Volume 102 ·  Issue 25 ·  2022

Extracorporeal membrane oxygenation (ECMO) technology has experienced from nothing, evolving from high-Tech technology with high mortality to the well-known last life-saving weapon. At present, ECMO technology is booming and widely used in the treatment of patients with severe respiratory failure and cardiogenic shock. In recent years, the use of ECMO in China has also made great progress, but there are some problems in the construction of ECMO centers and ECMO-related technologies. The article aims to discuss the current situation and problems faced in ECMO use in China, such as insufficient cases, regional differences, centre construction and related technical issues.

The anticoagulant management of extracorporeal membrane oxygenation(ECMO) is facing great challenges. Complications related to the coagulation system such as bleeding or embolism are one of the main factors affecting the mortality of patients. How to control the dynamic balance between thrombosis and bleeding complications has become the top priority of ECMO management. This article reviews the coagulation changes during ECMO support, how to choose appropriate anticoagulant drugs and anticoagulation monitoring methods, aiming to explore the best anticoagulation strategy for ECMO patients.

Neurological complications significantly affect the short-and long-term outcomes of patients with extracorporeal membrane oxygenation (ECMO). With the increasing application of ECMO, more and more attention has been paid to the neuromonitoring in ECMO patients. Although many neuromonitoring approaches have already been used clinically, the sensitivity and specificity utilizing one single neuromonitoring assessment to predict brain injury is still insufficient. Therefore, multidisciplinary experts in critical care medicine and extracorporeal life support organization advocate that multimodal monitoring (MMM) should be applied to improve the sensitivity and specificity of monitoring the occurrence of acute brain injury in patients with ECMO. With timely and appropriate intervention, the prognosis of patients with ECMO may be improved. However, there is still a lack of standardized implementation procedures for MMM, which needs further efforts. With continuous verification and improvement in multi-clinical centers, the standardized MMM procedures could be transformed into correct treatment decisions, thus to improve the outcomes of patients with ECMO.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a salvage therapy for critical patients with refractory cardiogenic shock caused by various reasons. It can temporarily replace cardiopulmonary function, and rapidly improve hypoxemia, increase systemic oxygen content and remove carbon dioxide. Although the Extracorporeal Life Support Organization (ELSO) guideline proposed clear indication for VA-ECMO, the heterogeneity of cardiac pathogeny is large, so the clear timing of ECMO initiation is still vague. We discuss the timing of ECMO initiation for external cardiopulmonary resuscitation (ECPR) and cardiogenic shock which is caused by fulminant myocarditis, acute myocardial infarction, acute pulmonary embolism, acute right heart failure related to lung transplantation, corona virus disease 2019 (COVID-19)-associated cardiovascular collapse. Also, we look forward to making more suggestions for clinicians′ judgment and choice for VA-ECMO.

The weaning of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is one of the clinical challenges, and hospitals have developed experience-based strategies, so there is still a lack of unified standards and procedures for weaning. This paper discusses this issue from the definition of weaning success, evaluation of patients before weaning, predictive indicators, weaning process, etc. Summarizing research progress and problems so that providing guidance for the development of ECMO in the future, such as perfecting weaning process and putting forward scoring system to predict weaning success and clinical outcome.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a great weapon to save patients with acute heart failure. At present, in most cases, VA-ECMO is perfused through femoral artery intubation, and the external blood flow is opposite to the direction of cardiac ejection, which will increase the left ventricular afterload and lead to left ventricular expansion, which is not conducive to the recovery of cardiac function. This paper reviews the development course of left ventricular decompression at home and abroad, summarizes the present situation of left ventricular decompression technology at home and abroad, analysis of left ventricular decompression technology advantages and existing problems, and put forward their own opinions, to analyze the prevention and solution of left ventricular distension in VA-ECMO, may explore better method, improve the success rate of treatment in patients with heart failure.

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is mainly used for reversible acute respiratory failure that is difficult to correct with mechanical ventilation and other conventional measures or preparation of lung transplantation. Acute respiratory distress syndrome (ARDS) is a typical clinical syndrome of acute respiratory failure. The timing of starting VV-ECMO in severe ARDS still face many controversies and challenges. This paper we discuss the current feasible assessment methods of when to start VV-ECMO in ARDS, such as, optimization of mechanical ventilation parameters, monitoring of respiratory dynamics and hemodynamics, assessment of lung recruitability and electrical impedance tomography (EIT) real-time monitoring, etc.

Differences in weaning strategies for veno-venous extracorporeal membrane oxygenation (VV-ECMO) are based on expert opinions rather than clinical evidence. Therefore, each center has its own "unique skills". The timing of VV-ECMO weaning has not received due attention. It is difficult to find research on the choice of VV-ECMO weaning timing in the database. There are few studies involving VV-ECMO that describe the weaning process in detail. At present, the weaning process of VV-ECMO is mainly based on expert opinions. This article classified the current VV-ECMO weaning strategies, appealed to a unified VV-ECMO weaning protocol in China as soon as possible, and further improved the prognosis of patients with extracorporeal life support.

The mortality of acute respiratory distress syndrome (ARDS) patients is very high, veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been proved to improve the prognosis of these patients, but the maximization of this benefit relies on the appropriate mechanical ventilation strategy; with the new research evidence arise, scholars have reached a certain consensus on how to implement mechanical ventilation in ARDS patients supported by VV-ECMO, but there are still many controversies. Based on the evidences of current researches and clinical experiences, this article analyzes the hot issues of mechanical ventilation strategy for these patients, including the implementation of early ′overprotective′ ventilation strategy, whether spontaneous breathing allowed, prone ventilation and ventilator weaning.

Sepsis is a critical medical problem that needs to be solved urgently worldwide. Some patients with sepsis have refractory shock or/and severe respiratory failure, which may require supporting with extracorporeal membrane oxygenation (ECMO). Particularly, it is important to choose the optimal mode and grasp the optimal timing of the initiation in the experienced ECMO center. The choice of mode is mainly based on the patient′s condition of oxygenation and hemodynamics. During the management of ECMO support, some issues like blood flow, anticoagulation and therapy of antibiotics should be noted. Thus far, the research of ECMO in adult patients with sepsis and septic shock are mainly retrospective, observational and with small sample size. Further exploration is needed in the future.

To investigate the correlation between the change of posterior tibial slope (PTS) after unicompartmental knee arthroplasty (UKA) and the contact force at the end stage of knee flexion and extension, as well as the postoperative range of motion.

The data of 38 cases (46 knees) of UKAs undertaken in China-Japan Friendship Hospital from June 2020 to June 2021 were analyzed in this study. A custom-designed force sensor was used to measure gap contact force in the medial gap of UKA. The correlations between each two of the three factors—the change of PTS (∆PTS), the gap contact force of full extension and deep flexion and the range of knee motion were analyzed.

Totally of 38 patients (46 knees) were enrolled, including 14 males and 24 females, aged (69.1±7.4) years, with an average follow-up of (11.2±3.7) months. The average gap contact force was (88.3±40.6)N, the adjusted contact force of the full extension gap was 81.7%±33.8%, while that of the deep flexion gap was 55.6%±31.0%. At the last follow-up, the fixed flexion degree[M(Q₁, Q₃)] was 0°(0°, 3°), which was significantly lower than the preoperative value of 0°(0°, 5°) (P<0.05); the postoperative max flexion degree was 115.9°±16.4°, it was increased when compared with the preoperative value of 112.0°±16.8° (P<0.05); and the postoperative PTS was 8.3°±2.7°, and there was no significant difference with the preoperative value (8.6°±2.1°,P>0.05). There was a positive correlation between ∆PTS and both the contact force of full extension gap and the fixed flexion degree (r=0.334 and 0.317, P<0.05). Besides, there was a negative correlation between ∆PTS and the contact force of the deep flexion gap (r=-0.397, P<0.05). However, the correlations between these two factors and the max flexion degree were not significant (P>0.05).

The reduction of PTS in UKA would reduce the contact force of the full extension gap, as well as the postoperative fixed flexion deformity. Besides, it could increase the contact force of the deep flexion gap, but would not influence the max flexion degree of the knee postoperatively.

To explore the characteristics, clinical features and prognostic effects of NOTCH1/FBXW7 gene mutations in T-cell acute lymphoblastic leukemia (T-ALL) patients.

The clinical data of 61 T-ALL patients who underwent second-generation gene sequencing in Henan Provincial People′s Hospital from March 2016 to March 2021 were retrospectively analyzed. There were 46 males and 15 females, with a median age [M (Q₁, Q₃)] of 18 (11, 30) years. The relationship between NOTCH1/FBXW7 gene mutation characteristics, clinical and laboratory parameters and their impact on event free survival (EFS) and overall survival (OS) were analyzed.

NOTCH1 gene mutations were found in 34 cases (55.7%, 34/61), including 22 cases of heterodimer domain (HD) mutations (64.7%), 7 cases of proline/glutamate/serine/threonine (PEST) mutations (20.6%), and 5 cases of both HD and PEST mutations (14.7%). FBXW7 gene mutations were detected in 9 cases (14.8%, 9/61), of which 5 cases had both NOTCH1 and FBXW7 gene mutations. Twenty-three (37.7%, 23/61) cases were wild type. The median white blood cell count of patients in NOTCH1/FBXW7 gene mutations group and wild-type group was 76.4×10⁹/L (8.3×10⁹/L, 149.2×10⁹/L), 54.1×10⁹/L (5.3×10⁹/L, 156.6×10⁹/L), respectively. Moreover, the hemoglobin was (89.1±27.1) g/L and (99.5±23.1) g/L, respectively, and the median proportion of bone marrow primordial cells was 84.5% (69.0%, 91.3%) and 60.0%(35.0%, 80.0%), respectively. The gene expression rate of SIL-TAL1, Hox11 and Hox11L2 was 7.9% (3/38) vs 17.4% (4/23), 18.4% (7/38) vs 4.3% (1/23), 5.3% (2/38) vs 13.0% (3/23), respectively (all P>0.05). However, the median platelet level in the NOTCH1/FBXW7 gene mutations group was 60.5×10⁹/L (36.8×10⁹/L, 100.3×10⁹/L), which was lower than that in the wild-type group [116.0×10⁹/L (63.0×10⁹/L, 178.0×10⁹/L)] (P=0.018). The median number of gene mutations in the group with NOTCH1/FBXW7 gene mutations group was 2.5 (1.8, 4.0), which was more than that in the group without NOTCH1/FBXW7 gene mutations group [0 (0, 1.0)] (P<0.001). The median EFS and OS of adult NOTCH1/FBXW7 gene mutations group were 28.0 (95%CI: 7.3-48.7) months and 30.0 (95%CI: 8.9-51.1) months, respectively, which were better than those of adult wild-type group [4.5 (95%CI: 0-11.6) months and 9.0 (95%CI: 0-19.1) months] (P=0.008 and 0.014).The median EFS and OS of children NOTCH1/FBXW7 gene mutations group were 12.0 (95%CI: 10.4-13.6) months and 19.0 (95%CI: 13.6-24.4) months, respectively, and those of wild-type group were 10.0 (95%CI: 8.9-11.1) months and 21.0 (95%CI: 0-51.4) months, respectively (P=0.673 and 0.434).

The mutation rate of NOTCH1/FBXW7 gene is higher in T-ALL patients. Patients with NOTCH1/FBXW7 gene mutations group have lower platelet count and better EFS and OS. NOTCH1/FBXW7 gene mutation may be used as a hierarchical basis for individualized treatment of adult T-ALL patients.

To investigate the association of central motion conduction time (CMCT) with corticospinal tract lesions and its clinical application.

Patients who completed transcranial magnetic stimulation-motor evoked potentials were included from Department of Neurology, Xuanwu Hospital between June 2020 and June 2021. The differences of CMCT values between corticospinal tract sign-positive group and tendon reflex-positive group and the relevant negative groups were compared. The consistency between increased CMCT values and the positive signs of corticospinal tract damage, as well as the significance of CMCT in different neurological diseases were further evaluated.

A total of 271 patients were included in the study, aged 12-86 (49±16) years, with 137 males (50.55%) and 134 females (49.45%). The CMCT values［M（Q₁，Q₃）］from Hoffmann′s sign-positive group [9.52 (8.54, 10.99) ms vs 9.03 (8.30, 9.53) ms], Babinski′s sign-positive group [19.54 (16.97, 24.43) ms vs 16.85(15.63, 18.55) ms] and tendon reflex-positive group [15.38 (9.27, 19.28) ms vs 10.49(8.79, 16.60) ms] were larger than those of relevant negative groups (all P<0.01). In the Babinski sign-positive group, 78.01%(181/232) of the patients had increased CMCT, while in the Hoffmann′s sign-positive group, only 26.03%(19/73) of the patients had increased CMCT, indicating that the contribution of CMCT from the lower extremities to the assessment of corticospinal tract lesions was better than that of the upper extremities. With the increase of CMCT values in lower limbs, Babinski sign positive rate increased, the difference was statistically significant(P<0.001). In nervous system diseases, the consistency between CMCT and pathological signs was 75.65% (205/271).

The contribution of CMCT from the lower extremities to the assessment of corticospinal tract lesions is superior to that of upper limbs. The higher increase of CMCT values are more reliable for corticospinal tract damage. CMCT has a good concordance with corticospinal tract lesions in some neurological diseases, which can be used to assist clinical diagnosis.

To investigate the immune mechanism of human airway epithelial cell injury induced by invasion of Candida albicans with different biofilm formation abilities.

Twenty-five strains of Candida albicans isolated and cultured in General Hospital of Ningxia Medical University from June to December 2019 were selected, and quality control strain SC5314 was used as the standard strain. An in vitro model of Candida albicans biofilm was established, and the biofilm formation ability of different Candida albicans was detected by crystal violet staining and enzyme plate method. The absorbance value at 570 nm (A₅₇₀) was determined by enzyme plate method. A₅₇₀≥0.5, 0.25<A₅₇₀<0.5 and A₅₇₀≤0.25 indicated strong biofilm Candida albicans form (SBF), moderate biofilm Candida albicans form (DRF) and weak biofilm Candida albicans form (WBF), respectively. The gas-liquid phase culture model of human airway epithelial cells was isolated and established in vitro and divided into five groups, including blank control group (n=20), standard strain group (n=20), strong biofilm group (n=19), weak biofilm group (n=17) and fluconazole-resistant group (n=18).The morphology of the epithelial cells was observed by scanning electron microscope (SEM), and the expression of marker protein in the model was detected by immunofluorescence in vitro. The level of lactate dehydrogenase (LDH) in cells was detected by microplate method, and the secretion of β-defensin (hBD2), granulocyte macrophage colony stimulating factor(GM-CSF) and granulocyte colony-stimulating factor (G-CSF) was detected by enzyme-linked immunosorbent assay (ELISA).

The strong biofilm strains grew with interlacing mycelia, and very few yeast cells could be seen wrapped in them.SEM observed that the mycelia of epithelial cells in gas-liquid phase culture could actively invade epithelial cells, and the expression of acetylated tubulin and keratin in cilia were significantly reduced, while the expression of Ki67 was down-regulated.The LDH levels in the blank control group, standard strain group, strong biofilm group, weak biofilm group, and fluconazole-resistant group were (12.21±5.68), (46.35±6.35), (18.69±4.38), (12.56±3.69), and (13.48±4.28) U/L, respectively, with statistically significant differences (P<0.001). Compared with standard strain group, LDH level in strong biofilm group, weak biofilm group and fluconazole resistant group were significantly decreased (all P<0.01). The hBD2 levels of the five groups were (26.14±0.77), (56.18±0.83), (30.66±2.59), (29.22±0.48), (28.28±1.56) ng/L, respectively, with statistically significant differences(P<0.001). Compared with the blank control group, SC5314-treated epithelial cells induced an increase of intracellular hBD2 expression (P<0.001). The differences in the expression of GM-CSF and G-CSF between different groups were not statistically significant(all P>0.05).

Strong biofilm Candida albican can inhibit cell proliferation, disrupt the integrity of epithelial cells and induce cell damage by down-regulating the expression of cell proliferation-related protein.

To investigate the current status of cognition and decision-making on seizure prophylaxis after aneurysmal subarachnoid hemorrhage in Chinese neurosurgeons. A questionnaire for this theme was designed and sent to respondents through the "Questionnaire Star" network platform. From July to October 2021, a total of 43 eligible questionnaires were collected. All respondents came from affiliated hospitals of medical schools across China. Each of these hospitals treated more than one hundred patients with aneurysmal subarachnoid hemorrhage per year. Only 9.3% (4/43) of respondents disagreed with the prophylactic use of anticonvulsants. However, 86.04% (37/43) of respondents performed seizure prophylaxis in clinical practice. Sodium valproate was the most commonly used regimen, and 94.59% (35/37) of respondents used this drug. The medication period differed sharply among different hospitals, from less than 3 days to longer than 14 days. The use of electroencephalography (EEG) was insufficient in Chinese patients, and a low seizure rate was reported according to the feedback from Chinese neurosurgeons. To date, seizure prophylaxis after subarachnoid hemorrhage was not yet standardized in China, and clinicians′ mastery of relevant knowledge is still not enough. Therefore, carrying out high-quality clinical research can help clarify the use of anticonvulsants, which could also positively impact rational drug use.

The clinical data, diagnosis, treatment, and prognosis of 10 patients with anti-glutamic acid decarboxylase (GAD) antibody-related cerebellar ataxia in Department of Neurology, Peking Union Medical College Hospital, from May 2015 to November 2021 were retrospectively analyzed. There were 8 female patients with a median age of 55 years old. Patients mainly presented with gait ataxia (10/10), dizziness (8/10), diplopia (6/10), and dysarthria (5/10). Four of them were complicated with other autoimmune disease, including vitiligo (3/4), Hashimoto thyroiditis (1/4), thrombocytopenia (1/4), and small cell lung cancer (1/4). All patients received immunotherapy, 6 out of 10 exhibited a good response, and half of them had satisfied functional prognosis. Patients of anti-GAD antibody-related cerebellar ataxia may be complicated with other autoimmune diseases, but underlying tumor is rare. More than half of patients have a good response to immunotherapy and satisfied prognosis.

Reactive cutaneous capillary hyperplasia (RCCEP) is a cutaneous immune adverse reaction with high incidence during immunotherapy. Grade 3 and above reactions greatly affect the appearance and quality of life of patients. This paper reports an elderly female patient with lung cancer who received immunotherapy combined with chemotherapy for 4 cycles and was treated with compound lactic acid bacteria metabolites, and achieved partial remission. The patient developed RCCEP Grade 1 after Cycle 2 treatment; After the fourth cycle of treatment, RCCEP increased slightly; Compound lactic acid bacteria metabolites were discontinued after cycle 4; After the fifth cycle of treatment, the patient's facial RCCEP increased significantly, reaching grade 3. This case suggests that complex lactic acid bacteria metabolites may have a positive role in improving RCCEP in patients with immunotherapy combined with chemotherapy.

Osteoporosis is a systemic metabolic bone disease characterized by decreased bone strength leading to increased bone fragility and fracture. Due to insufficient understanding of the serious consequences of osteoporosis, unclear identification of early symptoms and risk factors, low diagnosis and treatment rate, and even misunderstandings or blind spots in clinical treatment strategies, these may delay the opportunity of effective treatment for patients, resulting in serious consequences such as unsatisfactory treatment effect, repeated fractures, high disability rate, poor quality of life, loose screws and unstable internal fixation. Because a single anti-osteoporosis drug cannot be used throughout the whole disease, it is particularly important to adhere to long-term sequential treatment, and the combination of drugs with the same mechanism of action is not recommended unless necessary. Only by paying attention to these problems in the treatment of osteoporosis in clinic can we promote the rational application of osteoporosis treatment drugs.

With the further ageing of China's population, the number of patients with abdominal aortic aneurysm has also increased significantly. At present, the treatment of abdominal aortic aneurysm is still relatively simple, and surgical intervention is the main treatment. The treatment of some early and asymptomatic aneurysms is the direction we pay more attention to at this stage. Inflammatory bodies are the hot research topic at present, and many studies have proved that they play an important role in the occurrence of cardiovascular diseases. In-depth research on the relationship between inflammatory bodies and the pathogenesis of abdominal aortic aneurysm is expected to provide new targets for its future prevention, diagnosis and treatment. In this paper, the basic structure of inflammatory bodies such as nucleotide binding oligomerization domain-like receptor protein (NLRP) -3 and melanoma deficiency factor (AIM) -2, their expression level in abdominal aortic aneurysm and their role in the pathogenesis of abdominal aortic aneurysm were reviewed.

Initiation of venous-arterial extracorporeal membrane oxygenation (VA-ECMO) therapy for patients with cardiogenic shock has become an increasingly common measure, including patients with cardiac arrest who have failed conventional therapy. Patients with refractory cardiogenic shock who require VA-ECMO support may have the most severe ischemia-reperfusion injury. Although hypothermia is not currently demonstrated to significantly improve hemodynamics and mortality, moderate hypothermia attenuates the deleterious effects of ischemia-reperfusion injury and is well tolerated in patients with cardiac arrest and cardiogenic shock. In view of the absence of outcome data addressing this issue, in vitro life support currently recommends that these patients maintain normal body temperature. Although there is currently a lack of randomized clinical studies comparing standard therapy alone with standard therapy in combination with ECMO, the use of ECMO in the treatment of refractory cardiogenic shock is gradually increasing worldwide, so it is necessary to determine the optimal treatment. This HYPO-ECMO study was designed to verify whether early application of moderate hypothermia (33℃ ~34℃) can improve the prognosis of patients with refractory cardiogenic shock supported by VA-ECMO compared with strict control of normal body temperature (36℃ ~37℃).

Extracorporeal membrane oxygenation (ECMO) has been widely used to treat patients with severe respiratory failure caused by novel coronavirus pneumonia (COVID-19). Some reports have shown higher mortality rates in these COVID-19 patients treated with ECMO, while some other studies have found ECMO treatment to improve prognosis. Among them, a recent retrospective study found a pooled in-hospital mortality rate of 37.1%, which is comparable to mortality from pandemic influenza and non-COVID-19-caused acute respiratory distress syndrome. The consensus guidelines give cautious recommendations for the application of ECMO support in specific COVID-19 patients. Limited evidence from causal analyses of cohorts of ECMO-supported COVID-19 patients suggests that ECMO may have a survival benefit for such patients. However, considering different selection criteria, outcome judgment criteria, and patient baseline characteristics, the additional benefits of ECMO for patients with severe respiratory failure caused by COVID-19 are currently uncertain. At the start of the COVID-19 pandemic, a centralized national referral system was established in the UK, providing a unified pathway for those COVID-19 patients who may need ECMO support to be referred to specialist centres. The large number of referrals, as well as the detailed data recorded through the referral system, prompted the ability to use ECMO as an intervention to analyze a large cohort of patients with severe respiratory failure with COVID-19 with detailed records.