2017年 · 第56卷第12期

For many years, the assessment of cardiac function is usually centered on the left heart, while the assessment of the right heart is often neglected. The right heart is the end point of venous return, and all blood needs to pass through the right heart to overcome pulmonary resistance before it can be presented to the left heart. The right heart shares a ventricular septum with the left heart, and the increase in volume or pressure of the right heart is transmitted to the left heart through the ventricular septum, thus affecting the ejection of the left heart. Therefore, it is particularly important to evaluate the right ventricular function and clarify the influence of the right ventricular on the left ventricular and even the whole circulatory system. With the progress of theory and practice of severe hemodynamic therapy, it has been gradually realized that compared with left ventricular function involvement, right ventricular function involvement is more common in severe diseases. If the involvement is severe or fails to be corrected in time, it will enter a vicious circle of spontaneous deterioration, causing severe hemodynamic fluctuations and consequences. Therefore, the Severe Hemodynamic Therapy Collaborative Group consulted a large number of literatures, extensively solicited opinions and suggestions, and organized and formed the "Expert Consensus on the Management of Right Ventricular Function in Severe Cases" according to the internationally accepted methods. In conjunction with the publication of the consensus, Professor Liu Dawei was invited to write a monograph "Right Heart Function: From Behind the Scenes to the Foreground".

The right heart, as an integral part of the heart, seems to have become familiar over the years. However, due to the limitation of clinical observation indicators and direct intervention means, the management of right ventricular function has always kept a considerable distance from clinical medical treatment. In recent years, due to the progress of hemodynamic research, the discovery and recognition of clinical monitoring indicators, the evaluation and management of right ventricular function have demonstrated the importance of scientific research and clinical medical treatment, and have become an unavoidable problem in current clinical work.

At present, chronic lymphocytic leukemia (CLL) is still an incurable disease. With CD₂₀The emergence of monoclonal antibodies started the era of immunochemotherapy based on rituximab (R) for CLL.

The patient was a 21-year-old male, Han nationality. He was admitted to hospital on July 17, 2014 for "progressive limb weakness, atrophy for 8 years and breathing difficulty for 2 weeks". Eight years ago (13 years old), the patient had no obvious inducement to feel weakness in the limbs, which was obvious after activity, and it was laborious to go up stairs and lift heavy objects. The muscles of the limbs and body were slightly atrophied, and there was no sensation of flesh jumping, no numbness and other sensory abnormalities, and no dysphagia. Five years ago, the feeling of weakness and atrophy progressively aggravated, the muscle strength decreased significantly, the inability to do pull-ups, the gradual difficulty of squat, accompanied by obvious weight loss. Visited the local hospital, the serum muscle enzyme test was significantly elevated, and the electromyogram showed tonic potential. Considering tonic muscle dystrophy, checkDM1There were no genetic abnormalities. The patient's weakness symptoms gradually worsened, and in the past 2 weeks, he had no inducement to breathe and suffocate, so he was admitted to the hospital for further diagnosis and treatment. The patient has no symptoms such as muscle stiffness and cold environment stiffness since the onset of the disease. Past physical health, no history of similar diseases in the family. Physical examination: body temperature 36.5 ℃, pulse 80 beats/min, breathing 18 beats/min, blood pressure 90/70 mmHg (1 mmHg =0.133 kPa); Height 175 cm, weight 45 kg, BMI 14.69 kg/m²； The spirit is clear and the language is sharp, the body is thin and malnourished; Poor thoracic mobility, weak cough, coarse breathing sounds in both lungs, and no dry and wet rales; Heart Rhythm Qi; There was muscular atrophy in the distal and proximal extremities and trunk muscles, without tenderness, low muscle tone in the extremities, and slightly weak strength in raising the head (5^－Grade), both upper extremities proximal muscle strength grade 3, distal muscle strength grade 4, both lower extremities proximal muscle strength grade 3⁺Grade, distal muscle strength grade 4, positive Gower sign, tendon reflex of limbs (+), no abnormalities in sensory and co-taxic examinations.

The patient was a 37-year-old male. He was admitted to our hospital on June 15, 2016 due to "repeated dizziness and fatigue for more than 1 year". The patient developed dizziness, fatigue and facial edema without obvious trigger 1 year ago, and did not see a doctor. Five months ago, I suffered from "pneumonia and respiratory failure" and was given methylprednisolone 40 mg/d continuously for 8 days in the local hospital. Three months ago, limbs edema began, one month ago because of "centripetal obesity" to the local hospital, after two tests of serum cortisol and 24-h urine free cortisol (24hUFC) results were increased and normal, respectively (Table 1), suspected to be related to the use of the exogenous glucocorticoid methylprednisolone. 10 days ago, due to increased blood pressure (180/110 mmHg, 1 mmHg =0.133 kPa), I went to the local doctor, and re-examination found that serum cortisol and 24 hUFC were significantly increased (Table 1), thyroid stimulating hormone, luteinizing hormone, follicle stimulating hormone all decreased, serum potassium 2.92 mmol/L; MRI of pituitary gland showed slightly full morphology; Thoracic and abdominal CT showed bilateral adrenal hyperplasia, so he was transferred to our hospital with "Cushing's syndrome to be examined". The patient gained 5 kg in weight in the last 1 year. A 12-year history of previous sexual dysfunction.

Top Life Sciences Magazines for July 2017CellThe research of Professor Fang Jingyuan, Renji Hospital affiliated to Shanghai Jiaotong University School of Medicine and Shanghai Institute of Digestive Diseases and State Key Laboratory of Oncogenes and Related Genes, "Fusobacterium nucleatum promotes chemoresistance in colorectal cancer by regulating autophagy" was published [Yu T, Guo F, Yu Y, et al.Fusobacterium nucleatumpromotes chemoresistance to colorectal cancer by modulating autophagy. Cell, 2017, 170 (3): 548-563.]. This study takes the clinical problem of chemotherapy resistance as the starting point, and systematically studies Fusobacterium nucleatum from bioinformatics, genomics, molecular biology and in vivo animal models (Fusobacterium nucleatum, Fn) on the effect of postoperative chemotherapy in patients with colorectal cancer (CRC) and its molecular mechanism.

stroke mimic refers to a group of clinical syndromes that have symptoms similar to stroke attacks (such as hemiplegia, aphasia, disorders of consciousness, etc.) at admission and are clearly diagnosed as diseases other than acute ischemic stroke at discharge^[1](such as hemiplegic migraine, reversible posterior encephalopathy, hypoglycemia, etc.), which is not uncommon in clinical work. Todd's paralysis is a transient mild hemiplegia left after epileptic seizure, and it is also a kind of stroke simulation disease, which is prone to misdiagnosis and misdiagnosis. Based on the diagnosis and treatment of a patient with Todd's paralysis, this paper analyzes and summarizes it.

The incidence of coronary heart disease is increasing year by year in China, which seriously endangers people's health. Ischemic chest pain, namely "angina pectoris", is the main clinical manifestation of coronary heart disease. It is typically manifested as precordial or retrosternal squeezing pain induced by physical activity or emotional excitement, which can radiate to the left shoulder, arm, even the little finger and ring finger, and can also radiate to the neck, jaw, teeth, abdomen, etc. A few atypical symptoms only present as radiation site symptoms, such as toothache, sore throat, headache, etc., which are often misdiagnosed and missed. The term "cardiac cephalgia" was developed by Lipton et al.^[1]First proposed in 1997, it is a rare disease caused by underlying coronary artery (coronary) disease presenting as exertion headache with or without chest symptoms. Both of the two male patients reported by Lipton presented with exertion headache, which could be repeated with transient ST-segment changes in the ECG when exercise stress tests were performed. Coronary angiography confirmed three-vessel coronary disease, and headache symptoms were relieved after treatment for coronary artery disease. Because this part of patients may have a low overall prevalence, often lack typical angina manifestations, and may be difficult to distinguish from headaches caused by other causes, often causing delays in diagnosis and treatment, thus affecting the prognosis of patients. The following briefly introduces the epidemiology, etiology, clinical manifestations, diagnosis and treatment of cardiogenic headache, hoping to improve the understanding of medical staff and provide timely diagnosis and treatment for this part of patients.

Liver failure is a group of clinical syndromes mainly manifested by coagulation dysfunction, jaundice, infection, hepatic encephalopathy, hepatorenal syndrome, and even multiple organ failure, resulting in massive necrosis of liver cells due to various factors that damage the liver, resulting in serious impairment or decompensation of liver synthesis, detoxification, excretion and biotransformation. The disease of liver failure is critical and progresses rapidly. At present, there is a lack of specific treatment, and the clinical mortality rate is as high as over 60%. Although liver transplantation can effectively improve the prognosis of some patients, its widespread promotion in clinical practice is limited by its high cost, scarcity of liver source and long-term immunosuppression risk. Therefore, there is an urgent need for more effective therapeutic drugs and means in clinical practice. In recent years, a series of studies have found that granulocyte colony stimulating factor (G-CSF), as an effective mobilizer of bone marrow stem cells (BMSCs), can not only specifically regulate granulocyte proliferation and differentiation, enhance the function of mature granulocytes, but also mobilize bone marrow CD₃₄₊Stem cells release and migrate into the liver to promote the regeneration and differentiation of liver stem cells^[1]And by regulating various immune cell functions and signal transduction pathways in the liver, assisting in the recovery of liver function of end-stage liver disease represented by liver failure and reducing its short-term mortality rate^[2,3]This provides a new drug choice and hope for the clinical treatment of liver failure. However, there is still lack of sufficient evidence to show that G-CSF can affect the prognosis of patients with liver failure, especially the ideal timing, dosage, course of treatment and suitable population need to be clarified and standardized. This paper reviews the application progress and related mechanisms of G-CSF in the treatment of end-stage liver disease represented by liver failure in recent years, in order to evaluate the advantages and disadvantages of G-CSF in patients with liver failure, and provide evidence for clinical choice of G-CSF in the treatment of liver failure.

Idiopathic inflammatory myopathy (IIMs) is a heterogeneous disease characterized by proximal symmetric myasthenia and multiple organ involvement, mainly including polymyositis, dermatomyositis, immune-mediated necrotizing myopathy (IMNM), sporadic inclusion body myositis (sIBM) and juvenile idiopathic myositis (JIM) and other clinical subtypes. At present, the pathogenesis of IIMs is unclear, and there is evidence that the pathogenesis is related to autoimmunity: (1) Histopathological examination showed that T cells, macrophages, dendritic cells, B cells and plasma cells appeared in the muscle tissue of the patient; (2) Serum testing found that>50% of IIMs patients had autoantibodies against nuclear and cytoplasmic components. According to the diagnostic value of autoantibodies for IIMs, myositis-related autoantibodies are divided into two categories: myositis-specific autoantibodies (MSAs) and myositis-related autoantibodies (MAAs). MSAs can be associated with specific clinical subtypes, which can help predict complications, assist in the diagnosis, prognosis and selection of correct treatment strategies of myositis. In recent years, more and more MSAs have been discovered. The MSAs currently found in the serum of myositis patients and their relationship with clinical practice are reviewed below.

To establish the experts consensus on the right heart function management in critically ill patients. The panel of consensus was composed of 30 experts in critical care medicine who are all members of Critical Hemodynamic Therapy Collaboration Group (CHTC Group). Each statement was assessed based on the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) principle. Then the Delphi method was adopted by 52 experts to reassess all the statements. (1) Right heart function is prone to be affected in critically illness, which will result in a auto-exaggerated vicious cycle. (2) Right heart function management is a key step of the hemodynamic therapy in critically ill patients. (3) Fluid resuscitation means the process of fluid therapy through rapid adjustment of intravascular volume aiming to improve tissue perfusion. Reversed fluid resuscitation means reducing volume. (4) The right ventricle afterload should be taken into consideration when using stroke volume variation (SVV) or pulse pressure variation (PPV) to assess fluid responsiveness.(5)Volume overload alone could lead to septal displacement and damage the diastolic function of the left ventricle. (6) The Starling curve of the right ventricle is not the same as the one applied to the left ventricle,the judgement of the different states for the right ventricle is the key of volume management. (7) The alteration of right heart function has its own characteristics, volume assessment and adjustment is an important part of the treatment of right ventricular dysfunction (8) Right ventricular enlargement is the prerequisite for increased cardiac output during reversed fluid resuscitation; Nonetheless, right heart enlargement does not mandate reversed fluid resuscitation.(9)Increased pulmonary vascular resistance induced by a variety of factors could affect right heart function by obstructing the blood flow. (10) When pulmonary hypertension was detected in clinical scenario, the differentiation of critical care-related pulmonary hypertension should be a priority. (11) Attention should be paid to the change of right heart function before and after implementation of mechanical ventilation and adjustment of ventilator parameter. (12) The pulmonary arterial pressure should be monitored timingly when dealing with critical care-related pulmonary hypertension accompanied with circulatory failure.(13) The elevation of pulmonary aterial pressure should be taken into account in critical patients with acute right heart dysfunction. (14) Prone position ventilation is an important measure to reduce pulmonary vascular resistance when treating acute respiratory distress syndrome patients accompanied with acute cor pulmonale. (15) Attention should be paid to right ventricle-pulmonary artery coupling during the management of right heart function. (16) Right ventricular diastolic function is more prone to be affected in critically ill patients, the application of critical ultrasound is more conducive to quantitative assessment of right ventricular diastolic function. (17) As one of the parameters to assess the filling pressure of right heart, central venous pressure can be used to assess right heart diastolic function. (18). The early and prominent manifestation of non-focal cardiac tamponade is right ventricular diastolic involvement, the elevated right atrial pressure should be noticed. (19) The effect of increased intrathoracic pressure on right heart diastolic function should be valued. (20) Ttricuspid annular plane systolic excursion (TAPSE) is an important parameter that reflects right ventricular systolic function, and it is recommended as a general indicator of critically ill patient. (21) Circulation management with right heart protection as the core strategy is the key point of the treatment of acute respiratory distress syndrome. (22) Right heart function involvement after cardiac surgery is very common and should be highly valued. (23) Right ventricular dysfunction should not be considered as a routine excuse for maintaining higher central venous pressure. (24) When left ventricular dilation, attention should be paid to the effect of left ventricle on right ventricular diastolic function. (25) The impact of left ventricular function should be excluded when the contractility of the right ventricle is decreased. (26) When the right heart load increases acutely, the shunt between the left and right heart should be monitored. (27) Attention should be paid to the increase of central venous pressure caused by right ventricular dysfunction and its influence on microcirculation blood flow. (28) When the vasoactive drugs was used to reduce the pressure of pulmonary circulation, different effects on pulmonary and systemic circulation should be evaluated. (29) Right atrial pressure is an important factor affecting venous return. Attention should be paid to the influence of the pressure composition of the right atrium on the venous return. (30) Attention should be paid to the role of the right ventricle in the acute pulmonary edema. (31) Monitoring the difference between the mean systemic filling pressure and the right atrial pressure is helpful to determine whether the infusion increases the venous return. (32) Venous return resistance is often considered to be a insignificant factor that affects venous return, but attention should be paid to the effect of the specific pathophysiological status, such as intrathoracic hypertension, intra-abdominal hypertension and so on. Consensus can promote right heart function management in critically ill patients, optimize hemodynamic therapy, and even affect prognosis.

[Resource Type]Professional journals

[Resource Type]Professional journals