Volume 103 ·  Issue 23 ·  2023

Endovascular catheters play an important role in modern medical diagnosis and treatment. Catheter-related bloodstream infection (CRBSI) is one of the common complications during catheter indwelling, which seriously affects the prognosis of patients. In order to standardize the prevention, diagnosis and treatment strategies of catheter-related bloodstream infections in the Department of Anesthesiology in China, the perioperative Infection Control Branch of the Chinese Society of Cardiothoracic Anesthesia reached a consensus based on the current evidence-based medicine. The consensus elaborates on the aspects of diagnosis, prevention strategy, maintenance and treatment of catheter-associated bloodstream infection, aiming to provide reference for the standardized diagnosis, treatment and management of catheter-associated bloodstream infection in the Department of Anesthesiology.

To explore the effect of blood lipids on the lesion distribution pattern in patients with acute ischemic stroke by using MRI technology based on population standard spatial analysis.

The MRI data of 1 202 patients with acute ischemic stroke in General Hospital of Eastern Theater Command from January 2015 to December 2020 and Nanjing First Hospital from January 2013 to December 2021 were retrospectively collected, including 871 males and 331 females, aged 26 to 94 (64±11) years. According to the condition of blood lipids, they were divided into the dyslipidemia group (n=683) and the normal blood lipids group (n=519). After the automatic segmentation of diffusion-weighted imaging (DWI) images by artificial intelligence, the infarct sites were registered to the standard space which was used to draw the frequency heat map. The chi-square test was used to compare the difference in lesion location between the two groups. Generalized linear model regression analysis was used to observe the correlation between each blood lipid index and lesion site, and inter-group comparison and correlation analysis were used to observe the relationship between each blood lipid index and lesion volume.

Compared with the normal blood lipid group, the lesions in the dyslipidemia group were more extensive, mostly distributed in the occipital temporal region of the right posterior cerebral artery and the frontal region of the left middle cerebral artery. The brain regions of higher triglyceride(TG) and higher low-density lipoprotein cholesterol(LDL-C) groups were concentrated in the posterior circulation. The brain regions in the higher total cholesterol(TC) and lower high-density lipoprotein cholesterol(HDL-C) groups were concentrated in the anterior circulation(all P<0.05). In the anterior circulation infarct volume, the higher TC group was significantly higher than the normal TC group[(27.58±5.34) vs (17.73±1.18)ml, P=0.029]. In the posterior circulation infarct volume, the higher LDL-C group and the TG group were significantly higher than the normal LDL-C and TG groups[(7.55±2.51) vs (3.55±0.31) ml; (5.76±1.19) vs (3.36±0.30) ml](both P<0.05). Correlation analysis showed that TC and LDL-C were non-linearly (U-shaped) correlated with anterior circulation infarct volume (both P<0.05).

Different blood lipids have effects on the distribution pattern and volume of ischemic stroke infarcts. Different hyperlipidemia is related to the specific distribution site and the larger extent of infarction.

To investigate the clinical, biological and prognostic characteristics of leukemic non-nodal mantle cell lymphoma (nnMCL).

The clinical data of 14 patients with nnMCL and 238 patients with classical mantle cell lymphoma (cMCL) in Blood Diseases Hospital, Chinese Academy of Medical Sciences from November 2000 to October 2020 were retrospectively analyzed. Among the 14 patients with nnMCL, there were 9 males and 5 females, with the age [M (Q₁, Q₃)] of 57.5 (52.3, 67.0) years. Among the 238 patients with cMCL, there were 187 males and 51 females, with the age of 58.0 (51.0, 65.3) years. The clinical and biological characteristics of the two groups were recorded and compared. Follow-up and efficacy evaluation were conducted by re-examination during hospital stay and telephone follow-up and so on.

The proportion of CD200 expression in nnMCL patients was 8/14, which was higher than that in cMCL patients [14.6% (19/130)] (P=0.001). The proportion of CD23 expression in nnMCL patients was 8/14, which was higher than that in cMCL patients [13.5% (23/171)] (P<0.001). The proportion of CD5 expression in nnMCL patients was 10/14, which was lower than that in cMCL patients [97.4% (184/189)] (P=0.001). The proportion of CD38 expression in nnMCL patients was 4/14, which was lower than that in cMCL patients [69.6% (112/161)] (P=0.005). The expression proportion of sex-determining region of Y chromosome-related high-mobility-group box 11 (SOX11) in nnMCL patients was 1/5, which was lower than that in cMCL patients [77.9% (60/77)] (P=0.014). The proportion of immunoglobulin heavy chain variable region (IGHV) mutations in nnMCL patients was 11/11, which was higher than that in cMCL patients [26.0% (13/50)] (P<0.001). As of April 11, 2021, the follow-up time for nnMCL and cMCL patients was 31 (8-89) months and 48 (0-195) months, respectively. Among the 14 nnMCL patients, 6 patients were still under observation, and 8 patients were treated. The overall response rate (ORR) was 8/8, including 4 patients with complete remission and 4 patients with partial response. The median overall survival and median progression-free survival were not reached in nnMCL patients. In the cMCL group, 50.0% (112/224) patients achieved a complete response, 24.6% (55/224) patients achieved a partial response, and ORR was 74.6% (167/224). There was no statistically significant difference in ORR between the two groups (P=0.205).

nnMCL patients have an indolent progression, with higher expression rates of CD23 and CD200 and lower expression rates of SOX11, CD5 and CD38. Most patients have IGHV mutations, with a relatively good prognosis, and"watch and wait"approach is an optional treatment.

To explore the efficacy of intravenous thrombolysis with tenecteplase (TNK) in the treatment of branch atheromatous disease (BAD).

A total of 148 BAD patients hospitalized in the stroke center of Zhengzhou People′s Hospital from January 2020 to March 2023 were retrospectively included. According to whether TNK was used for treatment, the patients were divided into the TNK group (52 cases) and the control group (96 cases). The propensity score matching (PSM) method was used to eliminate baseline differences between the two groups, and 46 pairs were successfully matched. Early neurological deterioration (END) was defined as an increase in the national Institutes of Health Stroke Scale (NIHSS) scores within 7 days of stroke≥2. The 90-day modified Rankin Scale (mRS) was used to compare the long-term efficacy between the two groups. A binary logistic regression model was used to analyze the influencing factors of clinical outcomes in patients with BAD.

Among the 92 patients, 62 were males and 30 were females, with an average age of (61.0±9.5) years. After PSM, there were statistically significant differences in NIHSS score at discharge [2 (0, 4) vs 4 (3, 8)] and length of hospital stay [9 (6, 13) d vs 11 (9, 14) d] (both P<0.05) between the two groups. The proportion of mRS 0-2 in TNK group was higher than that in the control group [82.6%(38/46) vs 60.8%(28/46)], while the proportion of END and mRS≥4 was lower than that in the control group [10.8%(5/46) vs 30.4%(14/46); 8.7%(4/46) vs 26.0%(12/46)], with statistically significant differences (P<0.05). The 90-day mortality in the control group was 2.2% (1/46), while no death was detected in the TNK group.

Intravenous thrombolysis therapy with TNK can not only increase the proportion of 90-day mRS 0-2 in BAD patients, but also reduce the incidence of END.

To analyze the influence of vitamin D supplementation on clinical efficacy and drug retention rate of vedolizumab (VDZ) in patients with ulcerative colitis (UC).

Retrospective study. By retrieving the clinical database of the Second Affiliated Hospital of Wenzhou Medical University, the patients with moderately to severely active UC were collected, who underwent VDZ treatment from January 2020 to June 2022. The modified Mayo score and Mayo endoscopic score (MES) were employed to evaluate disease activity and intestinal inflammation in UC patients, respectively. According to whether vitamin D was supplemented during VDZ treatment, the patients were divided into supplementary group and non-supplementary group. According to baseline serum 25(OH) D level, UC patients were divided into vitamin D deficiency group and non-deficiency group. According to whether vitamin D was supplemented, the patients of each group were divided into supplementary subgroup and non-supplementary subgroup, respectively. The clinical response rate, clinical remission rate and mucosal healing rate at week 30 after receiving VDZ treatment and the retention rate of VDZ at the 72nd week were observed. The effect of baseline serum 25 (OH) D level on the efficacy of vitamin D supplementation was analyzed by chi-square test. The effects of vitamin D supplementation on the clinical efficacy and drug retention of VDZ in UC were analyzed by chi-square test and Kaplan-Meier curve, respectively.

A total of 80 patients with moderately to severely active UC, who were aged (39.4±13.0) years(18-75 years), 37 male and 43 female, were included. There were 43 cases in supplementary group and 37 cases in non-supplementary group. There were 59 cases in the deficiency group, including 32 cases in the supplementary subgroup and 27 cases in the non-supplementary subgroup. There were 21 cases in the non-deficiency group, including 11 cases in the supplementary subgroup and 10 cases in the non-supplementary subgroup. At week 30, the average level of serum 25(OH) D was shown to be higher in supplementary group than that at week 0 [(24.5±5.4) vs (17.7±6.7) μg/L, P<0.001]. At week 30, in contrast with non-supplementary group, erythrocyte sedimentation rate(ESR)[75.0% (24.3%, 86.7%) vs 32.7% (-2.6%, 59.3%), P=0.005] and modified Mayo score [(4.7±2.8) vs (2.3±2.7) points, P<0.001] and MES score [(1.2±1.1) vs (0.4±0.9) points, P=0.001] were significantly reduced, clinical response rate [79.1%(34/43) vs 56.8%(21/37), P=0.032], clinical remission rate [67.4%(29/43) vs 29.7%(11/37), P=0.001] and mucosal healing rate [72.1%(31/43) vs 37.8%(14/37), P=0.002] were higher. At week 72, drug retention rate of VDZ was shown to be higher in supplementary group than in non-supplementary group [55.8%(24/43) vs 27.0%(10/37), P=0.004]. The further analysis showed that vitamin D supplementation could only improve clinical response rate[71.9%(23/32) vs 44.4%(12/27), P=0.033], clinical remission rate[62.5%(20/32) vs 14.8%(4/27), P<0.001], mucosal healing rate[68.8%(22/32) vs 22.2%(6/27), P<0.001] and drug retention rate [53.1%(17/32) vs 13.8%(4/27), P=0.001] in the patients with vitamin D deficiency.

Vitamin D supplementation contributes to improving clinical response rate, clinical remission rate, mucosal healing rate and drug retention rate of VDZ in UC patients.

To summarize the efficacy and safety of minimally invasive esophagectomy through cervical and abdominal double single-port.

A total of 28 patients who underwent cervical and abdominal double single-port minimally invasive radical resection of esophageal cancer from January 2021 to October 2022 in the First Affiliated Hospital of Fujian Medical University were retrospectively collected, including 18 males and 10 females, aged 58-80 (72±4) years. All patients were placed in the supine position, the single port was operated through the cervical mediastinum first, then the single port was operated through the abdominal cavity, and finally the neck was anastomosed. The operative time, intraoperative blood loss, postoperative ambulation time, postoperative drainage tube removal time, postoperative complications, postoperative pathological examination results, postoperative discharge time of patients were recorded and followed.

In the included 28 patients, there were twenty-six patients successfully completed the cervical and abdominal double single-port minimally invasive radical resection of esophageal cancer, and two patients were transferred to the right thoracoscopic surgery due to oozing of blood and unclear visual field, without conversion to laparotomy or enlargement of the incision occurred. The operation time was 125 to 215 (152±32) minutes, including 43 to 100 (56±15) minutes in the mediastinum and 35 to 63 (40±5) minutes in the abdominal cavity. Intra-operative blood loss was 55-100 (45±20) ml. There were 8 to 14 (11±3) lymph nodes dissected in the mediastinum and 7 to 15 (9±3) lymph nodes dissected in the abdominal cavity. Twenty-eight patients were active in bed 1 to 2 days after surgery. The left cervical drainage tube was removed 2 days after surgery. There was no anastomotic fistula, anastomotic stenosis, pulmonary infection, chylothorax and stomach emptying disorder in the whole group. Pleural effusion occurred in 4 cases, all of them had pleural damage during the operation, and were cured after postoperative puncture and drainage; two cases had hoarseness and one case had cough after eating, all patients were discharged from hospital after eating liquid. Postoperative hospital median stay was [ M(Q₁, Q₃)] 7(6, 9) d. The postoperative pathological examination results of all patients were squamous cell carcinoma, and the postoperative pathological stage was pT1-3N0-1M0. The median postoperative follow-up was 25 (5, 35) months, and no patients had complications, recurrence, metastasis or death during the follow-up period.

The cervical and abdominal double single-hole minimally invasive radical resection of esophageal cancer is safe and feasible, with good short-term efficacy, which provide an opportunity for radical surgery for patients with advanced age, poor cardiopulmonary function or insufficient thoracic conditions.

To compare the intraoperative neurophysiological monitoring (IONM) results between patients with arthrogryposis multiplex congenita (AMC) and adolescent idiopathic scoliosis (AIS) and to analyze the influence of congenital spinal deformity on IONM in AMC patients, thus to evaluate the efficiency of IONM in AMC patients.

A cross-sectional study. The clinical data of 19 AMC patients underwent correction surgery from July 2013 to January 2022 in Nanjing Drum Tower Hospital were retrospectively reviewed. There were 13 males and 6 females with a mean age of (15.2±5.6) years, and the average Cobb angle of main curve was 60.8°±27.7°. And 57 female AIS patients of similar age and curve type with the AMC patients during the same period were selected as the control group, with an average age of (14.6±4.4) years and a mean Cobb angle of 55.2°±14.2°. The latency and amplitude of samatosensory evoked potentials (SSEPs) and transcranial electric motor evoked potentials (TCeMEPs) were compared between the two groups. The difference in IONM data between AMC patients with and without congenital spinal deformity was also evaluated.

The success rates of SSEPs and TCeMEPs were 100% and 14/19 for AMC patients, 100% and 100% for AIS patients. The SSEPs-P40 latency, SSEPs-N50 latency, SSEPs-amplitude, TCeMEPs-latency, TCeMEPs-amplitude showed no significant difference between AMC patients and AIS patients (P>0.05 for all). The side-difference of TCeMEPs-amplitude showed an increasing trend in AMC patients when compared with that in AIS patients, but there was no statistical difference between the two groups [(147.0±185.6) μV vs (68.1±311.4) μV, P=0.198]. The SSEPs-amplitude value was (1.4±1.1) μV on concave side in AMC patients with congenital spinal deformity, and it was (2.6±1.2) μV on concave side in AMC patients without congenital spinal deformity (P=0.041). The SSEPs-amplitude value was (1.4±0.8) μV on convex side in AMC patients with congenital spinal deformity, and it was (2.6±1.3) μV on convex side in AMC patients without congenital spinal deformity (P=0.028).

The values of SSEPs-P40 latency, SSEPs-N50 latency, SSEPs-amplitude, TCeMEPs-latency and TCeMEPs-amplitude are similar in AMC and AIS patients. The SSEPs-amplitude of AMC patients with congenital spinal deformity is lower than that of AMC patients without congenital spinal deformity.

To investigate the clinical efficacy and safety of ¹²⁵I seed implantation in the treatment of mediastinal lymph node metastasis of lung cancer.

Clinical data of 36 patients who underwent CT-guided ¹²⁵I seed implantation for mediastinal lymph node metastasis of lung cancer from August 2013 to April 2020 in three hospitals of the Northern radioactive particle implantation treatment collaboration group were retrospectively collected, including 24 males and 12 females, aged 46 to 84 years. Cox regression model was used to analyze the relationship between local control rate, survival rate and tumor stage, pathological type, postoperative D90, postoperative D100 and other variables, and to analyze the occurrence of complications.

The objective response rate of CT-guided ¹²⁵I seed implantation in the treatment of mediastinal lymph node metastasis of lung cancer was 75% (27/36), the median control time was 12 months, the 1-year local control rate was 47.2% (17/36), and the median survival time was 17 months. The 1-year and 2-year survival rates were 61.1% (22/36) and 22.2% (8/36) respectively. Univariate analysis showed that in the treatment of mediastinal lymph node metastasis with CT-guided ¹²⁵I implantation, factors related to local control included tumor stage (HR=5.246, 95%CI: 2.243-12.268, P<0.001), postoperative D90 (HR=0.191, 95%CI: 0.085-0.431, P<0.001), postoperative D100 (HR=0.240, 95%CI: 0.108-0.533, P<0.001); The factors affecting survival were tumor stage (HR=2.712, 95%CI: 1.356-5.425, P=0.005), postoperative D90 (HR=0.110, 95%CI: 0.041-0.294, P<0.001), postoperative D100 (HR=0.212, 95%CI: 0.092-0.489, P<0.001). Multivariate analysis showed that tumor stage (HR=5.305, 95%CI: 2.187-12.872, P<0.001) and postoperative D100 (HR=0.237, 95%CI: 0.099-0.568, P<0.001) were correlated with local control rate. Tumor stage (HR=2.347, 95%CI: 1.095-5.032, P=0.028) and postoperative D90 (HR=0.144, 95%CI: 0.051-0.410, P<0.001) were correlated with survival. In terms of complications, 9 of the 36 patients had pneumothorax, and 1 of them was cured by closed thoracic drainage for severe pneumothorax; 5 cases developed pulmonary hemorrhage and 5 cases developed hemoptysis, which recovered after hemostasis treatment. One case developed pulmonary infection and recovered after anti-inflammatory treatment. No radiation esophagitis and radiation pneumonia occurred; No grade 3 or higher complications occurred.

¹²⁵I seed implantation in the treatment of lung cancer mediastinal lymph node metastasis has a high local control rate and controllable adverse effects.

To explore the correlation between electrical impedance indicators and commonly used nutritional indicators in neurocritical care patients.

A cross-sectional study was conducted to collect 58 neurocritical care patients in neurosurgery Department of Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine from June to September 2022. Bioelectrical impedance tests were performed after surgery or one week after injury, and nutrition-related biochemical indicators of the patients were collected on the same day, including nutritional status related indicators, inflammation related indicators, anemia related indicators and blood lipid related indicators. The patients were assessed with acute physiology and chronic health evaluation (APACHE) Ⅱ score and sequential organ failure assessment (SOFA) score. Based on the results obtained, the patients were assessed with nutritional score and spearman correlation analysis. The correlations of electrical impedance with nutrition related indicators and nutrition risk related indicators were analyzed. The prediction model of nutritional status was constructed by multi-factor binary logistic regression. Stepwise regression was used to screen electrical impedance indicators related to nutritional status. The receiver operating characteristic (ROC) curve was plotted and the area under the curve (AUC) was calculated to evaluate the predictive ability of the nutritional status prediction model.

A total of 58 patients were collected, including 33 males and 25 females, and aged 72.0 (59.0, 81.8) years. Extracellular water (ECW) was positively correlated with interleukin 6 (r=0.529, P<0.001). The edema index [ECW/total body water (TBW)] was negatively correlated with albumin (r=-0.700, P<0.001), hematocrit (r=-0.641, P<0.001) and hemoglobin (r=-0.667, P<0.001). The phase angle was positively correlated with albumin (r_RA=0.667, r_LA=0.649, r_RL=0.669, r_LL=0.685, all P<0.001), hematocrit (r_RA=0.600, r_LA=0.604, r_TR=0.565, r_RL=0.529, r_LL=0.602, all P<0.001) and hemoglobin (r_RA=0.626, r_LA=0.635, r_TR=0.594, r_RL=0.624, r_LL=0.631, all P<0.001). By stepwise regression screening of predictive factors for nutritional status and incorporating age, gender and white blood cells as confounding factors into the model, the final model was obtained as follows: nutritional status=-0.01×age+1.22×gender-0.12×white blood cells+202.20×ECW/TBW+0.5 torso phase angle -82.16 [The OR value of ECW/TBW: 20.8 (95%CI: 3.7-117.1), P<0.001], with the AUC of 0.921.

Bioelectrical impedance indicators have good correlations with commonly used clinical nutritional indicators, and can provide a new method for nutritional evaluation of neurocritical care patients.

The current study aimed to investigate the clinical characteristics of Parkinson′s disease (PD) patients with concomitant periodic limb movements in sleep (PLMS). The clinical data of 36 PD patients who underwent polysomnography (PSG) in Beijing Tiantan Hospital from October 2018 to July 2022 were collected. Unified Parkinson′s Disease Rating Scale 3.0 and Hoehn & Yahr (H-Y) stage were used to evaluate the disease severity. Patients were divided into two groups: the PLMS+group periodic limb movements in sleep index [(PLMSI)≥15 times/h] and the PLMS-group (PLMSI<15 times/h), using the PLMSI 15 times/h as the cut-off value. The clinical characteristics between the two groups were compared. There were 15 patients (42%) in the PLMS+group and 21 patients (58%) in the PLMS-group, among which 12 patients (12/15) in the PLMS+group and 9 patients (42.9%) in the PLMS-group had rapid eye movement sleep behavior disorder (RBD). The rate of RBD in PLMS+group was higher than that in PLMS-group (P<0.05). There was statistically significant difference in the blood folate level between the PLMS-group and PLMS+group [6.20 (5.14, 11.70) ng/ml vs 4.41 (3.07, 5.64) ng/ml] (P<0.01). Folate deficiency was more common in the PLMS+group, while no statistically significant differences were found in homocysteine and ferritin levels (both P>0.05). Four patients in the PLMS+group had falling experience, while 14.3% (3/21) patients in the PLMS-group had falling experience. Patients in the PLMS+group were more likely to fall. The PLMS+group had higher arousal index according to PSG [PLMS-group: 11.90 (9.10, 15.80) times/h; PLMS+group: 21.50 (19.35, 29.90) times/h] (P<0.05). No statistically significant differences in other sleep parameters were detected between the two groups (all P>0.05). Meanwhile, the apnea-hypopnea index (AHI) in both groups was higher than normal (<5 times/h), of which the PLMS-group was 9.80 (4.70, 22.20) times/h and the PLMS+group was 8.20 (1.70, 11.15) times/h, indicating that PD patients were more likely to experience sleep apnea and hypopnea. PD patients with PLMS had lower folate level, higher risk for falls, higher sleep arousal index, more sleep fragmentation, and higher prevalence of RBD.

This study takes Cushing′s syndrome, a rare disease, as a model, and adopts the path of "Plan, Do, Check, Action" (PDCA) to explore new methods to optimize the clinical path, can improve the quality and efficiency of diagnosis and treatment of rare diseases. After sorting out the problems existing in the previous diagnosis and treatment mode, our team optimizes the path in various ways and establishes a standard operation procedure (SOP) for the new path. In the evaluation of the optimized mode, 55 patients with Cushing′s syndrome were admitted to the Department of Endocrinology, Peking Union Medical College Hospital, including 19 males and 36 females, aged (41.8±14.4) years (6-68 years). The pathway group (28 cases) and the control group (27 cases) were divided according to whether they were included in the new path management at the time of admission, and the effect of path optimization was assessed in terms of time, efficacy, safety and cost. The results showed that compared with the control group, the pathway group had a shorter time of hospitalization in the Department of Endocrinology and critical tests, such as blood cortisol rhythm, low-dose dexamethasone inhibition test, and bilateral inferior petrosal sinus sampling (all P<0.05). There was no significant differences in the decrease of total cortisol after operation, the incidence of postoperative complications, and hospitalization expenses (all P>0.05). The optimized path improves the medical efficiency while ensuring medical quality, safety and no increase in cost. This study proposes PDCA path optimization for complex diseases and establishes SOP process, which provides experience in management optimization for the patient-centered and clinical path-oriented diagnosis and treatment mode of rare diseases.

The 31-year-old female was admitted to the Department of Hematology of Peking Union Medical College Hospital on August 9, 2017 due to "yellowing skin since childhood, repeated aggravation with fatigue for more than 1 year". Significant prolongation of activated partial thromboplastin time (APTT) and simultaneous atrial and thoracic paravertebral occupancy were found during the course of the disease. Severe anemia difficult to explain by hereditary spherocytosis alone after atrial space-occupying resection. The diagnosis of antiphospholipid syndrome was confirmed by the pathological findings of atrial mass occupation with prolonged APTT as the entry point. At the same time, in view of the aggravation of postoperative anemia, further examination found that the patient had positive type III cryoglobulin and cold agglutinin tests. It was considered that the patient had both cryoglobulinemia and autoimmune hemolytic anemia, and on this basis, hereditary spherocytosis. After admission, warfarin anticoagulant therapy was continued, plus hydroxychloroquine and aspirin. For autoimmune hemolytic anemia, prednisone 1 mg/kg for 1 month and rituximab 375 mg/m²Single infusion. After 1 month, the patient's hemoglobin rose to 105 g/L, and the erythrocyte sedimentation rate returned to normal. After 3 months of treatment, the patient's cryoglobulinemia and cold agglutinin test turned negative.