2019年 · 第132卷第10期

Mammals have existed on Earth for millions of years. During this long period, mammals and their gut commensal microbes have coevolved and coadapted, forming a complex and inseparable interrelationship called "superorganisms." On the one hand, the food and gut environment play an important role in shaping the composition and function of gut microbiota. On the other hand, gut microbiota actively participates in host nutrition metabolism and profoundly affect host immunity. However, this natural coevolving process has been significantly changed in recent decades by antibiotic administration. Although antibiotic therapy is considered as a milestone in fighting infectious diseases, its negative effects on gut microbiota and host health have been recognized. Here, we will discuss the unfavorable effects and underlying mechanism of antibiotics on gut microbiota and host immunity, as well as possible solutions to reverse adverse effects brought about by antibiotic treatment.

Increased extravascular lung water (EVLW) in shock is common in the critically ill patients. This study aimed to explore the effect of cardiac output (CO) on EVLW and its relevant influence on prognosis.

The hemodynamic data of 428 patients with pulse-indicated continuous CO catheterization from Department of Critical Care Medicine, Peking Union Medical College Hospital were retrospectively collected and analyzed. The patients were assigned to acute respiratory distress syndrome group, cardiogenic shock group, septic shock group, and combined shock (cardiogenic and septic) group according to their symptoms. Information on 28-day mortality and renal function was also collected.

The CO and EVLW index (EVLWI) in the cardiogenic and combined shock groups were lower than those in the other groups (acute respiratory distress syndrome group vs. cardiogenic shock group vs. septic shock group vs. combined shock group: CO, 5.1 [4.0, 6.2] vs. 4.7 [4.0, 5.7] vs. 5.5 [4.3, 6.7] vs. 4.6 [3.5, 5.7] at 0 to 24 h, P=0.009; 4.6 [3.8, 5.6] vs. 4.8 [4.1, 5.7] vs. 5.3 [4.4, 6.5] vs. 4.5 [3.8, 5.3] at 24 to 48 h, P=0.048; 4.5 [4.1, 5.4] vs. 4.8 [3.8, 5.5] vs. 5.3 [4.0, 6.4] vs. 4.0 [3.2, 5.4] at 48 to 72 h, P=0.006; EVLWI, 11.4 [8.7, 19.1] vs. 7.9 [6.6, 10.0] vs. 8.8 [7.4, 11.0] vs. 8.2 [6.7, 11.3] at 0 to 24 h, P < 0.001; 11.8 [7.7, 17.2] vs. 7.8 [6.3, 10.2] vs. 8.7 [6.6, 12.2] vs. 8.0 [6.6, 11.1] at 24 to 48 h, P < 0.001; and 11.3 [7.7, 18.7] vs. 7.5 [6.3, 10.0] vs. 8.8 [6.3, 12.2] vs. 8.4 [6.4, 11.2] at 48 to 72 h, P < 0.001. The trend of the EVLWI in the septic shock group was higher than that in the cardiogenic shock group (P < 0.05). Moreover, there existed some difference in the pulmonary vascular permeability index among the cardiogenic shock group, the septic shock group, and the combined shock group, without statistical significance (P > 0.05). In addition, there was no significant difference in tissue perfusion or renal function among the four groups during the observation period (P > 0.05). However, the cardiogenic shock group had a higher 28-day survival rate than the other three groups [log rank (Mantel-Cox) = 31.169, P < 0.001].

Tissue-aimed lower CO could reduce the EVLWI and achieve a better prognosis.

Sepsis-3 definitions have been published recently; however, their diagnostic value remains controversial. This study was to assess the accuracy of Sepsis-3 definitions compared to Sepsis-1 definitions by stratifying mortality among adult critically ill patients with suspected infection.

A multicenter, prospective cohort study was conducted from November 10, 2017 to October 10, 2018, in five Intensive Care Units (ICUs) at four teaching hospitals. Thirty-day mortality was compared across categories for both Sepsis-3 definitions and Sepsis-1 definitions, which were evaluated by logistic regression analysis followed by measurement of the area under the receiver operating characteristic curve (AUROC) for predicting 30-day mortality rates.

Of the 749 enrolled patients, 644 (85.9%) were diagnosed with sepsis according to the Sepsis-1 definitions. Among those patients, 362 were diagnosed with septic shock (362/749, 48.3%). However, according to the Sepsis-3 definitions, there were 483 patients with a diagnosis of sepsis (483/749, 64.5%), among whom 299 patients were diagnosed with septic shock (299/749, 39.9%). According to the Sepsis-3 definitions, sepsis (sepsis and septic shock) patients had higher 30-day mortality (41.8%) than sepsis patients according to the Sepsis-1 definitions (31.8%, χ² = 5.552, P = 0.020). The AUROC of systemic inflammatory response syndrome (SIRS) and quick sequential organ failure assessment (qSOFA) scores with regard to 30-day mortality rates were 0.609 (0.566–0.652) and 0.694 (0.654–0.733), respectively. However, the AUROC of SOFA scores (0.828 [0.795–0.862]) were significantly higher than that of SIRS or qSOFA scores (P < 0.001).

In adult critically ill patients with suspected infection, the Sepsis-3 definitions were relatively accurate in stratifying mortality and were superior to the Sepsis-1 definitions.

www.chictr.org.cn (ChiCTR-OOC-17013223).

At present, there is no available delirium translated assessment method for 3.3 million Tibetans. This study aimed to provide a method for delirium assessment for Tibetan patients speaking this language by validating a translation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).

The study was conducted between July 2018 and November 2018. Patients were screened for delirium by a neurologist using the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV). Patients were subsequently screened by two nurses using Tibetan translations of the CAM-ICU. With DSM-IV criterion as the reference standard, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated to assess the validity of the CAM-ICU criterion. Interrater reliability was determined by comparing the CAM-ICU ratings of nurse 1 vs. nurse 2 using the κ coefficient.

Ninety-six patients were assessed independently by two nurses and one neurologist. According to DSM-IV standard, 42 out of 96 (43.8%) patients developed delirium. The sensitivities of Tibetan CAM-ICU were 90.5% for nurse 1 and 92.9% for nurse 2, respectively. Their specificities were 85.2% and 90.7%, respectively. The PPV were 82.6% for nurse 1 and 88.6% for nurse 2. Their NPV were 92.0% and 94.2%, respectively. The Tibetan CAM-ICU was done with good interrater reliability between nurse 1 and nurse 2 (κ= 0.91, P < 0.001).

The Tibetan CAM-ICU shows good validity and might be incorporated into clinical practice in Tibetan Intensive Care Units.

www.chictr.org.cn (No. ChiCTR1800018231)

New definitions for sepsis and septic shock (Sepsis-3) were published, but the strategy to adjust vasopressors after the initial guidelines is still unclear. We conducted a retrospective observational study to explore dosing strategy of norepinephrine (NE).

A retrospective observational study in the 15-bed mixed intensive care unit of a tertiary care university hospital. The study was performed on septic shock patients after 30 mL/kg fluid resuscitation and mean arterial pressure (MAP) levels reached >65 mmHg requiring NE. We divided patients into NE dosage increase and decrease groups, and collected hemodynamic and tissue perfusion parameters before (T1) and after (T2) adjusting NE dosage.

In both NE increase and decrease groups, central venous pressure (CVP) and pressure difference between usual MAP and MAP (dMAP) at the T1 time point were associated with lactate clearance. In groups LC HM (CVP <10 mmHg, dMAP > 0 mmHg) and HC HM (CVP ≥ 10 mmHg, dMAP > 0 mmHg), decrease in NE dosage decreased lactate level, while in group HC LM (CVP ≥ 10 mmHg, dMAP≤0 mmHg), both increase and decrease in NE dosage led to increase lactate level.

After patients with septic shock (Sepsis-3) resuscitated to reach the initial recovery target goals, combination of CVP and MAP refer to usual levels can help doctors make the next decision to make the correct choice of increase NE dosage or decrease NE dosage.

Carbapenem-resistant Acinetobacter baumannii (CRAB) have been a challenging concern of health-care associated infections. The aim of the current study was to investigate the molecular epidemiology and clonal dissemination of CRAB isolates in a Chinese teaching hospital.

Non-duplicate clinical A. baumannii isolates were collected from inpatients, and we measured the minimal inhibitory concentrations to determine antimicrobial susceptibility. Polymerase chain reaction (PCR) and sequencing were performed to detect carbapenem-resistance genes and occurrence of transposons among CRAB isolates. Moreover, the genetic diversity among isolates and clonal dissemination were determined by repetitive element PCR-mediated DNA fingerprinting (rep-PCR) and multilocus sequence typing (MLST).

A total of 67 CRAB isolates displayed resistance to most of the antibiotics tested in this study, except tigecycline. We detected bla_OXA-23, bla_OXA-51, bla_OXA-58, and bla_VIM genes in 94.0%, 100.0%, 1.5%, and 80.6% of the CRAB isolates, respectively. Nevertheless, 74.6% of the CRAB isolates co-harbored the bla_OXA-23 and bla_VIM. Only one type of transposons was detected: Tn2008 (79.1%, 53/67). Although 12 distinctive types (A-L) were determined (primarily A type) ST195 was the most prevalent sequence type (ST). ST368, ST210, ST90, ST829, and ST136 were also detected, and all belonged to clonal complex 208 (CC208) and global complex 2 (GC2).

The bla_OXA-23 and bla_VIM genes contributed to the resistance among CRAB isolates collected in our study. Notably, most of the CRAB strains co-harbored bla_OXA-23 and bla_VIM genes, as well as Tn2008, which could contribute to clonal dissemination. The prevalence of such organisms may underlie hospital acquired infections.

The use of mobile phone significantly improved the outcomes of tobacco cessation. However, its feasibility and acceptability were unclear in the Chinese population. This study was to explore the feasibility of using Wi-Fi access points (APs) as a platform to provide smoking cessation help at 17 airports and 38 railway stations across China.

This study was divided into two stages: platform development and population survey. In the first stage, a survey platform was developed and incorporated into Wi-Fi service at airports and railway stations, which could provide survey content as a pop-up window when participants tried to access the Wi-Fi service. In the second stage, a population survey was conducted to explore the intention to receive tobacco cessation support.

A total of 20,199 users participated and 13,628 users submitted the survey, with a response rate of 67.47%. The smoking rate was 30.9%. A total of 86.58% of smoking participants and 2.44% of non-smoking participants wished to receive tobacco cessation support, respectively. The multivariate analysis showed intention to receive support did not differ in age, gender, and heaviness of smoking (P > 0.05).

Providing tobacco cessation support via Wi-Fi APs is feasible and efficient, and smokers have high intention to receive tobacco cessation support. It is suggested hospitals, academia, information technology industries, and government agencies must work together to provide tobacco cessation support via mHealth.

Antibiotics are frequently used to treat critically ill patients, and its use is often accompanied by intestinal dysbiosis that might further lead to bacterial translocation (BT). Nevertheless, studies on the relationship between antibiotic therapy and BT are rare. In the present study, we investigated the effect of broad-spectrum antibiotics on BT in an experimental rat model of burn or sepsis injury.

The septic rat model was simulated by a second insult with lipopolysaccharides after burn injury. Ninety-two male Sprague-Dawley rats were randomly divided into control, burn, and sepsis groups (n = 8 or 9, each group), and the latter two groups were then treated with imipenem or ceftriaxone for 3 or 9 days. The mesenteric lymph nodes, liver, lungs, and blood were collected at each time point under sterile conditions for quantitative bacterial culture and strain identification. The differences between the groups were compared by Fisher exact test or Mann-Whitney U test.

Only minimal Escherichia coli translocation to the mesenteric lymph nodes was observed in the normal control group, in which the BT rate was 12.5%. Burn injury did not affect the BT rate (Burn group vs. Control group, 12.5% vs. 12.5%, P = 1.000), whereas the BT rate showed an increased trend after the second insult with lipopolysaccharide (Sepsis group vs. Control group, 44.4% vs. 12.5%, P = 0.294), and many strains of Enterobacteria spp. were detected in distant organs (liver, lung, and blood) [Sepsis group vs. Control group, 0 (0,3) vs. 0 (0,0), U = 20, P = 0.045]. After the antibiotic treatment, BT to the distant organs was increased in burned rats [Burn IT3 group vs. Burn group, 0 (0,2) vs. 0 (0,0); Burn IT9 group vs. Burn group, 0 (0,1) vs. 0 (0,0); Burn CT9 group vs. Burn group, 0 (0,2) vs. 0 (0,0); all U = 20 and P = 0.076] but decreased in septic rats [Sepsis CT3 group vs. Sepsis group, 0 (0,0) vs. 0 (0,3), U = 20, P = 0.045]. The total amount of translocated bacteria, regardless of which antibiotic was used, was increased in burned rats [Burn IT9 group vs. Burn group, 2.389 (0,2.845) vs. 0 (0,2.301) Log₁₀ colony-forming units (CFU)/g, U = 14, P = 0.034; Burn CT3 group vs. Burn group, 2.602 (0,3.633) vs. 0 (0,2.301) Log₁₀ CFU/g, U = 10.5, P = 0.009], but there was a slightly decreased trend in septic rats [Sepsis IT9 group vs. Sepsis group, 2.301 (2,3.146) vs. 0 (0,4.185) Log₁₀ CFU/g, U = 36, P = 0.721; Sepsis CT9 group vs. Sepsis group, 2 (0,3.279) vs. 0 (0,4.185) Log₁₀ CFU/g, U = 32.5, P = 0.760]. Remarkably, the quantity of Enterococci spp. dramatically increased after broad-spectrum antibiotic treatment in both the burned and septic groups [Burn IT3 group vs. Burn group, 1 (0,5.164) vs. 0 (0,0) Log₁₀ CFU/g, U = 16; Burn IT9 group vs. Burn group, 1 (0,2.845) vs. 0 (0,0) Log₁₀ CFU/g, U = 16; Burn CT3 group vs. Burn group, 2.602 (0,3.633) vs. 0 (0,0) Log₁₀ CFU/g, U = 8; Burn CT9 group vs. Burn group, 1 (0,4.326) vs. 0 (0,0) Log₁₀ CFU/g, U = 16; Sepsis IT3 group vs. Sepsis group, 2.477 (0,2.903) vs. 0 (0,0) Log₁₀ CFU/g, U = 4.5; Sepsis IT9 group vs. Sepsis group, 2 (0,3.146) vs. 0 (0,0) Log₁₀ CFU/g, U = 9; Sepsis CT3 group vs. Sepsis group, 1.151 (0,2.477) vs. 0 (0,0) Log₁₀ CFU/g, U = 18; Sepsis CT9 group vs. Sepsis group, 2 (0,3) vs. 0 (0,0) Log₁₀ CFU/g, U = 13.5; all P < 0.05].

Broad-spectrum antibiotics promote BT in burned rats but prevent BT in septic rats, especially preventing BT to distant organs, such as the liver and lung. Moreover, Enterococci spp. with high drug resistance and high pathogenicity translocated most after antibiotic treatment.

It is important to modulate the expression of glucocorticoids receptor (GR) in tress and maintain the immunity homeostasis in sepsis process. Rhubarb have been shown to have potential effects on anti-inflammatory and immune modulation. The present study was designed to investigate the effects of rhubarb on the expression of GR and cellular immunity in burn-induced septic rats.

Sixty-six healthy male Sprague Dawley (SD) rats were randomized into sepsis group (n = 24), rhubarb group (n = 24), and control group (n = 18); each group were further randomized into 12, 24, and 72 h subgroups according to different time points. During onset of the sepsis model, the rats in the rhubarb group were infused with 50 mg/kg rhubarb powder dissolved into 1 mL saline through gastric tube, while sepsis and control groups were treated with saline. The binding activity of GR in liver cytosol and binding capacity of GR in peripheral blood leucocyte were analyzed by radiation ligands binding assay. The percentages of CD4⁺, CD8⁺,CD4⁺CD25⁺T cells, CD19⁺B cells as well as natural killer (NK) cells in the lymphocytes in peripheral blood were detected by flow cytometer. For assessing the differences among groups, one-way analysis of variance (ANOVA) with Scheffe multi-comparison techniques were employed. Comparisons between time-based measurements within each group were performed with ANOVA repeated measurement.

The binding activity of GR in liver cytosol and binding capacity of GR in peripheral blood leucocyte were significantly decreased in a time-dependent manner in sepsis group (t = 23.045, P < 0.01; t = 24.395, P < 0.05, respectively), which were increased in a time-dependent manner after rhubarb administration (t = 19.965, P < 0.05; t = 17.140, P < 0.05, respectively). Twelve hours after sepsis, the percentages of CD4⁺ T cells, CD4⁺/CD25⁺ T cell ratio, and CD19⁺ B cells in the peripheral blood were significantly increased in the sepsis group (t = -3.395, P < 0.01; t = 2.568, P < 0.05; t = 2.993, P < 0.05, vs. control mice, respectively). However, the percentage of NK cells in the peripheral blood were significantly decreased in the sepsis group (t = -2.022, P < 0.05, vs. control mice). Twelve hours after sepsis, the percentage of CD8⁺ T cells were significantly decreased in the peripheral blood in the sepsis group (t = -2.191, P < 0.05, vs. control mice) and were significantly increased in the rhubarb group (t = 2.953, P < 0.05, vs. sepsis mice). Seventy-two hours after sepsis, the ratio of CD4⁺/CD25⁺ T cell in peripheral blood were significantly increased in the sepsis group (t = 2.508, P < 0.05, vs. control mice) while were significantly decreased in the rhubarb group (t = 3.378, P < 0.05, vs. control mice). Furthermore, the percentages of CD19⁺ B cell in peripheral blood were significantly decreased at 72 h in the rhubarb group (t = 2.041, P < 0.05 vs. sepsis group).

Rhubarb might play potential anti-inflammatory and immunomodulatory roles in the sepsis processes.

Estradiol, as an important hormone in follicular development and endometrial receptivity, is closely related to clinical outcomes of fresh in vitro fertilization embryo transfer (IVF-ET) cycles. The aim of this retrospective study was to evaluate the association between elevated serum estradiol (E₂) levels on the day of human chorionic gonadotrophin (hCG) administration and IVF-ET pregnancy and birth outcomes.

A total of 1771 infertile patients with their first fresh IVF-ET cycles were analyzed retrospectively between January 2011 and January 2016 in Peking University First Hospital. Patients were categorized by serum E₂ levels on the day of hCG administration into six groups: group 1 (serum E₂ levels ≤ 1000 pg/mL, n = 205), group 2 (serum E₂ levels 1001–2000 pg/mL, n = 457), group 3 (serum E₂ levels 2001–3000 pg/mL, n = 425), group 4 (serum E₂ levels 3001–4000 pg/mL, n = 310), group 5 (serum E₂ levels 4001–5000 pg/mL, n = 237), and group 6 (serum E₂ levels > 5000 pg/mL, n = 137). The retrieved oocyte and MII oocyte numbers and implantation and clinical pregnancy rates of the groups were compared as the first objective of the study. For the 360 women with singleton births among all patients, the area under the corresponding receiver operating characteristic curve (ROC curve) was calculated to assess the predictive value of the E₂ change for the probability of low birth weight (LBW) infants as the second objective.

The retrieved oocyte and MII oocyte numbers and implantation and clinical pregnancy rates gradually increased from groups 1 to 5 but decreased in group 6. The parameters of group 1 were statistically worse than those of the other groups, from group 2 to group 6 (the number of retrieved oocytes, t = 13.096, t = 23.307, t = 23.086, t = 26.376, t = 19.636, P < 0.003; the number of retrieved MII oocytes, t = 10.856, t = 20.868, t = 21.874, t = 23.374, t = 19.092, P < 0.003; the implantation rate, χ² = 12.179, χ² = 22.239, χ² = 23.993, χ² = 23.344, χ² = 16.758, P < 0.003; the clinical pregnancy rate, χ² = 16.415, χ² = 28.074, χ² = 35.387, χ² = 37.025, χ² = 24.590, P < 0.003). ROC analysis revealed that when a serum peak E₂ of 3148 pg/mL was used to predict LBW.

The results indicate that serum E₂ levels have a concentration-dependent effect on clinical outcomes. The optimal range of the E₂ level during a fresh IVF-ET cycle is 1000 to 3148 pg/mL.

Chronic progressive external ophthalmoplegia (CPEO) is a mitochondrial encephalomyopathy caused by multiple mtDNA abnormalities. There is little information about the changes of ocular fundus with CPEO. The aim of this work was to measure and evaluate changes in the macular retinal thickness and optic nerve head in patients with CPEO using spectral-domain optical coherence tomography and to compare the findings with those of healthy individuals.

Totally, 18 CPEO patients were enrolled in this study. Healthy volunteers matched for gender, age, and diopter settings were included as a control group. The retinal thickness of macular central fovea, inner and outer retinal layer thickness of perifoveal macular, optic nerve head parameters, and peripapillay retinal nerve fiber layer thickness (pRNFLT) for all included cases were measured using spectral-domain optical coherence tomography. A paired t test was used to compare the differences in the studied parameters between the two groups. The correlations between macular retinal thickness, pRNFLT, disease duration, and age of onset were also analyzed.

Among the macular parameters, retinal thickness of macular central fovea (t = -2.135, P < 0.05) and outer retinal layer thickness (t = -1.994, P < 0.05) of patients in the CPEO group were statistically significant lower than those of patients in the normal control group. For the optic nerve head parameters, the patients in the CPEO group showed a larger rim volume (t = -2.499, P < 0.05) and nerve head volume (t = -2.103, P < 0.05). The overall pRNFLT of patients in the CPEO group was statistically significant lower than that of patients in the control group (t = -4.125, P < 0.05). The comparison of pRNFLT in eight sectors showed that the pRNFLT of patients in the CPEO group was statistically significant lower than that of the control group mainly in the inferior and temporal sectors. The degree of pRNFL defect negatively correlated with the disease duration (r = -0.583, P < 0.05).

The retinal thickness of patients with CPEO was significantly thinner, which was mostly the outer retina. The patients’ optic discs had a low volume and the loss of the retinal nerve fiber layer was obvious. With the extension of the disease duration, the retinal nerve fiber layer defect was even more significant.

Blood purification (BP) is one of the most important rescue measures for patients with critical illness in the intensive care unit (ICU), especially for those with acute kidney injury. The purpose of this nationwide survey was to reveal the real world of current BP practice in different ICUs all over China. This study was designed to be a multi-center cross-sectional study.

All adult patients (over 18 years of age), who were admitted to ICU and required BP in 35 sub-centers across China were included during 30-day survey period in 2018. Demographic characteristics and clinical data were recorded including the timing of treatment initiation, indications, modality, relative contraindication, establishment of vascular access, selection of filter/membrane, settings, anti-coagulation, executive department, complication, intake, and output.

This nationwide survey may contribute to reveal the real world of current BP practice in different ICUs all over China.

Chinese Clinical Trial Registry, ChiCTR-EOC-17013119; http://www.chictr.org.cn/showproj.aspx?proj=22487.

Previous studies on whether or not levosimendan improved the prognosis of patients with sepsis and septic shock have been inconsistent. We aimed to provide an updated analysis of the therapeutic value of levosimendan in adult patients with sepsis and septic shock, in order to provide evidence-based medical evidence for its use.

PubMed, Embase, Cochrane Library, Wanfang Data, and CNKI were searched until August 2018 without language restriction. Randomized controlled studies of levosimendan with either inotropic drugs or placebo for the treatment of sepsis or septic shock were enrolled. The primary outcome was mortality, and cardiac index and serum lactate levels were the secondary outcomes.

A total of 20 randomized controlled studies were included in this meta-analysis, including 1467 patients, with 738 patients in the experimental group (levosimendan group) and 729 patients in the control group (other inotropic drugs or placebo). There were no significant differences in mortality between the levosimendan and control groups (fixed-effect relative risk [RR] = 0.90, 95% confidence interval [CI] [0.79, 1.03], P = 0.13). Levosimendan increased the cardiac index (VMD [weighted mean difference] = 0.51, 95% CI [0.06, 0.95], P = 0.02); and serum lactate levels were lower (VMD = -1.04, 95% CI [-1.47, -0.60], P < 0.00001).

Based on current clinical evidence, levosimendan does not reduce mortality in adult critically ill patients with sepsis and septic shock. Physicians should use levosimendan with caution in patients with sepsis and septic shock.

Poor tissue perfusion/cellular hypoxia may persist despite restoration of the macrocirculation (Macro). This article reviewed the literatures of coherence between hemodynamics and tissue perfusion in circulatory shock.

We retrieved information from the PubMed database up to January 2018 using various search terms or/and their combinations, including resuscitation, circulatory shock, septic shock, tissue perfusion, hemodynamic coherence, and microcirculation (Micro).

The data from peer-reviewed journals printed in English on the relationships of tissue perfusion, shock, and resuscitation were included.

A binary (coherence/incoherence, coupled/uncoupled, or associated/disassociated) mode is used to describe resuscitation coherence. The phenomenon of resuscitation incoherence (RI) has gained great attention. However, the RI concept requires a more practical, systematic, and comprehensive framework for use in clinical practice. Moreover, we introduce a conceptual framework of RI to evaluate the interrelationship of the Macro, Micro, and cell. The RI is divided into four types (Type 1: Macro-Micro incoherence + impaired cell; Type 2: Macro-Micro incoherence + normal cell; Type 3: Micro-Cell incoherence + normal Micro; and Type 4: both Macro-Micro and Micro-cell incoherence). Furthermore, we propose the concept of dynamic circulation-perfusion coupling to evaluate the relationship of circulation and tissue perfusion during circulatory shock.

The concept of RI and dynamic circulation-perfusion coupling should be considered in the management of circulatory shock. Moreover, these concepts require further studies in clinical practice.

In kidney diseases, uncontrolled blood pressure, inflammation, oxidative stress, imbalanced immunity response, and metabolic dysfunction were associated with the progressive deterioration of renal function. Short-chain fatty acids (SCFAs), as a group of metabolites fermented by gut microbiota exerted regulatory effects on kidney diseases through their activation of transmembrane G protein-coupled receptors and their inhibition of histone acetylation. In this review article, we updated recent research advances that provided an opportunity to explore our understanding in physiology and function of SCFAs in kidney disease.

We performed a comprehensive search in both PubMed and Embase using "short-chain fatty acids" and "kidney" with no restrictions on publication date.

After reading through the title and abstract for early screening, the full text of relevant studies was identified and reviewed to summarize the roles of SCFAs in kidney diseases.

Though controversial, growing evidence suggested SCFAs appeared to have a complex but yet poorly understood communications with cellular and molecular processes that affected kidney function and responses to injury. From recent studies, SCFAs influenced multiple aspects of renal physiology including inflammation and immunity, fibrosis, blood pressure, and energy metabolism.

The roles of intestinal SCFAs in kidney diseases were exciting regions in recent years; however, clinical trials and animal experiments in kidney diseases were still lacked. Thus, more research would be needed to obtain better understanding of SCFAs’ potential effects in kidney diseases.

Acute pancreatitis (AP) remains a common and lifethreatening gastrointestinal emergency, which is usually induced by gallstones, hyperlipidaemia, alcohol abuse, pancreatic carcinoma, and trauma.^[1]According to the 2012 Atlanta consensus, AP is divided into three general grades of severity: mild (MAP), moderate (MSAP), and severe (SAP).^[2]MAP is often self-limiting, while SAP is associated with high fatality, aggregate costs, and long hospital stay.^[3]The prognosis of AP was reported to have improved but the incidence of which increased in western countries and Japan.^[4,5,6]Regrettably, very few studies on AP in Chinese were published.^[7]To obtain a better understanding of the variations in demography, etiology, and treatment of AP, we conducted a large-scale retrospective study in 5375 patients at Ruijin Hospital in the period 1996 to 2015.

Despite recent advances in antibiotic use, increasing numbers of human immunodeficiency virus (HIV)-negative patients withPneumocystis jiroveciipneumonia (PCP) are being admitted to intensive care units (ICUs), and show a mortality rate of over 50%.^[1]A high neutrophil count in bronchoalveolar lavage (BAL) fluid is a predictor of poor prognosis in HIV-negative patients with PCP.^[2]Recently, programmed death ligand 1 (PDL1) has been identified on neutrophils.^[3]However, the role of PD-L1-expressing neutrophils has not been investigated in PCP. Therefore, the purpose of the present study was to examine the expression of PD-L1 on circulating neutrophils and to evaluate their clinical relevance in patients with PCP.

To the Editor:Incomplete intestinal obstruction, which can be seen in extensive burn patients, can be caused by superior mesenteric artery (SMA) syndrome, abdominal and intestinal tumors, an inflammatory mass near the ligamentous ligament, presence of a congenital giant duodenum, or other conditions. Cholecystitis is a rare cause of incomplete intestinal obstruction that can result in serious consequences for burn patients who are not diagnosed early, and do not receive timely treatment. Currently, there are few published reports of intestinal obstruction secondary to cholecystitis in these patients. We present a case and discuss complications in management of incomplete intestinal obstruction caused by cholecystitis and pericholecystic fluid in extensive burn patients.

To the Editor:Early bystander cardiopulmonary resuscitation (CPR) is crucial for survival and long-term quality of life of patients with out-of-hospital cardiac arrest.^[1]Training schoolchildren how to perform CPR is highly recommended by many countries and health organizations, including the World Health Organization.^[2,3]Schoolteachers with previous training are highly suggested as CPR instructors to teach schoolchildren.^[4,5]The CPR knowledge and previous training of the teachers are very important for their willingness to teach CPR and the quality of their teaching.^[6,7]A 6-year longitudinal study confirmed that teachers who previously attended a 60-min theoretical and practical CPR course could provide adequate resuscitation training in schools.^[8]In Belgium, some Flemish primary schoolteachers had a high interest in CPR training and were also willing to teach CPR.^[7]In China, little is known about teachers’ CPR knowledge and the attitude toward CPR education. The main goal of this study was to evaluate Chinese primary and secondary teachers’ current CPR knowledge, previous training, and the attitude toward CPR education.

To the Editor:Appropriate donor-to-recipient size matching is of crucial importance in lung transplantation. Although tailoring of the lung has been described as a successful means of overcoming size disparities, its merits and demerits remain unclear. Here, we present a case of recurrent hypoxemia after unmatched single lung transplantation. The causes of the hypoxemia were right middle lobe resection and the consequential pulmonary trunk stenosis that lead to unbalanced ventilation–blood flow ratio, which was diagnosed by pulmonary angiography and properly treated by the implantation of stents. The diagnostic protocol and treatment experience may have value for future clinical lung transplantations.

To the Editor:A 51-year-old woman presented with a palpable mass in the lower outer region of the left breast. There was no history of skin redness or nipple discharge. Craniocaudal mammography [Figure 1A] showed a circular homogenous mass with well-defined margins and without calcification located in the posterior region of the left breast. Ultrasonography (US) [Figure 1B] of the left breast demonstrated a heterogeneous, hypoechoic lesion with an accompanying peripheral blood flow signal. The resistance index (RI) and elastic score were 0.6 and 4.0, respectively. Magnetic resonance imaging again displayed an approximately 2.6 cm × 2.5 cm mass with characteristic decreased signal intensity on T1-weighted images, and an area of very high-signal intensity was observed in fat-suppressed T2-weighted images in the lower outer region of her left breast [Figure 1C]. Additionally, the lesion presented a high signal on diffusion weighted imaging [Figure 1D], and the apparent diffusion coefficient (ADC) value of this tumor was 0.893 × 10^-3mm²/s. On contrast-enhanced T1-weighted fat-saturated images [Figure 1E], the lesion revealed heterogeneous rim enhancement, and its time-intensity curve showed a plateau pattern.

To the Editor:Os odontoideum (OO) is a rare congenital anomaly of the second cervical vertebra that is defined as occurring when an independent ossicle is separated from the base of the odontoid process.^[1]In general, it requires surgeries for the patients who suffer from OO-associated atlantoaxial dislocation (AAD), especially for young patients due to their immature bones and the unavoidable tumbles and physical impacts in their daily lives.^[2]In clinical practice, the use of posterior screw-rod fixation systems enables unique three-dimensional fixation. The use of these systems can provide effective correction and bone fusion for OO-associated AAD.^[3]For the treatment of irreducible atlantoaxial dislocation (IrAAD), posterior stabilization, and the use of additional transoral decompression were thought to be necessary, as reported in the literature.^[4]To our knowledge, few procedures have been proven to be simple and effective treatments for IrAAD. In our study, we enrolled 15 adolescents with OO-associated AAD that was treated with modified C1–C2 pedicle screw fixation, and for the patients who failed to benefit from pre-operation skull traction, we administered a direct posterior compound reduction technique.

To the Editor:Hair loss or alopecia is a very common disease, which has the potential to impact the quality of life, physical attractiveness, and interpersonal relationships. In recent years, lasers and light therapy have been used as alternative or supplementary therapy for hair loss. In 2007, low-level laser therapy was approved by the United States Food and Drug Administration as a safe and effective treatment on hair loss.^[1]The non-ablative 1550 nm fractional laser also appears to be useful for increasing hair density in patients with androgenetic alopecia.^[2]Moreover, our previous study found that ablative CO₂fractional laser therapy in combination with hair growth factors proves more effective for the treatment of patients with androgenetic alopecia than topical hair growth factors alone.^[3]However, the detailed mechanisms underlying hair re-growth and injury induced by the laser remains unclear. In the present study, we assessed the expression of several inflammatory cytokines related to wound healing and Wnt signal pathway molecules at different time points before and after CO₂fractional laser therapy. Potential mechanisms behind fractional CO₂laser-induced hair growth were then explored in mice.