2016年 · 第55卷第09期

With the rapid development of critical care medicine in China, the discipline of critical care medicine is growing day by day. Through the joint efforts of critical care medicine people, the framework of critical care medicine research system has been initially formed. However, the output rate of critical care medicine research is still low, and the gap with the United States is still large. Improving the output rate and influence of critical care medicine research cannot only rely on the existing few high-level researchers and research teams, but requires the joint efforts of my country's critical care medicine department and all critical care medicine people. Professors Huang Liwei and Qiu Haibo were invited to write a monograph "Scientific Research in Critical Care Medicine in China: Innovation and Breakthrough".

Throughout the history of the development of critical care medicine in China, it can be found that at first, the department of critical care medicine established its disciplinary status by virtue of its outstanding treatment level of acute and critical illness, which gradually made the department of critical care medicine the most complex and intensive clinical discipline in monitoring and treatment technology. After more than 20 years of development, with the stage of empirical medicine and evidence-based medicine experienced by modern medicine until today, medicine is entering a new era of precision medicine. Under the environment of constantly changing medical models, it is no longer possible to seek solutions to clinical problems based on experience alone. Therefore, the transformation from monitoring and treatment technology-intensive to scientific research-intensive is the only way for the development of critical care medicine.

Ramipril and Rosiglitazone Reduced Diabetes Rate Evaluation (DREAM) trial since 2006^[1]Since it was shown that hypoglycemic therapy with rosiglitazone significantly increases the incidence of heart failure events in diabetic patients, the cardiovascular safety of hypoglycemic drugs has received increasing attention. In 2008, the U.S. Food and Drug Administration (FDA) emphasized that "in order to establish the safety of new hypoglycemic drugs in the treatment of type 2 diabetes, sponsors should provide evidence that the use of new drugs does not increase the risk of cardiovascular events". Subsequently, the State Food and Drug Administration (CFDA) also issued guidelines for cardiovascular risk assessment of new drugs for the treatment of type 2 diabetes, stating that "for new clinical studies in the planning stage, the sponsor should establish an independent cardiovascular endpoint committee to predetermine the blinded determination of cardiovascular events in all phase II and phase III trials". In recent years, with the continuous clinical trials of new hypoglycemic drugs, most new drugs have not shown to bring clear cardiovascular benefits while lowering blood sugar. On the contrary, some drugs still have cardiovascular safety concerns. Three large-scale clinical trials targeting dipeptidyl peptidase (DPP-4) inhibitors in the treatment of diabetes-the cardiovascular endpoint study of saxagliptin in diabetic patients (SAVOR)^[2]Cardiovascular endpoint study to observe alogliptin and standard of care (EXAMINE)^[3]and Sitagliptin Cardiovascular Endpoint Study (TECOS)^[4]On the basis of the original hypoglycemic therapy, saxagliptin, alogliptin and sitagliptin were compared with placebo, respectively, confirming the cardiovascular safety of long-term treatment with DPP-4 inhibitors, but these hypoglycemic drug treatments did not show clear cardiovascular benefit; In patients with chronic cardiac insufficiency, DPP-4 inhibitors may also cause an increased incidence of heart failure hospitalizations.

Patients with heart disease are often accompanied by psychological problems such as anxiety, tension and depression due to psychological stress and heavy psychological burden, which in turn will increase the incidence and mortality of cardiovascular events. A large number of clinical studies have shown that mental and psychological abnormalities (such as depression and anxiety) are closely related to the high incidence and mortality of coronary heart disease^[1,2,3]。 Therefore, in 2014, the American College of CardiologyCirculationDepressive status was included as one of the independent risk factors for poor prognosis in patients with acute coronary syndrome (ACS) in the scientific statement published on^[4,5]。 Clinical studies have found that approximately 50% of Chinese hospitalized patients with coronary heart disease are complicated by different degrees of anxiety and/or depression, among which women and elderly patients are the high risk groups^[6]。 Percutaneous coronary intervention (PCI) has become one of the main treatments for coronary heart disease. According to statistics, the number of PCI cases completed in China every year is about 500,000, and it is increasing year by year. Its number has become second only to the United States, ranking second in the world; However, patients after PCI often complicate with mental and psychological abnormalities such as anxiety and depression, which affect each other and have seriously affected the prognosis of patients with coronary heart disease after PCI^[7]。

The patient was a 76-year-old female. He was admitted to the Department of Gastroenterology of our hospital for "repeated hematochezia for 1 week"; Physical examination at admission: temperature 36.7℃, pulse 97 beats/min, breathing 22 beats/min, blood pressure 95/65 mmHg (1 mmHg =0.133 kPa). Anemic appearance, clear breathing sounds in both lungs, no dry or wet rales; The heart boundary was enlarged to the left, and a grade 4/6 systolic jet murmur was heard in the first auscultation area of the aortic valve, which was conducted to the neck; The abdomen is soft, the liver and spleen are not large, there is no tenderness and rebound pain, and there is no edema in both lower limbs. Hemoglobin was 65 g/L and red blood cell count was 2.04×10 at admission¹²/L, mean erythrocyte volume (MCV), mean erythrocyte hemoglobin content (MCH) and mean erythrocyte hemoglobin concentration (MCHC) were within the normal range. Its stool is bright red, and it is considered that the possibility of upper gastrointestinal bleeding is small. After admission, colonoscopy showed sigmoid mucosa congestion and vasodilation, but no obvious ulcers and bleeding spots were found. Small intestinal capsule endoscopy also showed no obvious abnormalities. Angiography of the digestive tract showed no vascular malformations and bleeding spots. Prothrombin time (PT) and international normalized ratio (INR) were normal, and APTT was 50.0 s (reference value 31.5-43.5 s). After active hemostasis, fluid rehydration, blood transfusion and other treatments, the blood pressure and hemoglobin content of the patient increased significantly. Echocardiography showed left ventricular hypertrophy, left ventricular ejection fraction (LVEF) 45%; The aortic valve was thickened and calcified, the systolic opening was obviously limited, the valve annulus diameter was 24 mm, the aortic sinus (35 mm) and ascending aorta were widened (42 mm), and the anterior blood flow velocity of the aortic valve was 4.7 m/s. Therefore, the cardiology department of our hospital was invited for consultation. Combined with the patient's history of repeated hematochezia, and the characteristics of no organic lesions found on gastrointestinal angiography and endoscopy, the patient was considered to be Hyde's syndrome, and the von Willebrand factor (vWF) value of macromolecular mass was 33% (reference value 50% ~160%), which confirmed the clinical diagnosis. Because the patient is old and complicated with chronic obstructive pulmonary disease (COPD), diabetes and other chronic diseases, the risk of surgical aortic valve replacement is extremely high, so it is recommended that the patient be transferred to another hospital for transcatheter aortic valve implantation (TAVI). One Venus-A valve was implanted during the operation, and he recovered well. After discharge, the patient came to our hospital again for follow-up, and the vWF value was 89% and LVEF was 56%. He continued to be treated with oral antithrombotic drugs. Since the follow-up, there has been no more events of blood in stool, and many times of occult blood in stool were negative.

The patient was a 43-year-old male. The main cause was "progressive numbness of both lower limbs for 8 years, aggravated with weakness for 1 month" and was admitted to hospital on January 15, 2015. In January 2007, the patient had numbness, distension and pain in both lower limbs without obvious trigger, which could improve after massage. At 2: 00 a.m. on December 10, 2014, when moving things, I suddenly felt weakness in both lower limbs, accompanied by numbness and pain, and the symptoms aggravated after rest. On December 16th, a foreign hospital was diagnosed as "lumbar disc herniation", and he was given mannitol and glucocorticoids (referred to as hormones) for 5 days (details unknown), but the symptoms were further aggravated. On December 21st, the outside hospital considered "myelitis". After two lumbar punctures, dexamethasone was given intravenous drip and intrathecal injection, and the symptoms of weakness and swelling and pain in both lower limbs were still gradually worsening. The patient occasionally had fever since the onset of the disease, with the highest body temperature of 37.4℃, no significant weight loss, good spirit, diet and sleep, dysuria for 2 weeks, and normal stool. Past history: The memory and computing power left after brain trauma in 1979 were slightly poor; Brain trauma caused by car accident in 1996, no sequelae; In December 2014, a hospital diagnosed "left femoral head necrosis" (details unknown).

February 2016MedicineA multicenter study headed by Professor Taisheng Li of Peking Union Medical College Hospital and Professor Chloe L. Thio of Johns Hopkins Hospital, "Association of combined antiretroviral therapy with decreased liver fibrosis fraction in HIV-infected patients" was published online [Li Y, Xie J, Han Y, et al. Combination antiretroviral therapy is associated with reduction in liver fibrosis scores in HIV-1-infected subjects. Medicine (Baltimore), 2016, 95 (5): e2660]. This study is a longitudinal observational study. Using two simple and easily available non-invasive indicators, Aspartate Transaminase to Platelet index (APRI) and FIB-4 (Fibrosis 4 Score), the prevalence of liver Fibrosis and the response of liver Fibrosis to combined antiviral therapy in HIV-infected people in China are reported for the first time.

We often pay too much attention to the effect of diet on blood sugar, and neglect the effect of exercise on blood sugar. Reasonable sports nutrition can greatly reduce blood sugar fluctuations caused by exercise or diet. Excessive fluctuations in blood glucose are the most important risk factors for chronic complications of diabetes. We hope to achieve the goal of maintaining stable blood sugar and preventing and treating complications through structured exercise intervention mode and reasonable diet. Structured exercise intervention is the intervention of multiple exercise combinations formed by reasonably matching the basic needs of health elements in exercise according to physical health, and matching with dietary nutrition.

Delirium is a group of clinical syndromes with acute, fluctuating and extensive cognitive impairment as the main manifestations. It belongs to a kind of mental illness state. Its symptoms include different degrees of consciousness impairment, attention impairment and extensive cognitive impairment (including vivid hallucinations, delusions, etc.), and often accompanied by psychomotor disorders, sleep-wake cycle disorders and other manifestations^[1]。 Delirium can occur in people of all ages, from young children to old age, but the incidence is highest in the elderly population. In recent years, delirium patients aged ≥65 years are often classified into a relatively special group of delirium people, called "senile delirium (Delirium in elderly people) "^[2,3,4]。 It has a higher incidence than non-senile delirium and is particularly severe in the ICU. Epidemiological surveys show that delirium affects more than 50% of elderly hospitalized patients, and the incidence of elderly delirium in ICU can even be as high as 82%^[3,4]。 If senile delirium cannot be identified and intervened in time, it may lead to unplanned removal of tracheal tube, intravenous catheter, surgical drainage tube and other serious clinical adverse events. Besides affecting the treatment of primary disease, it can also prolong the ICU stay, increase the mortality rate of patients, and affect the long-term cognitive function and prognosis of patients^[4,5]。 In European and American countries, the burden of diseases related to senile delirium is increasingly heavy, and the corresponding medical expenses can reach $164 billion to $182 billion per year. There are even professional delirium associations/societies in Europe and the United States, which demonstrate the importance they attach^[4,5]。 With the aging of the global population, the proportion of elderly patients in ICU in European and American countries has exceeded 50%, and this proportion may be higher in my country^[6,7]。 Senile delirium has become a prominent problem that seriously affects the short-term and long-term clinical prognosis of elderly patients in ICU. Therefore, it is necessary to improve the understanding and diagnosis of senile delirium in ICU^[8,9]。

Acute respiratory distress syndrome (ARDS) is a common critical disease causing respiratory failure. Various etiologies lead to systemic inflammatory response, causing the damage of alveolar epithelial cells and pulmonary vascular endothelial cells is its basic pathophysiological changes^[1]Promoting the recovery of injured cells is the fundamental treatment for ARDS. It was found that mesenchymal stem cells (MSC) can regulate systemic inflammatory response and repair alveolar epithelium and vascular endothelial cells damaged by ARDS^[2,3,4]。 However, the homing rate of MSC to injured lung tissue was low^[5]It is a key problem that limits its significant lung repair role. Studies have shown that chemokines mediate cell homing, among which chemokine CXCL12 and its receptor play a prominent role in cell adhesion and trans-endothelial processes^[6,7]。 To investigate the effects of CXCL12 and its receptors on the homing of MSC to lung tissue injured by ARDS may provide new ideas and methods for clinical effective treatment of ARDS.

The infection rate of Helicobacter pylori (Hp) is about 50% worldwide, and the infection rate in some developing countries is as high as 80% ~90%. A survey in China shows that the infection rate of Hp is 56.22%^[1]。 At present, it is believed that Hp infection is related to a variety of digestive and non-digestive diseases, and eradication of Hp has important clinical significance. However, Hp eradication failure is a problem that must be faced in clinical practice, and drug resistance is the main reason for eradication failure. This review aims to systematically search and analyze published reports of resistance of adult Hp to commonly used clinical antimicrobial drugs in mainland China, so as to better guide clinical eradication treatment.

tenofovir disoproxil fumarate (TDF) is a nucleotide reverse transcriptase inhibitor (NRTIs). After oral absorption, it degrades to the active substance tenofovir, which is then converted to the active metabolite tenofovir bisphosphate. The latter can exert anti-HIV effects by directly and competitively binding to natural deoxyribose substrates to inhibit viral reverse transcriptase, and inserting into DNA to terminate DNA strands. Because of its strong antiviral activity and good safety, TDF has been recommended by many countries as a first-line therapeutic drug for widespread use since the US Food and Drug Administration (FDA) approved it for HIV-infected patients in 2001. The Chinese government approved TDF as the first-line treatment for HIV-infected patients in 2012. During use, TDF has been reported to be related to proximal tubular injury and acute renal failure including decreased glomerular filtration rate, including Fanconi syndrome (also known as multiple tubular dysfunction syndrome, manifested as renal glycosuria, aminoaciduria, hypercalcuria, hypophosphatemia, hypouricemia, hypokalemia, hypocalcemia, etc.), and its nephrotoxicity has received wide attention. The research progress of TDF in renal safety, nephrotoxicity mechanism and nephrotoxicity monitoring in HIV-infected patients is summarized as follows.

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