2013年 · 第126卷第10期

The 2012 revision of the Surviving Sepsis Campaign;International Guideless for Management of Severe Sepsis and Septic Shock was recently published (February 2013) in Critical Care Medicine and Intensive Care Medicine.1,2 The effort to create this document occurred over two years and likely represents the most comprehensive buy-in of any international medical guidelines to date with 30 sponsoring organizations.Included in this list of sponsoring organizations is the Chinese Society of Critical Care Medicine-China Medical Association and the Chinese Society of Critical Care Medicine.The evidence based medicine (EBM) grading system continues to evolve under the leadership of the Grades of Recommendation Assessment Development and Evaluation Group (GRADE Group),based in Canada.3 Each recommendation is graded based on quality of evidence and strength of recommendation。

Critical care medicine began in 1982 in China and is still in a phase of rapid development.Despite the inadequate resources compared with those of developed countries,critical care medicine has been recognized as a specialty by the government and by other specialties.National critical care societies are dedicated to promoting professional education and the academic improvement of critical care medicine in China.Although critical care services and clinical research are still underdeveloped due to scarce resources,great improvement is expected in the near future。

Abstract：Background The lowering of body temperature is a common,almost reflexive step in the daily care of septic shock patient.However,the effect of different magnitudes of fever control on the outcome of refractory septic patients with a very poor outcome is controversial and has yet to be explored.Methods This prospective trial examined sixty-five refractory septic shock patients with a core temperature higher than 38.5℃.Patients were randomly assigned to a group achieving a "low temperature" range (LT group:36.0-37.5 ℃) or to a group achieving a "high temperature" range (HT group:37.5-38.3 ℃C) by physical methods including a water-flow cooling blanket and ice packs.A target core temperature was achieved in 1-2 hours post-treatment,and maintained for 72 hours.Averaged values of core temperature as well as hemodynamic,respiratory,and laboratory variables were analyzed at baseline and during the first 72 hours after fever control.Results Thirty-four (52.31％) patients were assigned to the LT group and thirty-one (47.69％) patients were assigned to the HT group.The mean core temperature was significantly lower in the LT group than in the HT group (36.61 vs.37.85 ℃,respectively； P ＜ 0.0001).The average heart rate (HR) (75.5 vs.91.9 beats/min,respectively； P ＜ 0.0001) and the mean cardiac output (CO) (5.35 vs.6.45 L/min,respectively； P =0.002) were also statistically significant lower in the LT group than in the HT group.The averaged serum lactate level was significantly higher in the LT group compared to the HT group (5.59 vs.2.82 mmol/L,respectively； P=-0.008).Fibrinogen and activated partial thromboplatin time were also different between the two groups.The 28 days mortality was significantly higher in the LT group than in the HT group (61.8vs.25.8％,respectively； P=0.003).A Cox-regression model analysis showed that mean core temperature during the 72 h period was an independent predictor of 28 days mortality (odds ratio (OR) =0.42,95％Cl 0.25,0.6； P=0.001).Conclusion Controlling fever to a lower range (36.0-37.5 ℃C) may be harmful to patients with refractory septic shock by worsening tissue perfusion,compared to controlling it within a higher range (37.5-38.3 ℃C).An understanding of the mechanisms responsible for these observations requires further investigation。

Abstract：Background Weaning difficulties occur in 31％ of total intubated patients,and result in prolonged weaning duration.A computer-driven automated weaning system can perform a spontaneous breathing trial (SBT) automatically and display a message when the trial is successfully passed.Such a system might have a beneficial effect on difficult-to-wean patients.The aim of this study was to examine whether the computer-driven automated weaning system can accelerate discontinuation of mechanical ventilation and improve outcomes in difficult-to-wean patients.Methods This randomized controlled study included 39 difficult-to-wean patients who failed their first spontaneous breathing trial.Before initiating weaning,eligible patients were randomly allocated to wean by computer-driven automated weaning system (CDW group,n=19) or a physician-controlled local protocol (PW group,n=20).Weaning duration,defined as the time from inclusion until first extubation,was the primary endpoint.Secondary endpoints were total duration of mechanical ventilation,the length of intensive care unit (ICU) stay,the number of reintubations,the mortality rate in the ICU,the number of noninvasive ventilations,the number of complications in the ICU,and the number of ventilator-associated pneumonia cases.Results The weaning duration was reduced with the computer-driven weaning as compared with the usual protocol (median 29.0 hours vs.45.5 hours,P=0.044).Total duration of mechanical ventilation and duration of the ICU stay did not differ between the CDW and PW groups.There was no difference in the number of reintubations between the CDW and PW groups (3 and 4 patients,P=-0.732).The study groups showed comparable numbers of tracheostomy,selfextubations,ventilator-associated pneumonia,and non-invasive ventilation.Mortality in the ICU was similar in the CDW and the PW groups (21.1％ vs.20.0％,P=-0.935).Conclusion The computer-driven automated weaning system can reduce weaning duration in difficult-to-wean patients as compared with a physician-controlled weaning protocol。

Abstract：Background Surviving sepsis campaign (SSC) bundles have been demonstrated to significantly improve survival in sepsis and septic shock patients worldwide.Compliance with these protocols and resultant mortality in sepsis patients was investigated in intensive care units (ICUs) in China.Methods Adult patients with severe sepsis or septic shock treated from September 2007 to October 2008 in 11 ICUs of Chinese teaching hospitals were included.The primary outcome was compliance with resuscitation and management bundles.Secondary outcomes included individual bundle protocol impact and the effects of the completed bundle protocol number on 28-day mortality.Results Overall compliance during 6-hr resuscitation and 24-hour management bundles were 5.5％ and 17.4％,respectively,and 28-day mortality was 33.0％.Compliance with protocols for blood cultures before antibiotics (42.2％),central venous pressure ≥8 mmHg (65.9％),central venous oxygen saturation ≥70％ (25.0％),and optimized glucose control (82.1％),were significantly associated with decreased 28-day mortality (P ＜0.05).When adjusted for age,acute organ dysfunction,and APACHE Ⅱ score,compliance with the blood culture before antibiotics protocol produced the most significant decrease in 28-day mortality (OR,0.33； 95％ Cl,0.16-0.70； P=-0.004).Compliance with ≥5 protocols in the 6-hour resuscitation bundle was also associated with lower 28-day mortality in septic shock patients (OR,0.17； 95％ Cl,0.06-0.54； P =0.001).Conclusions Compliance with resuscitation and management bundles is generally poor in China； however,when applied,6-hour resuscitation bundle are associated with significant reductions in 28-day mortality for sepsis patients。

Abstract：Background Multidrug-resistant Acinetobacter baumannii (MDRAB) is an important and emerging hospital-acquired pathogen worldwide.This study was conducted to identify the sources of MDRAB and its role in respiratory tract colonization and nosocomial pneumonia in intensive care unit (ICU) patients.Methods We conducted a prospective active surveillance study of MDRAB in three ICUs at a Chinese Hospital from April to August 2011,to identify the sources of MDRAB and its role in respiratory tract colonization and nosocomial pneumonia.Results One hundred and fourteen (13.0％) MDRAB isolates were detected from 876 specimens,with a sensitivity of 11.6％ (55/474) in screening of the pharyngeal and tracheal swabs,and 14.7％ (59/402) of the sputum/endotracheal aspirates.MDRAB colonization/infection was found in 34 (26.8％) of 127 patients,including 16 (12.6％) cases of pure colonization and 18 (14.2％) cases of pneumonia (two pre-ICU-acquired cases of pneumonia and 16 ICU-acquired cases of pneumonia).Previous respiratory tract MDRAB colonization was found in 22 (17.3％) patients:eight (6.3％)were pre-ICU-acquired colonization and 14 (11.0％) ICU-acquired colonization.Of eight pre-ICU-colonized patients,five were transferred from other wards or hospitals with hospitalization ＞72 hours,and three came from the community with no previous hospitalization.Overall,6/22 colonized patients presented with secondary pneumonia； only two (9.1％) colonized MDRAB strains were associated with secondary infections.Respiratory tract MDRAB colonization had no significant relationship with nosocomial pneumonia (P=-0.725).In addition,acute respiratory failure,mechanical ventilation,renal failure,and prior carbapenem use were risk factors for MDRAB colonization/infection.Conclusions A high proportion of cases of MDRAB colonization/infection in ICU patients were detected through screening cultures.About one-third were acquired from general wards and the community before ICU admission.The low incidence of MDRAB colonization-related pneumonia questions the appropriateness of targeted antibiotic therapy。

Abstract：Background Rapid detection of bacteremia is important for critically ill patients.Procalcitonin (PCT) has emerged as a marker of sepsis,but its characterization for predicting bacteremia is still unclear.This study aimed to investigate the role of change of PCT within 6 to 12 hours after new fever in predicting bacteremia.Methods An observational study was conducted in the ICU of our hospital from January 2009 to March 2010.Adult patients with new fever were included and grouped as bacteremia and non bacteremia group.Serum PCT concentration was measured at admission and within 6 to12 hours after new fever (designated PCT0 and PCT1).Other results of laboratory tests and therapeutic interventions were recorded.Multivariate Logistic regression analysis was used to identify the risk factors of bacteremia.The area under the ROC curve (AUC) was constructed to evaluate the discriminative power of variables to predict bacteremia.Results Totally 106 patients were enrolled,60 of whom had bacteremia and 46 did not have bacteremia,.The acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) and sequential organ failure assessment (SOFA) scores were 13.1±7.8 and 5.0±2.2 at admission,respectively.There was no significant difference in PCT0 between the bacteremia group and nonbacteremia group； 1.27μg/L (range,0.10-33.3) vs.0.98μg/L (range,0.08-25.7),(P=-0.157).However,the PCT1 and the rate of change of PCT were significantly higher in bacteremia group； PCT1 was 6.73μg/L (1.13-120.10)vs.1.17μg/L (0.10-12.10) (P=0.001),and the rate of change was 5.62 times (1.05-120.6) vs.0.07 times (-0.03-0.18)(P＜0.001).The area under the ROC curve (AUC； 95％ confidence interval) of the rate of change of PCT was better for predicting bacteremia than that of PCT1； 0.864 (range,0.801-0.927) vs.0.715 (range,0.628-0.801),(P＜0.05).The AUCs of PCT0 and other parameters (such as WBC count,granulocyte percentage and temperature) were not significantly different (all P＞0.05).The best cut-off value for the rate of change was 3.54 times,with a sensitivity of 88.5％ and a specificity of 98.0％.It was also an independent predictor of bacteremia (odds ratio 29.7,P＜0.0001) and wasn't correlated with the presence or absence of co-infection,neutropenia or immunodeficiency (P＞0.05).Conclusion The rate of change of PCT is useful for early detection of bacteremia during new fever and superior to the PCT absolute value and other parameters in non-selected ICU patients。

Abstract：Background Streke volume variation (SW) is a robust indicator of fluid responsiveness during volume change.We compared the sensibility of SW by Vigileo/Flotrac to central venous pressure (CVP) when volume changes in patients undergoing intraoperative acute normovolemic hemodilution (ANH) and acute hypervolemic hemodilution (AHH).Methods Forty patients were randomly divided into an ANH group (n=20) and an AHH group (n=20).All patients received general anesthesia and were mechanically ventilated.Data were collected from 7 different time-points in the ANH group:baseline,after withdrawal of 5％,10％,and 15％ of the estimated blood volume (EBV) and after replacement with an equal volume of 6％ hydroxyethyl starch 130/0.4 (HES) in 5％ EBV increments to baseline.There were four time points in the AHH group:baseline,after 5％,10％,and 15％ expansion of the EBV with 6％ HES.At each time-point,CVP,SW and other hemodynamic parameters measurements were obtained.Results After removal of 10％ and 15％ EBV,SW significantly increased from 10.9±3.0 to 14.1±3.4 and 10.9±3.0 to16.0±3.3 (P ＜0.01),and returned to a final value of 10.6±3.4 after volume replacement.The CVP value was unchanged after removal and replacement of 15％ of the EBV.There were no significant changes in SW after 5％,10％ whereas there was a significant reduction after 15％ (8.2±1.7) expansion of the EBV compared with baseline (9.9±1.8) (P=-0.033).However,there was a significant increase in CVP after10％ (10.3±2.4),15％ (11.3±2.2) expansion of the EBV compared with baseline (8.2±2.7) (P ＜0.01).Conclusion SW is a more sensitive parameter for volume than CVP during hypovolemia,on the contrary CVP is more sensitive than SW during hypervolemia。

Abstract：Background Central venous pressure (CVP) and intrathoracic blood volume index (ITBVI) were used to assess the fluid status.It has previously been shown that CVP is not as accurate as ITBVI for all the shock patients.We therefore hypothesized that the change of CVP has the ability to predict fluid responsiveness in some clinical cases of shock.Methods From September 1st 2009 to September 1st 2011,sixty-three patients with shock from different Intensive Care Unit (ICU) were collected into this retrospective study.All the patients received fluid challenge strategy (infusing 300 ml hydroxyethyl starch in 20 minutes),were monitored with CVP and pulse-indicated continuous cardiac output (PICCO).The correlation between changes in cardiac index (△CI),CVP (△CVP) and ITBVI (△ITBVI) were analyzed.Fluid responsiveness was defined as an increase in CI≥10％.Receiver operating characteristic (ROC) curves were generated for △CVP and △ITBVI.Results For all the patients,there was no correlation between △CI and △CVP (P=0.073),but in the subgroup analysis,the correlation between △CI and △CVP was significant in those younger than 60 years old (P=-0.018) and those with hypovolemic shock (P=0.001).The difference of areas under the ROC curves of △CVP and △ITBVI were not statistically significant in the group younger than 60 years old or hypovolemic shock group (P ＞0.05,respectively).However,no similar results can be found in the group older than 60 years old and the other two shock type groups from ROC curves of △CVP and △ITBVI.Conclusions △CVP is not suitable for evaluating the volume status of the shock patients with fluid resuscitation regardless of their condition.However,in some ways,△CVP have the ability to predict fluid responsiveness in the younger shock patients or in the hypovolemic shock patients。

Abstract：Background Broad-spectrum antibiotic administration promotes intestinal colonization of exogenous fungal pathogens in healthy animals and has been recognized as one of the risk factors of invasive fungal infection in clinical settings.It is unclear whether broad-spectrum antibiotic treatment would change the intestinal mycobiota without exogenous fungal challenge in the context of sepsis.Methods We established a rat model of double-hit sepsis using burn injury and endotoxin challenge.Rats with burn injury or double-hit sepsis received imipenem treatment for 3 days or 9 days,and their colon contents were sampled for selective fungal culture and isolation counts.Results Imipenem treatment promoted the overgrowth of the commensal fungus Geotrichum capitatum in rats with burn injury.Imipenem treatment also promoted colon colonization by exogenous fungi in rats with burn injury and double-hit sepsis,including Trichosporon cutaneum,Candida albicans,Candida krusei,and Candida glabrata.A longer duration of imipenem treatment had a stronger impact on colon colonization by exogenous fungi.Conclusion Imipenem treatment facilitates the overgrowth of commensal fungi and colonization by exogenous,potentially pathogenic fungi in the colons of rats with burn injury or double-hit sepsis。

Abstract：Background Interleukin (IL)-33 is a recently identified member of the IL-1 family that binds to the receptor,ST2L.This study examined IL-33 production in mouse liver and investigated its role in hepatic ischemia/reperfusion (I/R) injury.Methods Male BALB/c mice ((22±3) g) were subjected to 90 minutes partial hepatic ischemia,followed by 6 hours reperfusion.First,mice were randomized into two groups:control group (laparotomy only,without blocking blood supply) and ischemia model group.IL-33 mRNA and serum protein levels were measured at 30,60,90 minutes after ischemia and 2 and 6 hours after reperfusion.Second,mice were randomized into four groups:control,model (injection of rabbit IgG polyclonal antibody),recombinant IL-33 intervention and anti-ST2L antibody intervention group.Mice were sacrificed 6 hours after reperfusion.Liver pathology was observed via transmission electron microscopy.Serum aspartate aminotransferase (AST),alanine aminotransferase (ALT),IL-4,IL-5,IL-13,interferon-γ (IFN-γ) and tumor necrosis factor-α (TNF-a) levels were measured.Results Levels of IL-33 mRNA and protein did not change during ischemia (P ＞0.05) but increased significantly during reperfusion (P ＜0.05).After reperfusion for 6 hours,serum levels of ALT,AST,IL-4,IL-5,IL-13,IFN-γ and TNF-α were significantly increased (P ＜0.05),and hepatocellular ultrastructure was damaged.Pretreatment with IL-33 attenuated severity of liver damage compared with controls,but pretreatment with anti-ST2L antibody increased severity.Serum levels of IL-4,IL-5 and IL-13 protein increased whereas IFN-γ decreased following IL-33 pretreatment.Pretreatment with anti-ST2L antibody significantly decreased serum IL-4,IL-5,IL-13 levels and increased serum IFN-γ levels compared with controls (P ＜0.05).There was no change in the level of TNF-α.Conclusion IL-33 is produced systematically and locally in liver during I/R injury.Pretreatment with IL-33 is therapeutic for hepatic I/R injury,possibly via inducing a Th1 to Th2 shift。

Abstract：Background Myocardial apoptosis is involved in the pathogenesis of sepsis-related myocardial depression.However,the underlying mechanism remains unknown.This study investigated the role of mitochondrial damage and mitochondria-induced oxidative stress during cardiac apoptosis in septic rats.Methods Seventy-two Sprague-Dawley rats were randomly divided into a control group and septic group receiving lipopolysaccharide injection.Heart tissue was removed and changes in cardiac morphology were observed by light microscopy and scanning electron microscopy.In situ apoptosis was examined using terminal transferase-mediated dUTP nick end-labeling assay and nuclear factor-kappa B activation in myocardium by Western blotting to estimate myocardial apoptosis.Appearance of mitochondrial cristae and activation of cytochrome C oxidase were used to evaluate mitochondrial damage.Oxidative stress was assessed by mitochondrial lipid and protein oxidation,and antioxidant defense was assessed by mitochondrial superoxide dismutase and glutathione peroxidase activity.Results Sepsis-induced inflammatory cell infiltration,myocardium degeneration and dropsy were time-dependent.Expanded capillaries were observed in the hearts of infected rats 24 hours post-challenge.Compared with sham-treated rats,the percentage of cell apoptosis increased in a time-dependent manner in hearts from septic rats at 6 hours,12 hours and 24 hours post-injection (P ＜ 0.05).The expression of nuclear factor-kappa B p65 decreased gradually in the cytosol and increased in the nucleus during sepsis,indicating that septic challenge provoked the progressive activation of nuclear factor-kappa B.Mitochondrial cristae and activation of cytochrome C oxidase increased in a time-dependent manner.Both superoxide dismutase and glutathione peroxidase activities decreased,while mitochondrial lipid and protein oxidation increased between 6 and 24 hours after lipopolysaccharide challenge.Conclusions Septic challenge induced myocardial apoptosis and mitochondrial damage.Furthermore,mitochondrial damage via alteration of defenses against reactive oxygen species might play an important role in myocardial apoptosis during sepsis。

Abstract：Background There are two major pathological hallmarks of AIzheimer's disease.One is the progressive accumulation of beta-amyloid (Aβ) in the form of senile plaques； the other is hyperphosphorylated tau,causing neuronal apoptosis.Some inhalation anesthetics,such as isoflurane and desflurane,have been suggested to induce Aβ accumulation and cause AD-like neuropathogenesis.Whether intravenous anesthetics have similar effects is still unclear.We therefore set out to determine the relationship between propofol and AD-like pathogenesis.Methods PC12 cells were cultured in serum-free medium for 12 hours prior to drug treatment.Various concentrations from 5 μmol/L to 80 μmol/L of aggregated Aβ25-35 were added to determine a proper concentration for further study.After exposure to 10 μmol/L Aβ25-35 alone or with 20 μmol/L propofol for 6 hours,PC12 cell viability was determined by MTT assay.Western blotting and immunocytochemical staining were performed to observe the protein expression of the Bcl-2 family,tau phosphorylation at different sites,and tau protein kinases and phosphatases.Results Aβ25-35 induced a decrease in PC12 cell viability in a dose-dependent manner.Exposure to 10 μmol/L Aβ25-35 for 6 hours resulted in the mild cell survival,accompanied by a decline in Bcl-2,and an increase in phosphorylation of GSK-3β and tau at different sites.Compared with the Aβ25-35 group,cells treated with propofol alone showed no significant difference,while cells co-incubated with propofol and Aβ25-35 showed a significantly higher survival rate (P ＜0.01 or P ＜0.05).Tau phosphorylation at Ser396,Ser404 and Thr231 and the level of GSK-3β in PC12 cells increased after exposure to 10 μmol/L Aβ25-35.Co-incubation with propofol attenuated cellular apoptosis by inhibiting tau phosphorylation.Conclusions These data indicate that propofol may protect PC12 cells from Aβ25-35-induced apoptosis and tau hyperphosphorylation through the GSK-3β pathway,therefore it may be a safer anesthesia for AD and elderly patients。

Abstract：Background Folate plays a critical role in nucleotide synthesis and DNA methylation,and was considered to be associated with anti-carcinogenesis.Results from studies that concern the relationship between the folate intake or serum folate levels and lung cancer risk showed no consistency,which requires our further comprehensive metaanalysis.Methods Systematic literature search was conducted to identify the relevant studies (published prior to February 2013)according to standard protocol.Estimated effects were calculated under both random-effects and fixed-effects models.Heterogeneity between studies and publication bias were also evaluated.Results A total of 4390 cases and 6138 controls from 6 case-control studies revealed a significant overall inverse association between folate intake and lung cancer risk (OR =0.74,95％ Cl =0.65-0.84,P＜ 0.001).Summary of 1438 cases and 2582 controls from 4 case-control studies and 44 cases out of a cohort of 1988 participants suggested a marginal association without significance (OR =0.78,95％ Cl =0.60-1.02,P =0.075) between high serum folate levels and less lung cancer susceptibility； however,subgroup analysis about population-based case-control studies showed that high serum folate levels significantly associated with the reduced lung cancer risk (OR =0.76,95％ Cl =0.58-1.00,P =0.048).Conclusion Higher folate intake can be a protective factor against lung cancer risk,and higher serum folate level is probably associated with reduced lung cancer risk in marginal manner,though more studies are warranted to confirm these associations。

Abstract：Background The diagnosis of Pneumocystis pneumonia (PCP) in immunocompromised patients is still challenging today due to the absence of an in vitro culture system and the low diagnostic accuracy of microscopic examinations.Herein,weperformed a meta-analysis to evaluate the accuracy of real-time polymerase chain reaction (PCR) in the diagnosis of PCP.Methods We searched Web of Knowledge and Medline from 1990 to May 2010 for studies reporting diagnostic accuracy data regarding the use of real-time PCR in the diagnosis of PCP in immunocompromised patients.Results Ten individual studies were included.Overall,the sensitivity of real-time PCR was 97％ (95％ CI:93％-99％)；the specificity was 94％ (95％ CI:90％-96％).The area under the HSROC curve (95％ CI) for real-time PCR was 0.99(0.97-0.99).In a subgroup analysis regarding studies involving HIV patients among the study population,the sensitivity and specificity were 97％ (95％ CI:93％-99％) and 93％ (95％ CI:89％-96％),respectively.Regarding studies using Bronchoalveolar lavage (BAL) samples only:sensitivity =98％ (95％ CI:94％-99％)； specificity =93％ (95％ CI:89％-96％),respectively.Regarding studies using microscopy as a reference standard:sensitivity =97％ (95％ CI:92％-99％)；specificity =93％ (95％ CI:88％-96％).However,high between-study statistical heterogeneity was observed in all analyses.Conclusions Real-time PCR has a good diagnostic accuracy and may provide a useful adjunctive tool for the diagnosis of PCP in immunocompromised patients.Further studies are needed in order to identify any differences in the diagnostic performance of real-time PCR in HIV and non-HIV immunocompromised patients。

Hemodynamics is as scientific domain involving the characteristics and regularity of the movement of blood components throughout the entire body.Hemodynamic monitoring is important in revealing pathophysiologic changes during disease processes,despite almost all monitoring methods not improving outcomes.1,2 Recently,hemodynamics has grown theoretically and methodologically from individual parameters.Hemodynamic therapy,as a breakthrough concept,is important in the physiologic evaluation of patients,in selecting optimal treatments,in adjusting the intensity of treatment and in targeting the direction of therapy。

Osteosarcoma is the most common primary malignant bone sarcoma,and occurs predominantly in children and young adults.The overall survival of patients with osteosarcoma remains low at approximately 60％.1 The prognosis of osteosarcoma patients is highly associated with response to chemotherapy.Although multiple chemotherapy regimens have improved the outcome of patients with osteosarcoma,resistance to current regimens has been reported in more than 30％ of patients,2highlighting the need for novel,targeted therapies。

Since the first report of totally endoscopic coronary artery bypass graft (CABG) using da Vinci Surgical System (Intuitive Surgical,Sunnyvale,CA,USA) in 1999,the robotic technology has been applied to internal thoracic artery (ITA) harvesting for more than 10 years.We present the experience of robotic ITA skeletonized harvesting in 200 cases using the da Vinci S or da Vinci SI Surgical System.The learning curves of ITA harvesting time and the results of ITA graft patency were evaluated。

Due to the increasing number of diabetic patients,the number of people affected by diabetic retinopathy is expected to increase.Diabetic retinopathy is a complication of diabetes and the most serious frequent eye disease in the world.Large-scale retinal screening for diabetic patients is necessary to prevent visual loss and blindness.The analysis of digital retinal images,obtained by the fundus camera,is viewed as a feasible approach because retinal blood vessels have been shown to change in diameter,branching angles,or tortuosity as a result of diabetic retinopathy.The morphological change can help identify the different stages of diabetic retinopathy.In addition,the acquisition of retinal image is nonintrusive and low cost.Automatic segmentation of the retinal blood vessel is a prerequisite for this analysis.1-3 This article presents a method to detect blood vessel based on sobel operators.4 Small and fast computation is the outstanding merit of this method。

Hemodynamic instability plays a major role in the pathogenesis of systemic inflammation,tissue hypoxia,and multiple organ dysfunction syndrome associated with severe acute pancreatitis (SAP).Aggressive fluid replacement is one of the key interventions for the hemodynamic support in severe acute pancreatitis.1Although the need for fluid resuscitation in severe pancreatitis is well established,the goals and components of this treatment are still a matter of debate.We used resuscitation strategies according to early goaldirected therapy (EGDT);we measured the effects of these volume resuscitation on clinical outcomes such as organ function and mortality.Because frozen plasma is cheaper and more easily acquired than albumin for patients,we hypothesized that fluid resuscitation with frozen plasma according to EGDT would be associated with reduced incidence of organ failure and mortality as compared with individuals resuscitated with normal crystalloid and plasma substitute volume resuscitation。

Cervical cancer is the second most common cancer in women worldwide.There is a strong and consistent association of genital HPV infection with cervical cancer and its precancerous lesions.1 This study was undertaken to describe the prevalence of cytological abnormality in relation to HPV infection in general female population of Qujing city,Yunnan province,southwest China。

Syncope is an important problem in clinical practice;however,in nearly one third of cases reported the certain reason of syncope could not be found even with advanced technology.The causes of syncope include reflex mediated,cardiac,neurological and cerebrovascular,but some uncommon causes should be kept in mind to avoid misdiagnosis。

Afifty-year-old male patient was admitted with dyspnoea and cough.Four days before admission,he was episode of dyspnoea,could not prostrate with nonproductive cough when he was offered with a gastroscopy examination in a local hospital due to anepithymia.The patient had no history of medication or allergies.However,he had smoked for more than thirty years-sixty cigarettes per day.Chest distress without haemoptysis,pink frothy sputum,apsychia,amaurosis,and fever was developed。

To the editor:Cryoglobulinaemia is a clinical syndrome caused by cryoglobulin,which is classified into three subtypes.Type Ⅱ and Ⅲ are also named as mixed cryoglobulinaemia (MC),which typically manifests as skin lesions,renal involvement,arthralgia and peripheral neuropathy.1 There were few articles reporting falsepositive serological tests of syphilis in MC.2 Here,we report a patient with peripheral neuropathy caused by cryoglobulinaemia with false-positive syphilis tests。

To the editor:Acute fatty liver of pregnancy (AFLP) is a rare but life-threatening complication of pregnancy.1 The aim of the present study was to explore the clinical feature of AFLP. From January 1996 to January 2012,forty-two cases of AFLP were identified at Beijing Ditan Hospital.Six patients had positive test results for hepatitis B.All patients had an abdominal ultrasound examination,but bright liver were only seen in 25 cases.Four cases were confirmed by liver biopsy。

To the Editor:A 49-year-old man presented with 2-month history of obstructive urinary symptoms and elevated prostatespecific antigen prostate specific antigen (PSA) level (total PSA 6.41 ng/ml,F/T 0.143).The patient had no history of radiation or hormonal therapy.Digital rectal examination revealed a hard prostate and a mass growth to the left side.Pelvic computed tomography revealed a prostatic mass presumably invading the bladder neck (Figure 1A).Intravenous pyelogram showed left ureteral obstruction (Figure 1A)。

To the editor:Since the outbreak of pandemic influenza A (H1N1) virus from the spring of 2009,there is little information about the complete picture of pregnancy and newborn outcomes in the literature.1,2 We followed up a case of a pregnant woman with severe acute respiratory distress syndrome (ARDS) secondary to 2009 H1N1 influenza A,who had extracorporeal membrane oxygenation (ECMO) as a rescue therapy for reversible refractory hypoxemia。

To the editor:We read with great interest the article by Yan and o-author 1 entitled A case of sudden death due to arrhythmogenic right ventricular cardiomyopathy,which was published in the previous issue of Chinese Medical Journal. They presented a case of sudden death due to arrhythmogenic right ventricular cardiomyopathy (ARVC) based on autopsy findings.In lethal cases due to ARVC,they also suggested taking genetic testing as a regular examination to identify their family members who are at risk of ARVC,and seek treatment early.This case gives detailed information and highlights the structural abnormalities and management of the ARVC。