2020年 · 第133卷第18期

The coronavirus disease 2019 (COVID-19) pandemic has become a global health crisis.^[1,2]Healthcare workers play key roles during the pandemic, but a serious shortage of personnel may occur at peak times. In order to control the rapid spreading of an outbreak, adequate staffing is needed to manage infected patients and to prevent infections of surrounding patients, staff members, as well as the local community.^[3]Although there are multiple modes for the organization and deployment of medical staff to deal with the rapidly increasing population of COVID-19 patients, successful experiences from Wuhan, China may prove helpful as a model for effectively dealing with this urgent situation.^[4]

The peripheral perfusion index (PI), as a real-time bedside indicator of peripheral tissue perfusion, may be useful for determining mean arterial pressure (MAP) after early resuscitation of septic shock patients. The aim of this study was to explore the response of PI to norepinephrine (NE)-induced changes in MAP.

Twenty septic shock patients with pulse-induced contour cardiac output catheter, who had usual MAP under NE infusion after early resuscitation, were enrolled in this prospective, open-label study. Three MAP levels (usual MAP -10 mmHg, usual MAP, and usual MAP +10 mmHg) were obtained by NE titration, and the corresponding global hemodynamic parameters and PI were recorded. The general linear model with repeated measures was used for analysis of variance of related parameters at three MAP levels.

With increasing NE infusion, significant changes were found in MAP (F = 502.46, P < 0.001) and central venous pressure (F = 27.45, P < 0.001) during NE titration. However, there was not a significant and consistent change in continuous cardiac output (CO) (F = 0.41, P = 0.720) and PI (F = 0.73, P = 0.482) at different MAP levels. Of the 20 patients enrolled, seven reached the maximum PI value at usual MAP -10 mmHg, three reached the maximum PI value at usual MAP, and ten reached the maximum PI value at usual MAP +10 mmHg. The change in PI was not significantly correlated with the change in CO (r = 0.260, P = 0.269) from usual MAP -10 mmHg to usual MAP. There was also no significant correlation between the change in PI and change in CO (r = 0.084, P = 0.726) from usual MAP to usual MAP +10 mmHg.

Differing MAP levels by NE infusion induced diverse PI responses in septic shock patients, and these PI responses may be independent of the change in CO. PI may have potential applications for MAP optimization based on changes in peripheral tissue perfusion.

The relationship between macrocirculation and microcirculation remains controversial. The loss of coherence between microcirculation and macrocirculation has already been found in late-stage sepsis shock. The objective of this study was to determine the earliest possible time of detecting the loss of coherence between microcirculation and macrocirculation in early-stage endotoxemic shock.

We randomized 24 female New Zealand white rabbits into two groups: endotoxemic shock group (n = 14) and control group (n= 10). Rabbits in the endotoxemic shock group were equipped with arterial and venous catheters and received an intravenous infusion of Escherichia coli lipopolysaccharide (LPS, 2 mg/kg over 10 min). Rabbits in the control group received the same dose of saline infusion. Microcirculatory perfusion parameters were assessed in the sublingual mucosa using sidestream dark-field video microscopy. Systemic hemodynamics and blood lactate levels were measured at baseline and over a 120-min period.

Ninety minutes after completing LPS infusion, all animals in the endotoxemic shock group developed a hypodynamic septic condition, characterized by low cardiac output and increased systemic vascular resistance; 120 min after completing LPS infusion, the mean arterial pressure decreased by 25% (P = 0.01), confirming ongoing endotoxemic shock. However, significant decreases in sublingual microcirculatory parameters of small vessels (microvascular flow index, perfused vessel density, and proportion of small perfused vessels) were observed 30 min after completing LPS infusion (P = 0.01, for all), and threshold decreases of 30% were found 60 min after completing LPS infusion (P = 0.001, for all) in the endotoxemic shock group. Lactate levels significantly increased to more than 2 mm/L at 90 min and more than 4 mm/L at 120 min in the endotoxemic shock group (P = 0.02 and P = 0.01, respectively).

Changes in microcirculatory perfusion precede changes in macrocirculation and lactate levels in a rabbit model of endotoxemia shock. Microcirculation, macrocirculation, and oxygen metabolism are distinct in early-stage endotoxic shock.

Acinetobacter baumannii (A. baumannii) has become one of the most important opportunistic pathogens inducing nosocomial pneumonia and increasing mortality in critically ill patients recently. The interaction between A. baumannii infection and immune response can influence the prognosis of A. baumannii related pneumonia. The target of the present study was to investigate the role of immunodeficiency in A. baumannii induced pneumonia.

Male BALB/c mice were randomly divided into the normal immunity control (NIC) group, normal immunity infection (NIA) group, immune compromised control (CIC) group, and immune compromised infection (CIA) group (n = 15 for each group). Intraperitoneal injection of cyclophosphamide and intranasal instillation of A. baumannii solution were used to induce compromised immunity and murine pneumonia, respectively. The mice were sacrificed at 6 and 24 h later and the specimens were collected for further tests. Seven-day mortality of mice was also assessed.

After A. baumannii stimulation, the recruitment of neutrophils in mice with normal immunity increased sharply (P = 0.030 at 6 h), while there was no significant raise of neutrophil counts in mice with compromised immune condition (P = 0.092 at 6 h, P = 0.772 at 24 h). The Th cell polarization presented with pulmonary interleukin (IL)-4 and interferon (IFN)-γ level in response to the A. baumannii in CIA group were significantly depressed in comparison with in NIA group (IFN-γ: P = 0.003 at 6 h; P = 0.001 at 24 h; IL-4: P < 0.001 at 6 h; P < 0.001 at 24 h). The pulmonary conventional dendritic cell accumulation was even found to be inhibited after A. baumannii infection in immunocompromised mice (P= 0.033). Correspondingly, A. baumannii associated pneumonia in mice with compromised immunity caused more early stage death, more severe histopathological impairment in lung.

A. baumannii could frustrate the immune response in immunocompromised conditions, and this reduced immune response is related to more severe lung injury and worse outcome in A. baumannii induced pneumonia.

The association between free triiodothyronine (FT3) and long-term prognosis in dilated cardiomyopathy (DCM) patients has not been evaluated. The purpose of this study was to determine whether the level of FT3 could provide prognostic value in patients with DCM.

Data of consecutive patients diagnosed with DCM were collected from October 2009 to December 2014. FT3 was measured by fluoroimmunoassay. Other biochemical markers, such as free thyroxin (FT4), thyroid-stimulating hormone, red blood cell, hemoglobin, blood urea nitrogen, and serum creatinine, were tested at the same time. Follow-up was performed every 3 months. The primary endpoint was all-cause mortality. Pearson analysis was used to evaluate the correlation of FT3 and other lab metrics with DCM patients’ prognosis. The association of long-term mortality in DCM and FT3 was compared using Cox hazards model.

Data of 176 patients diagnosed with DCM were collected. Of them, 24 patients missed FT3 values and six patients were lost to follow-up. Altogether, data of 146 patients were analyzed. During the median follow-up time of 79.9 (53.5-159.6) months, nine patients lost, 61 patients died (non-survival group), and 85 patients survived (survival group). FT3 was significantly lower in non-survival group than that in survival group (3.65 ± 0.83 pmol/L vs. 4.36 ± 1.91 pmol/L; P = 0.003). FT3 also showed a significantly positive correlation with red blood cell and hemoglobin, negatively correlated with age, blood urea nitrogen and serum creatinine (P < 0.05), respectively. Patients in the group of lower FT3 levels (FT3 ≤ 3.49 pmol/L) suffered from a higher risk of all-cause mortality (P for log-rank = 0.001). In multivariate Cox regression analysis, FT3 level was significantly associated with all-cause mortality (hazard ratio: 0.70, 95% confidence interval 0.52-0.95, P for trend = 0.021).

Low levels of FT3 were associated with increased all-cause mortality in patients with DCM.

Developing effective spinal cord repair strategies for spinal cord injury (SCI) is of great importance. Emerging evidence suggests that microRNAs (miRNAs) are closely linked to SCI recovery. This study aimed to investigate the function of miR-34c in the neuronal recovery in rats with SCI.

A rat model with SCI was established. Differentially expressed miRNAs were identified by a microarray analysis. MiR-34c expression in rats was measured by reverse transcription quantitative polymerase chain reaction. Altered expression of miR-34c or C-X-C motif ligand 14 (CXCL14) was introduced in SCI rats to measure their roles in neuronal recovery. Western blot analysis was performed to determine the phosphorylation of Janus kinase 2 (JAK2) and signal transducer and activator of transcription-3 (STAT3). Neuronal apoptosis in rat spinal cord tissues was detected. The concentrations of SCI recovery-related proteins thyrotropin releasing hormone (TRH), prostacyclin (PGI2), and ganglioside (GM) were evaluated by enzyme-linked immunosorbent assay. Data were analyzed using a t-test with a one-way or two-way analysis of variance.

Rats with SCI presented decreased grip strength (112.03 ± 10.64 vs. 17.32 ± 1.49 g, P < 0.01), decreased miR-34c expression (7 days: 3.78 ± 0.44 vs. 0.95 ± 0.10, P < 0.05), and increased CXCL14 expression (7 days: 0.61 ± 0.06 vs. 2.91 ± 0.27, P < 0.01). MiR-34c was found to directly bind to CXCL14. Overexpression of miR-34c increased grip strength (11.23 ± 1.08 vs. 31.26 ± 2.99 g, P < 0.01) and reduced neuronal apoptosis in spinal cord tissues (53.61% ± 6.07% vs. 24.59% ± 3.32%, P < 0.01), and silencing of CXCL14 also increased the grip strength (12.76 ± 1.13 vs. 29.77 ± 2.75 g, P < 0.01) and reduced apoptosis in spinal cord tissues (55.74% ± 6.24% vs. 26.75% ± 2.84%, P < 0.01). In addition, miR-34c upregulation or CXCL14 downregulation increased the concentrations of TRH, PGI2, and GM, and reduced phosphorylation of JAK2 and STAT3 in rats with SCI (all P < 0.01).

The study provided evidence that miR-34c could promote neuronal recovery in rats with SCI through inhibiting CXCL14 expression and inactivating the JAK2/STAT3 pathway. This study may offer new insights into SCI treatment.

The coronavirus disease 2019 (COVID-19) has been declared a global pandemic and is a major public health issue worldwide. COVID-19 is a systemic disease damaging multiple organs, including the lung as the main target organ.

The predictive value of hemoglobin A1c (HbA1c) levels in non-diabetic patients with myocardial infarction undergoing percutaneous coronary intervention (PCI) is still controversial. This study aimed to evaluate whether HbA1c levels were independently associated with adverse clinical outcomes in non-diabetic patients with coronary artery disease (CAD) who had undergone PCI by performing a meta-analysis of cohort studies.

This meta-analysis included non-diabetic patients with CAD who had undergone PCI. A systematic search for publications listed in the PubMed, Embase, and Cochrane Library databases from commencement to December 2018 was conducted. Studies evaluating the adverse clinical outcomes according to abnormal HbA1c levels in non-diabetic patients diagnosed with CAD who had undergone PCI were eligible. The primary outcomes were long-term all-cause deaths and long-term major adverse cardiac events, and the secondary outcome was short-term all-cause deaths. The meta-analysis was conducted with RevMan 5.3 and Stata software 14.0. Odds ratios (ORs) were pooled using a random or fixed-effects model, depending on the heterogeneity of the included studies. Sub-group analysis or sensitivity analysis was conducted to explore potential sources of heterogeneity, when necessary.

Six prospective cohort studies involving 10,721 patients met the inclusion criteria. From the pooled analysis, abnormal HbA1c levels were associated with increased risk for long-term all-cause death (OR 1.39, 95% confidence interval [CI] 1.16-1.68, P = 0.001, I² = 45%). Sub-group analysis suggested that abnormal HbA1c levels between 6.0% and 6.5% predicted higher long-term major adverse cardiac event (including all-cause deaths, non-fatal myocardial infarction, target lesion revascularization, target vessel revascularization, recurrent acute myocardial infarction, heart failure requiring hospitalization, and stent thrombosis) risk (OR 2.05, 95% CI 1.46-2.87, P < 0.001, I² = 0). Contrarily, elevated HbA1c levels were not associated with increased risk of short-term all-cause death (OR 1.16, 95% CI 0.88-1.54, P = 0.300, I²= 0).

An abnormal HbA1c level is an independent risk factor for long-term adverse clinical events in non-diabetic patients with CAD after PCI. Strict control of HbA1c levels may improve patient survival. Further studies in different countries and prospective cohort studies with a large sample size are required to verify the association.

The skin is the outermost protective organ susceptible to damage by external injury and retains undesired scars after wound healing, which often diminishes the quality of life and causes economic burden. Periostin, an extracellular matrix component, is reportedly closely associated with skin wound healing and pathologic scar formation. It is expressed in various normal tissues, often associated with fibroblasts, and involved in remodeling of the extracellular matrix environment.^[1,2]In some disease states, such as myocardial infarction, cancer, liver fibrosis, and pathologic scarring of the skin, periostin is reportedly a vital regulator of the progression of the disease and significantly over-expressed.^[3]This article summarizes recent advancements in studies on the role of periostin in skin wound healing and pathologic scar formation.

The coronavirus disease 2019 (COVID-19) has caused a global outbreak and became a major public health issue globally. It has been found that COVID-19 patients are commonly complicated with coagulation abnormities, which are closely associated with the severity and prognosis of patients. A thorough understanding of the prevalence of coagulopathy and potential causes of abnormities of coagulation parameters in COVID-19 patients is crucial for clinicians to standardize the diagnosis and management of COVID-19 associated coagulopathy.

Cardiogenic shock (CS) is a life-threatening condition in intensive care unit, which leads to death of many critically ill patients. Although survival of CS patients seems to have improved, it continues to carry a poor prognosis, and mortality rates range from 60% to 80%.^[1]

Thrombolytic therapy within 4.5 h from symptom onset is a recognized effective and standard therapy for acute ischemic stroke (AIS), but some patients still have a poor clinical outcome. The evaluation and control of predictors for AIS poor clinical outcomes is integral to achieving optimal treatments, but the prognostic value of admission blood glucose (ABG) for this purpose is unclear and still under debate. ABG evaluated in patients without diabetes mellitus (DM) often suggests acute stress hyperglycemia, while ABG may have a close relationship with long-term blood glucose control in patients with DM. However, in most studies about the influence of ABG on the prognosis of recombinant tissue-type plasminogen activator (rtPA) therapy after AIS, patients were not classified into those with and without DM. The present study was designed to investigate the prognostic value of ABG for clinical outcomes of AIS after thrombolysis according to DM status in a Chinese population.

Homocystinuria due to cystathionin-β-synthase (CBS) deficiency is a rare genetic disease that most often diagnosed in childhood and can cause damage to the multiple systems.^[1,2]The inherited mode ofCBSgene deficiency is usually autosomal recessive inheritance. More than 160 mutations have been identified inCBSgenes so far (http://cbs.lf1.cuni.cz/index.php), one of the most common mutations is c.833T>C point mutation, and then followed by c.572C>T, c.919G>A, and c.1006C>T point mutations. In 2018, Liet al^[2]found eight brand new mutation sites in patients with CBS deficiency in China, pointing out that theCBSmutant site spectrum of Chinese people is significantly different from that of other races. In this paper, we further conducted a retrospective analysis of seven homocystinuric patients ofCBSdeficiency admitted to our institute.

Bloodstream infections (BSIs) have emerged as a worldwide concern because of their increasing incidence, mortality, and associated healthcare cost. Strains in ESKAPE includingEnterococcus faecium(E. faecium),Staphylococcus aureus(S. aureus),Klebsiella pneumonia(K. pneumonia),Acinetobacter baumannii(A. baumannii),Pseudomonas aeruginosa(P. aeruginosa), andEnterobacterspp., as well asEscherichia coli(E. coli), account for more than half of the causative pathogens of BSI.^[1]Moreover, the incidences and resistance rates of ESKAPE andE. colihave changed in recent years. A study in Rome found thatE. coli, followed byS. aureus,was the most frequently identified microorganism; further, the study revealed that, regardless of hospital or community-onset, the number of extended-spectrum β-lactamases-producingE. coliwas increasing, and carbapenemase-producingK. pneumoniaehad become more prevalent during the study period.^[1]A recent study suggested upward resistance trends of ESKAPE andE. coliorganisms isolated from blood cultures from 2014 to 2018 in a hospital in Italy.^[2]The frequencies and resistance rates of ESKAPE andE. coliare most likely interrelated with the spectrum of disease, geographical situation, antimicrobial management, and hand hygiene. Since 2012, some requirements have been gradually executed according to the Measures for the Administration of Clinical Application of Antibiotics (Decree No. 84 of the Ministry of Health), the Guidelines for Clinical Application of Antibiotics (2015 edition), and the Notice on Continuous Management of Clinical Application of Antibiotics (General Office of the National Health Commission, 2018) at our hospital. However, it is unclear whether these measures are effective to minimize the antibiotic resistance rate. This study investigated the resistance rates and antimicrobial resistance indexes (ARIs) of ESKAPE andE. coliisolated from blood samples at our hospital, and aimed to contribute to the research on ESKAPE andE. coliin China as well as the availability of methods for antibiotic administration.

Acute pulmonary embolism (APE) is a challenging condition with frequently missed or delayed diagnosis, and thus may be fatal. In emergency patients with a history of coronary heart disease, the electrocardiogram (ECG) results are often not specific, and APE is difficult to diagnose. Consequently, the patients tend to be diagnosed with acute coronary syndrome (ACS), and either undergo reexamination with myocardial enzyme observations in the emergency department, or are admitted to the hospital for coronary angiography. The 2008 European Society of Cardiology (ESC) guidelines on the diagnosis and management of acute pulmonary embolism stated that the clinical risk assessment of APE should be based on the Wells score.^[1]However, despite this official recommendation, the Wells score is not widely used in emergency medicine, especially for patients with coronary heart disease and concomitant APE. The present study analyzed the predictive value of the Wells score combined with the D-dimer level in identifying APE in patients with coronary heart disease.

The infratemporal fossa approach was designed for the removal of large tumors located at the temporal bone and lateral skull base.^[1]This approach has several subtypes, including types A, B, C, and D. The infratemporal fossa type B (ITFB) approach exposes the petrous apex, clivus, and horizontal segment of the internal carotid artery (ICA) and is used to remove tumors in this area.^[2]The classical ITFB approach to fully exposing the horizontal segment of the ICA includes subtotal resection of the petrous bone, removal of the anterior wall of the external auditory canal and zygomatic arch, resection of the articular disc and condylar process of the mandible, downward traction of the mandible, and transection of the mandibular branch of the trigeminal nerve and middle meningeal artery.^[3]

Anomalous systemic artery to the non-sequestrated lung (ASANSL) is a rare congenital anomaly that was previously classified as a Pryce type I sequestration; it comprises an anomalous systemic artery (ASA) to the normal lung.^[1]To more clearly determine the features of ASANSL, we collected data on 15 cases and reviewed the relevant literature. It has been concluded that multi-slice computed tomography (MSCT) can be used as a highly reliable and minimally invasive tool for diagnosing ASANSL and planning the treatment plan.

To the Editor:Ankle sprains account for about 40% of all sports injuries, and 20% to 33% of ankle sprains will cause ankle instability.^[1]Functional ankle instability (FAI) does not yet have an accurate and widely accepted measurable definition, although many surgeons have treated it for years when it is combined with anterior talofibular ligament injury, calcaneofibular ligament injury, or both. In China, some unnecessary ligament-repairing surgeries may be performed just because of imaging evidence of ligament injury and possible (but not sure) FAI, leading to some unsatisfactory results. Several self-reported questionnaires have been developed to help define FAI but no validated Chinese version existed, although China has the highest number of patients with FAI. The International Ankle Consortium has recommended the Ankle Instability Instrument, the Cumberland Ankle Instability Tool, and the Identification of Functional Ankle Instability (IdFAI) questionnaire, which is based on the first two questionnaires, to assess FAI.^[2]The IdFAI has the highest accuracy of the three questionnaires.^[3]The original English version of IdFAI has been translated into many languages, and the Japanese, Korean, Brazilian, and Persian versions have been validated. We developed a Chinese version of the IdFAI (IdFAI-C) and determined its validity by assessing its discriminate validity, internal consistency, accuracy, and test-retest reliability.

To the Editor:Kasabach-Merritt syndrome (KMS) is a very rare life-threatening aggressive vascular tumor that is related to Kaposiform hemangioendothelioma and tufted angioma. It is characterized by thrombocytopenia and intravascular coagulation that occasionally develops into disseminated intravascular coagulation.^[1,2]A rare incidence of diffuse infiltrative pancreatic hemangioma with a high possibility of missed diagnosis of KMS makes it a fatal disease. Here, we described a case diagnosed with diffuse infiltrative hemangioma (DIH) of pancreas accompanied by KMS and provided ultrasonic data for early and accurate diagnosis, and successful treatment experiences with sirolimus.

To the Editor:Widely used statins lower the risk of death from cardiovascular diseases. However, statin-associated skeletal muscle complaints hinder their clinical application to some extent.Yang xin shitablet (YXST), a traditional Chinese medicine formula, can effectively improve the clinical symptoms of patients with cardiovascular diseases when combined with conventional drugs. However, the synergistic effects of YXST combined with a statin and the potential mechanisms remain unknown. Hence, exploring the effects and mechanisms of YXST in improving statin-induced muscle injury can be beneficial for the exercise rehabilitation and prognosis of patients with cardiovascular disease.