the difference between Hct and plasma Alb, the more amount of fluid required to maintain normal blood pressure.

Hematocrit and plasma albumin levels difference may be a potential biomarker to discriminate preeclampsia and eclampsia in patients with hypertensive disorders of pregnancy.

BACKGROUND: We evaluated whether alterations of hemoglobin (HB), hematocrit (HCT), serum albumin level (ALB), and the difference of HCT and ALB can be used in the diagnosis of preeclampsia and eclampsia in patients with hypertensive disorders of pregnancy (HDP). METHODS: A total of 509 individuals were recruited and divided into 4 groups: Group 1, 170 healthy non-pregnant women; Group 2, 125 normal pregnant women; Group 3, 105 pregnant women diagnosed with gestational and chronic hypertension; Group 4, 109 pregnant women diagnosed as having preeclampsia and eclampsia. Data of HB, HCT, ALB, globulin (GLB) were collected at the time of a prenatal examination during the third trimester. RESULTS: Alterations in the HCT and the ALB levels in these groups were significantly different. Group 4 had a higher mean HCT-ALB value (P<0.01), but lower ALB and GLB values compared with the other three groups. We used Groups 2 and 3 as the respective reference to draw the receiver operating characteristic (ROC) curves of HCT-ALB in Group 4, and found that the threshold values of maximum index corresponding were 12.95 and 12.65 (sensitivity>57.0%, specificity>98.9%), respectively. CONCLUSIONS: The value of HCT-ALB>12.65 might be used as a potential biomarker for the auxiliary diagnosis of preeclampsia and eclampsia in HDP.

Lung-protective Ventilation in Patients with Brain Injury: A Multicenter Cross-sectional Study and Questionnaire Survey in China.

BACKGROUND: Over the years, the mechanical ventilation (MV) strategy has changed worldwide. The aim of the present study was to describe the ventilation practices, particularly lung-protective ventilation (LPV), among brain-injured patients in China. METHODS: This study was a multicenter, 1-day, cross-sectional study in 47 Intensive Care Units (ICUs) across China. Mechanically ventilated patients (18 years and older) with brain injury in a participating ICU during the time of the study, including traumatic brain injury, stroke, postoperation with intracranial tumor, hypoxic-ischemic encephalopathy, intracranial infection, and idiopathic epilepsy, were enrolled. Demographic data, primary diagnoses, indications for MV, MV modes and settings, and prognoses on the 60th day were collected. Multivariable logistic analysis was used to assess factors that might affect the use of LPV. RESULTS: A total of 104 patients were enrolled in the present study, 87 (83.7%) of whom were identified with severe brain injury based on a Glasgow Coma Scale ≤8 points. Synchronized intermittent mandatory ventilation (SIMV) was the most frequent ventilator mode, accounting for 46.2% of the entire cohort. The median tidal volume was set to 8.0 ml/kg (interquartile range [IQR], 7.0-8.9 ml/kg) of the predicted body weight; 50 (48.1%) patients received LPV. The median positive end-expiratory pressure (PEEP) was set to 5 cmH2O (IQR, 5-6 cmH2O). No PEEP values were higher than 10 cmH2O. Compared with partially mandatory ventilation, supportive and spontaneous ventilation practices were associated with LPV. There were no significant differences in mortality and MV duration between patients subjected to LPV and those were not. CONCLUSIONS: Among brain-injured patients in China, SIMV was the most frequent ventilation mode. Nearly one-half of the brain-injured patients received LPV. Patients under supportive and spontaneous ventilation were more likely to receive LPV. TRIAL REGISTRATION: ClinicalTrials.org NCT02517073 https://clinicaltrials.gov/ct2/show/NCT02517073.

Influence of a Decaying Cyclonic Eddy on Biogenic Silica and Particulate Organic Carbon in the Tropical South China Sea Based on 234Th-238U Disequilibrium.

Eddies play a critical role in regulating the biological pump by pumping new nutrients to the euphotic zone. However, the effects of cyclonic eddies on particle export are not well understood. Here, biogenic silica (BSi) and particulate organic carbon (POC) exports were examined inside and outside a decaying cyclonic eddy using 234Th-238U disequilibria in the tropical South China Sea. For the eddy and outside stations, the average concentrations of BSi in the euphotic zone were 0.17±0.09 µmol L-1 (mean±sd, n = 20) and 0.21±0.06 µmol L-1 (n = 34). The POC concentrations were 1.42±0.56 µmol L-1 (n = 34) and 1.30±0.46 µmol L-1 (n = 51). Both BSi and POC abundances did not show change at the 95% confidence level. Based on the 234Th-238U model, BSi export fluxes in the eddy averaged 0.18±0.15 mmol Si m-2 d-1, which was comparable with the 0.40±0.20 mmol Si m-2 d-1 outside the eddy. Similarly, the average POC export fluxes were 1.5±1.4 mmol C m-2 d-1 and 1.9±1.3 mmol C m-2 d-1 for the eddy and outside stations. From these results we concluded that cyclonic eddies in their decaying phase have little effect on the abundance and export of biogenic particles.

Cerebral energy metabolism during transient hyperglycemia in patients with severe brain trauma.

OBJECTIVE: To study whether transient hyperglycemia adversely affects cerebral energy metabolism in patients with severe traumatic brain lesions. DESIGN AND SETTING: Prospective, nonrandomized study in the neurosurgical intensive care unit of a university hospital. PATIENTS: 108 patients treated for severe traumatic brain lesions. INTERVENTIONS: All patients were treated according to neurosurgical intensive care routine including monitoring of intracranial pressure. One microdialysis catheter was inserted via a burr hole frontally to that used for the intraventricular catheter ("better" position). In patients with focal lesions one or more catheters were inserted into cerebral cortex surrounding an evacuated focal contusion or underlying an evacuated hematoma ("worse" position). Perfusion rate was 0.3 micro l/min and samples were taken every 30 or 60 min. The levels of glucose, pyruvate, lactate, glutamate, and glycerol were analyzed and displayed bedside. MEASUREMENTS AND RESULTS: There were 18 episodes of moderate (12-15 mmol/l) and 6 episodes of pronounced (>15 mmol/l) hyperglycemia. Moderate hyperglycemia did not change intracerebral levels of lactate, pyruvate, glutamate, glycerol, or lactate/pyruvate ratio. Lactate concentrations increased during pronounced hyperglycemia. Pronounced cerebral lactic acidosis and a moderate increase in interstitial glycerol concentration indicating cell membrane degradation was observed in a single patient with pronounced, long-lasting hyperglycemia. CONCLUSIONS: Cerebral energy metabolism was affected by transient hyperglycemia only at blood glucose concentration above 15 mmol/l as shown by a moderate increase in interstitial lactate level.

Assessment of the lower limit for cerebral perfusion pressure in severe head injuries by bedside monitoring of regional energy metabolism.

BACKGROUND: In patients with severe traumatic brain lesions, the lower limit for cerebral perfusion pressure (CPP) is controversial. The aim of this prospective study was to assess this limit from bedside measurements of cerebral energy metabolism and to clarify whether the penumbra zone surrounding a focal lesion is more sensitive to a decrease in CPP than less-injured areas. METHODS: Fifty patients with severe head injury were included after evacuation of an intracranial hematoma and/or focal brain contusion. They were treated according to intensive care routine (Lund concept), including continuous monitoring of intracranial pressure. One microdialysis catheter was inserted in less-injured brain tissue ("better" position), and one or two catheters were inserted into the boundary of injured cerebral cortex ("worse" position). Concentrations of glucose, pyruvate, and lactate were analyzed and displayed bedside and were related to CPP (n = 29,495). RESULTS: Mean interstitial glucose concentration was unaffected by the level of the CPP within the studied ranges. Increases in lactate concentration (P = 0.0008) and lactate-pyruvate ratio (P = 0.01) were obtained in the "worse" but not in the "better" position at CPP less than 50 mmHg compared with the same positions at CPP greater than 50 mmHg. CONCLUSIONS: The study results support the view that CPP may be reduced to 50 mmHg in patients with severe traumatic brain lesions, provided that the physiologic and pharmacologic principles of the Lund concept are recognized. In the individual patient, preservation of normal concentrations of energy metabolites within cerebral areas at risk can be guaranteed by intracerebral microdialysis and bedside biochemical analyses.