HBV infection decreases risk of liver metastasis in patients with colorectal cancer:A cohort study

AIM:To evaluate the effect of hepatitis B virus (HBV) infection on liver metastasis of colorectal cancer.METHODS:A total of 1298 colorectal cancer patients were recruited from January 2001 to March 2005 in this study.Enzyme-linked immunosorbent assay was used to test serum HBV markers for colorectal cancer.Patients were divided into study (infection) group and control (non-infection) group.Clinical features of patients in two groups were compared.RESULTS:Liver metastasis was found in 319 out of the 1298 colorectal cancer patients.The incidence of liver metastasis was significantly lower in study group than in control group (14.2% vs 28.2%,P < 0.01).HBV infection significantly decreased the risk of liver metastasis [hazard ratio (HR):0.50,95% confidence interval (95% CI):0.38-0.66],but the incidence of extrahepatic metastasis was significantly higher in study group than in control group (31.9% vs 17.0%,P < 0.01).The HR was the lowest in chronic hepatitis B group (HR:0.29,95% CI:0.12-0.72).The number of liver metastatic lesions was significantly less in study group than in control group with a higher surgical resection rate.However,no significant difference was found in survival rate between the two groups (P=0.95).CONCLUSION:HBV infection decreases the risk of liver metastasis in patients with colorectal cancer and elevates the surgical resection rate of liver metastatic lesions.

Effect of early goal directed therapy on tissue perfusion in patients with septic shock

BACKGROUND:This study aimed to observe the effect of early goal directed therapy(EGDT)on tissue perfusion,microcirculation and tissue oxygenation in patients with septic shock.METHODS:Patients with early septic shock(<24 hours) who had been admitted to the ICU of Zhongda Hospital Affiliated to Southeast University from September 2009 through May 2011 were enrolled(research time:12 months),and they didn't meet the criteria of EGDT.Patients who had one of the following were excluded:stroke,brain injury,other types of shock,severe heart failure,acute myocardial infarction,age below 18 years,pregnancy,end-stage disease,cardiac arrest,extensive burns,oral bleeding,difficulty in opening the mouth,and the onset of septic shock beyond 24 hours.Patients treated with the standard protocol of EGDT were included.Transcutaneous pressure of oxygen and carbon dioxide(PtcO_2,PtcCO_2) were monitored and hemodynamic measurements were obtained.Side-stream dark field(SDF) imaging device was applied to obtain sublingual microcirculation.Hemodynamics,tissue oxygen,and sublingual microcirculation were compared before and after EGDT.If the variable meets the normal distribution,Student's t test was applied.Otherwise,Wilcoxon's rank-sum test was used.Correlation between variables was analyzed with Pearson's product-moment correlation coefficient method.RESULTS:Twenty patients were involved,but one patient wasn't analyzed because he didn't meet the EGDT criteria.PtcO_2 and PtcCO_2 were monitored in 19 patients,of whom sublingual microcirculation was obtained.After EGDT,PtcO_2 increased from 62.7+24.0 mmHg to 78.0±30.9mmHg(P<0.05) and tissue oxygenation index(PtcO_2/FiO_2) was 110.7+60.4 mmHg before EGDT and 141.6±78.2 mmHg after EGDT(P<0.05).The difference between PtcCO_2 and PCO_2 decreased significantly after EGDT(P<0.05).The density of perfused small vessels(PPV) and microcirculatory flow index of small vessels(MFI) tended to increase,but there were no significant differences between them(P>0.05).PtcO_2,PtcO_2/FiO_2,and PtcCO_2 were not linearly related to central venous saturation,lactate,oxygen delivery,and oxygen consumption(P>0.05).CONCLUSION:Peripheral perfusion was improved after EGDT in patients with septic shock,and it was not exactly reflected by the index of systemic perfusion.

Changes of microcirculation in healthy volunteers and patients with septic shock in Xining

Objective: The purpose of this study is to investigate the characteristic of microcirculation in healthy volunteers and patients with septic shock in both Xining(2 260 m) and Nanjing(10 m). Methods: A total of 62 cases, 33 healthy volunteers, 22 cases in Xining,(2 260 m above sea level) and 11 cases in Nanjing(10 m above sea level); and 29 septic shock, 13 cases in Xining and 16 cases in Nanjing were collected. The total vessel density(TVD), perfused vessel density(PVD), proportion of perfused vessel(PPV) and microcirculation flow index(MFI) of both healthy volunteers and septic shock had been investigated by using sidestream dark field(SDF). Analyzed and managed the image data by using AVA3.0 software. Results: In the healthy volunteers in Xining area(22 cases),the volume of TVD(15.59 ± 2.58 mm/mm^2), PVD(15.58 ± 2.58 mm/mm^2) and PPV(96.60% ± 4.63%) were significant higher than the volume of TVD(10.0 ± 2.10 mm/mm^2), PVD(10.81 ± 2.38 mm/mm^2) and PPV(84.24% ± 8.00%) of the volunteers(11 cases) in Nanjing(11 cases). But the MFI(2.17 ± 0.31) of the healthy volunteers in the Xining was significant lower(P<0.05) than the MFI(3.21 ± 0.34) in the healthy volunteers of Nanjing. In the septic shock group(13 cases) in the Xining, the volume of TVD(5.44 ± 1.94 mm/mm^2), PVD(4.18 ± 1.61 mm/mm^2), PPV(42.14%± 5.38%) and MFI(1.05 ± 0.32) compared with the volume of the healthy volunteers in Xining, the TVD(15.59 ± 2.58 mm/mm^2), PVD(5.58 ± 2.58 mm/mm^2), PPV(96.60% ± 4.63%) and MFI(2.17 ± 0.30) were significant lower(P<0.05). In the healthy volunteers compare with septic shock group in Nanjing area, the TVD(6.80±1.72 vs 10.00±2.10, P<0.05), PVD(5.86±1.58 vs10.81±2.38,P<0.05), PPV(45.42±4.86 vs 84.24±4.86, P<0.05), MFI(1.28±0.28 vs 3.21±0.34 P<0.05), there was significant decreased. In the septic shock group in the Xining compared with the septic shock in Nanjing, there was no significant difference. 10 of 13 patients with septic shock were survived in Xining. 13 of 16 patients with septic shock were survived in Nanjing. Conclusion: The changes of physiological and pathophysiological characteristic in microcirculation induced by hypoxia would be useful for clinical treatment of septic shock at high altitude.

Performance of risk stratification systems for gastrointestinal stromal tumors: A multicenter study

BACKGROUND Gastrointestinal stromal tumors(GISTs) are the most common mesenchymal tumor type in the gastrointestinal system. Presently, various classification systems to prognosticate GISTs have been proposed.AIM To evaluate the application value of four different risk stratification systems for GISTs.METHODS Patients who were diagnosed with GISTs and underwent surgical resection at four hospitals from 1998 to 2015 were identified from a database. Risk of recurrence was stratified by the modified National Institute of Health(NIH)criteria, the Armed Forces Institute of Pathology(AFIP) criteria, the Memorial Sloan Kettering Cancer Center(MSKCC) prognostic nomogram, and the contour maps. Receiver operating characteristic(ROC) curves were established to compare the four abovementioned risk stratification systems based on the area under the curve(AUC).RESULTS A total of 1303 patients were included in the study. The mean age of the patients was 55.77 ± 13.70 yr; 52.3% of the patients were male. The mean follow-up period was 64.91 ± 35.79 mo. Approximately 67.0% the tumors were located in the stomach, and 59.5% were smaller than 5 cm; 67.3% of the patients had a mitotic count ≤ 5/50 high-power fields(HPFs). Thirty-four tumors ruptured before and during surgery. Univariate analysis demonstrated that tumor size > 5 cm(P <0.05), mitotic count > 5/50 HPFs(P < 0.05), non-gastric location(P < 0.05), and tumor rupture(P < 0.05) were significantly associated with increased recurrence rates. According to the ROC curve, the AFIP criteria showed the largest AUC(0.754).CONCLUSION According to our data, the AFIP criteria were associated with a larger AUC than the NIH modified criteria, the MSKCC nomogram, and the contour maps, which might indicate that the AFIP criteria have better accuracy to support therapeutic decision-making for patients with GISTs.

Accumulated Clinical Experiences from Successful Treatment of 1377 Severe and Critically Ill COVID-19 Cases

Summary:In late December 2019,COVID-19 was firstly recognized in Wuhan,China and spread rapidly to all of the provinces of China.The West Campus of Wuhan Union Hospital,the designated hospital to admit and treat the severe and critically ill COVID-19 cases,has treated a large number of such patients with great success and obtained lots of valuable experiences based on the Chinese guideline(V7.0).To standardize and share the treatment procedures of severe and critically ill cases,Wuhan Union Hospital has established a working group and formulated an operational recommendation,including the monitoring,early warning indicators,and several treatment principles for severe and critically ill cases.The treatment experiences may provide some constructive suggestions for treating the severe and critically ill COVID-19 cases all over the world.

Effect of post recruitment maneuver ventilation by different tidal volume on lung vascular endothelial diastole function in rats with acute lung injury

BACKGROUND： This study aimed to observe the effect of recruitment maneuver （RM） and post-RM ventilation at different tidal volume on lung vascular diastole endothelial function in rats with acute lung injury （ALI）.METHODS： A ALl rat model was produced by intravenous infusion of lipopolysaccharide （6 mg/ kg）. Twenty-five rats were randomly divided into five groups： control group （n=5）, ALl group （n=5）, low tidal volume group （LV group, VT 6 mL/kg, n=5）, sustained inflation （SI） with low tidal volume group （SI＋LV group, VT 6 mL/kg, n=5）, and SI with moderate tidal volume group （SI＋MV group, VT 12 mL/ kg, n=5）. RM was performed with SI, airway pressure 30 cmH2O for 30 seconds, and positive end- expiratory pressure （PEEP） was set to 5 cmH2O. Lung tissue was taken after 5 hours of mechanical ventilation. Mean arterial blood pressure （MAP） was monitored during the experiment. Endothelin-1 （ET-1）, endothelial nitricoxide synthase （eNOS）, Ach-induced endothelium-dependent relaxation response of isolated pulmonary artery rings were determined at 5 hours. RESULTS：LPS increased ET-1 level, decreased the expression of eNOS in lung tissue, impaired the Ach-induced endothelium-dependent relaxation response in the pulmonary artery, without obvious effect on systemic hemodynamics. SI＋LV significantly reduced LPS-induced elevation of ET-1 level, increased the expression of eNOS, significantly improved endothelial dysfunction, and improved the dysfunction of endothelium-dependent relaxation in the pulmonary artery. CONCLUSIONS：RM with a high or low tidal volume ventilation could improve the lung vascular endothelial function of rats with acute lung injury, and RM with low tidal volume ventilation could lower significantly the injury of lung vascular endothelial diastole function in rats with acute lung injury.

Effects of pulmonary stretch reflex on lung injury in rabbits with acute respiratory distress syndrome

BACKGROUND： Pulmonary stretch reflex plays an important role in regulation of respiratorymovement. This study aimed to evaluate the effect of pulmonary stretch reflex on lung injury inrabbits with acute respiratory distress syndrome （ARDS）.METHODS： ARDS rabbits were given intratracheal infusion of hydrochloric acid and ventilatedwith neurally adjusted ventilatory assistance （NAVA） with a tidal volume （VT） of 6 mL/kg and theelectrical activity of diaphragm （EAdi）-determined positive end expiratory pressure. After isolation ofthe bilateral vagus nerve trunk, the rabbits were randomized into two groups： sham operation （SHAM）group （n=5） and bilateral vagotomy （VAG） group （n=5）. Gas exchange and respiratory mechanicswere detected at baseline, after lung injury and 1, 2, and 3 hours after ventilation respectively.Pulmonary permeability index, pathological changes and infl ammatory response were also measured.RESULTS： Compared with the SHAM group, PaO2/FiO2 in the VAG group decreased signifi cantly2 and 3 hours after ventilation （P〈0.05）. There was no significant difference in PaCO2 betweenthe SHAM and VAG groups （P〉0.05）, and the VAG group had a high VT, peak pressure （Ppeak）,and mean pressure （Pm） compared with the SHAM group 1, 2, 3 hours after ventilation （P〈0.05）.Compared to the SHAM group, dead space fraction （VD/VT） and respiratory system elastance （Ers）in the VAG group increased （P〈0.05） and static pulmonary compliance （Cst） decreased markedly（P〈0.05） after ventilation for 3 hours. Lung wet/dry weight ratio （W/D） （8.4±1.2 vs. 6.6±1.0）, lung injuryscore （6.3±1.8 vs. 3.8±1.3）, tumor necrosis factor-# （TNF-#） （779±372 pg/mL vs. 355±130 pg/mL）and interleukin-8 （IL-8） （169±21 pg/mL vs. 118±17 pg/mL） increased significantly in the VAG groupcompared with the SHAM group （P〈0.05）.CONCLUSION： Lung injury is aggravated after bilateral vagotomy, demonstrating thatpulmonary stretch refl ex may have protective effect on the lung.

Predictors and long-term prognosis of early and late recurrence for patients undergoing hepatic resection of hepatocellular carcinoma: a large-scale multicenter study

Recurrence is common among patients undergoing hepatic resection for hepatocellular carcinoma(HCC),which greatly limits long-term survival.We aimed to identify predictors and long-term prognosis of early and late recurrence after HCC resection.Methods:Multicenter data of patients who underwent HCC resection between 2002 and 2016 were analyzed.Recurrence was divided into early(≤2 years)and late recurrence(>2 years after surgery).Predictors of early and late recurrence,and prognostic factors of post-recurrence survival(PRS)were identified by univariate and multivariate analyses.Results:Among 1,426 patients,554(38.8%)and 348(24.4%)developed early and late recurrence,respectively.Independent predictors associated with early recurrence included preoperative alpha-fetoprotein level>400μg/L,resection margin<1 cm,and tumor size>5.0 cm,multiplicity,macrovascular and microvascular invasion,and satellites of the initial tumor at the first diagnosis of HCC;independent predictors associated with late recurrence included male,cirrhosis,and tumor size>5.0 cm,multiplicity,macrovascular and microvascular invasion,and satellites of the initial tumor.Patients with early recurrence had a lower likelihood of undergoing potentially curative treatments for recurrence(37.2%vs.48.0%,P<0.001)and a worse median PRS(13.5 vs.36.6 months,P<0.001)vs.patients who had late recurrence.Multivariate analysis revealed that early recurrence and irregular postoperative surveillance were independently associated with worse PRS[hazard ratio(HR)=1.250,95%CI:1.016-1.538,P=0.035;and HR=1.983,95%CI:1.677-2.345,P<0.001].Conclusions:Predictors associated with early and late recurrence after curative resection for patients with HCC were generally same,although several did differ.Patients with late recurrence had better long-term survival than patients with early recurrence.

Residual circulating tumor DNA after adjuvant chemotherapy effectively predicts recurrence of stage II-III gastric cancer

Background Circulating tumor DNA(ctDNA)is a promising biomarker for predicting relapse in multiple solid cancers.However,the predictive value of ctDNA for disease recurrence remains indefinite in locoregional gastric cancer(GC).Here,we aimed to evaluate the predictive value of ctDNA in this context.Methods From 2016 to 2019,100 patients with stage II/III resectable GC were recruited in this prospective cohort study(NCT02887612).Primary tumors were collected during surgical resection,and plasma samples were collected perioperatively and within 3 months after adjuvant chemotherapy(ACT).Somatic variants were captured via a targeted sequencing panel of 425 cancer-related genes.The plasma was defined as ctDNA-positive only if one or more variants detected in the plasma were presented in at least 2%of the primary tumors.Results Compared with ctDNA-negative patients,patients with positive postoperative ctDNA had moderately higher risk of recurrence[hazard ratio(HR)=2.74,95%confidence interval(CI)=1.37–5.48;P=0.003],while patients with positive post-ACT ctDNA showed remarkably higher risk(HR=14.99,95%CI=3.08-72.96;P<0.001).Multivariate analyses indicated that both postoperative and post-ACT ctDNA positivity were independent predictors of recurrence-free survival(RFS).Moreover,post-ACT ctDNA achieved better predictive performance(sensitivity,77.8%;specificity,90.6%)than both postoperative ctDNA and serial cancer antigen.A comprehensive model incorporating ctDNA for recurrence risk prediction showed a higher C-index(0.78;95%CI=0.71–0.84)than the model without ctDNA(0.71;95%CI=0.64–0.79;P=0.009).Conclusions Residual ctDNA after ACT effectively predicts high recurrence risk in stage II/III GC,and the combination of tissue-based and circulating tumor features could achieve better risk prediction.

Acute Respiratory Distress Syndrome： Challenge for Diagnosis and Therapy

Objective：Acute respiratory distress syndrome （ARDS） is a devastating clinical syndrome whose diagnosis and therapy are still in question.The aim of this review was to discuss the current challenge for the diagnosis and treatment of ARDS.Data Sources：Data sources were the published articles in English through December 2017 in PubMed using the following key words：＂acute respiratory distress syndrome,＂ ＂definition＂,＂diagnosis,＂ ＂therapy,＂ ＂lung protective strategy,＂ ＂right ventricular dysfunction,＂ and ＂molecular mechanism.＂Study Selection：The selection of studies focused on both preclinical studies and clinical studies of therapy of ARDS.Results：The incidence of ARDS is still high,and ARDS causes high intensive care units admissions and high mortality.The Berlin Definition proposed in 2012 is still controversial owing to lack of sensitivity and specificity.ARDS is still under recognition and it is associated with high mortality.Lung protective strategies with low tidal volume （VT） and lung recruitment should consider the physiology of ARDS because ARDS presents lung inhomogeneity;the same low VT might increase local stress and strain in some patients with low compliance,and lung recruitment could injure lungs in ARDS patients with low recruitability and hemodynamic instability.Acute cor pulmonale is common in severe ARDS.ARDS itself and some treatments could worsen acute cor pulmonale.Molecular understanding of the pathogenic contributors to ARDS has improved,but the molecular-associated treatments are still under development.Conclusions：ARDS is a devastating clinical syndrome whose incidence and mortality has remained high over the past 50 years.Its definition and treatments are still confronted with challenges,and early recognition and intervention are crucial for improving the outcomes of ARDS.More clinical studies are needed to improve early diagnosis and appropriate therapy.

Physiological Correlation of Airway Pressure and Transpulmonary Pressure Stress Index on Respiratory Mechanics in Acute Respiratory Failure

Background： Stress index at post-recruitment maneuvers could be a method of positive end-expiratory pressure （PEEP） titration in acute respiratory distress syndrome （ARDS） patients. However, airway pressure （P_aw） stress index may not reflect lung mechanics in the patients with high chest wall elastance. This study was to evaluate the P stress index on lung mechanics and the correlation between P stress index and transpulmonary pressure （P_L） stress index in acute respiratory failure （ARF） patients. Methods： Twenty-four ARF patients with mechanical ventilation （MV） were consecutively recruited from July 2011 to April 2013 in Zhongda Hospital, Nanjing, China and Ospedale S. Giovanni Battista-Molinette Hospital, Turin, Italy. All patients underwent MV with volume control （tidal volume 6 ml/kg） for 20 rain. PEEP was set according to the ARDSnet study protocol. The patients were divided into two groups according to the chest wall elastance/respiratory system elastance ratio. The high elastance group （H group, n = 14） had a ratio _〉30%, and the low elastance group （L group, n = 10） had a ratio 〈30%. Respiratory elastance, gas-exchange, P stress index, and Pt stress index were measured. Student＇s t-test, regression analysis, and Bland-Altman analysis were used for statistical analysis. Results： Pneumonia was the major cause of respiratory failure （71.0%）. Compared with the L group, PEEP was lower in the H group （5.7 ± 1.7 cmH,O vs. 9.0 ± 2.3 cmH2O, P 〈 0.01 ）. Compared with the H group, lung elastance was higher （20.0 ± 7.8 cmH20/L vs. 11.6 ± 3.6 cmH,O/L, P 〈 0.01）, and stress was higher in the L group （7.0 ±1.9 vs. 4.9 ± 1.9, P = 0.02）. A linear relationship was observed between the P stress index and the P stress index in H group （x2 = 0.56, P 〈 0.01 ） and L group （x2 = 0.85, P 〈 0.01）. Conclusion： In the ARF patients with MV, P,w stress index can substitute for PL to guide ventilator settings.

Epidemiological Study of Sepsis in China： Protocol of a Cross-sectional Survey

Background： Sepsis is the leading cause of death among critically ill patients. Herein, we conducted a national survey to provide data on epidemiology and treatment of sepsis in the clinical practice in China, which has no detailed epidemiological data available on sepsis. Methods： This was a prospective cross-sectional survey from December 1, 2015 to January 31, 2016 in all provinces/municipalities of the mainland of China. The primary outcome of this study was the incidence of sepsis, and the secondary outcome was its etiology in China. Patients with sepsis admitted to the Intensive Care Units were included in this study. The demographic, physiological, bacteriological, and therapeutic data of these patients were recorded. The incidence of sepsis was estimated using the data from the sixth census in China, reported by the Chinese National Health and Family Planning Commission and the National Bureau of Statistics as the standard population. The independent risk factors for increased mortality from sepsis were calculated. Conclusions： This study indicated the incidence and outcome of sepsis in China. It also showed the most common etiology of different sites and types of infection, which could guide empiric antibiotic therapy. Moreover, it provided information on the independent risk factors for increased mortality due to sepsis. The findings provide evidence to guide clinical management and may help improve the outcome in septic patients.

Venovenous extra-corporeal membrane oxygenation for severe acute respiratory distress syndrome: a matched cohort study

Background:Although the use of extra-corporeal membrane oxygenation (ECMO) has been rapidly increasing,the benefit of ECMO in patients with acute respiratory distress syndrome (ARDS) remains unclear.Our objective was to investigate the effect of venovenous ECMO (VV-ECMO) on adult patients with severe ARDS.Methods:We conducted a multi-center,retrospective,cohort study in the intensive care units (ICUs) of six teaching hospitals between January 2013 and December 2018.Patients with severe ARDS who received W-ECMO support were included.The detailed demographic data and physiologic data were used to match ARDS patients without ECMO.The primary endpoint was the 28-day mortality.Results:Ninety-nine patients with severe ARDS supported by VV-ECMO and 72 patients without ECMO were included in this study.The acute physiology and chronic health evaluation Ⅱ score was 23.1 ± 6.3 in the ECMO group and 24.8 ± 8.5 in the control group (P =0.1195).The sequential organ failure assessment score was 12.8 ± 3.4 in the ECMO group and 13.7 ± 3.5 in the control group (P =0.0848).The 28-day mortality of patients with ECMO support was 39.4%,and that of the control group was 55.6%.The survival analysis curve showed that the 28-day mortality in the ECMO group was significantly lower than that in the control group (P =0.0097).Multivariate Cox regression analysis showed that the independent predictors of the 28-day mortality were the requirement of vasopressors before ECMO (hazard ratio [HR]:1.006;95% confidence interval [CI]:1.001-1.013;P =0.030) and duration of mechanical ventilation before ECMO (HR:3.299;95% CI:1.264-8.609;P =0.034).Conclusions:This study showed that ECMO improved the survival of patients with severe ARDS.The duration of mechanical ventilation and the requirement of vasopressors before ECMO might be associated with an increased risk of death.

Effects of Propofol on Respiratory Drive and Patient-ventilator Synchrony during Pressure Support Ventilation in Postoperative Patients： A Prospective Study

Background： Propofol is increasingly nsed during partial support mechanical ventilation such as pressure support ventilation （PSV） in postoperative patients. However breathing pattern, respiratory drive, and patient-ventilator synchrony are affected by the sedative used and the sedation depth. The present study aimed to evaluate the physiologic effects of varying depths ofpropofbl sedation oll respiratory drive and patient-ventilator synchrony during PSV in postoperative patients. Methods： Eight postoperative patients receiving PSV for 〈24 h were enrolled. Propofol was administered to achieve and maintain a Ramsay score of 4, and the inspiratory pressure support was titrated to obtain a tidal volume （VT） of 6-8 ml/kg. Then, tile propolbl dose was reduced to achieve and maintain a Ramsay score of 3 and then 2. At each Ramsay level, the patient underwent 30-rain trials of PSV. We measured the electrical activity of the diaphragm, flow, airway presstlre, neuro-ventilatory efficiency （NVE）, and patient-ventilator synchrony. Results： Increasing the depth of sedation reduced the peak and mean electrical activity of the diaphragm, which suggested a decrease in respiratory drive, while VT remained unchanged. The NVE increased with an increase in the depth of sedation. Minute ventilation and inspiratory duty cycle decreased with an increase in the depth of sedation, but this only achieved statistical significance between Ramsay 2 and both Ramsay 4 and 3 （P 〈 0.05）. The ineffective triggering index increased with increasing sedation depth （9.5 -4- 4.0%, 6.7 - 2.0%, and 4.2-2.1% for Ramsay 4, 3, and 2, respectively） and achieved statistical significance between each pair of depth of sedation （P 〈 0.05）. The depth of sedation did not affect gas exchange. Conclusions： Propofol inhibits respiratory drive and deteriorates patient-ventilator synchrony to tile extent that varies with tile depth of sedation. Propolbl has less effect on breathing pattern and has no effect on VT and gas exchange in postoperative patients with PSV.

T-cell Co-inhibitory Molecules in Sepsis-induced Immunosuppression： From Bench to Bedside

Sepsis, which is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, is a leading cause of death in the Intensive Care Unit （ICU） Epidemiological studies have shown that the incidence of sepsis has been gradually increasing during the past decades,

Neural control of pressure support ventilation improved patient-ventilator synchrony in patients with different respiratory system mechanical properties:a prospective,crossover trial

Background:Conventional pressure support ventilation(PSP)is triggered and cycled off by pneumatic signals such as flow.Patient-ventilator asynchrony is common during pressure support ventilation,thereby contributing to an increased inspiratory effort.Using diaphragm electrical activity,neurally controlled pressure support(PSN)could hypothetically eliminate the asynchrony and reduce inspiratory effort.The purpose of this study was to compare the differences between PSN and PSP in terms of patient-ventilator synchrony,inspiratory effort,and breathing pattern.Methods:Eight post-operative patients without respiratory system comorbidity,eight patients with acute respiratory distress syndrome(ARDS)and obvious restrictive acute respiratory failure(ARF),and eight patients with chronic obstructive pulmonary disease(COPD)and mixed restrictive and obstructive ARF were enrolled.Patient-ventilator interactions were analyzed with macro asynchronies(ineffective,double,and auto triggering),micro asynchronies(inspiratory trigger delay,premature,and late cycling),and the total asynchrony index(AI).Inspiratory efforts for triggering and total inspiration were analyzed.Results:Total AI of PSN was consistently lower than that of PSP in COPD(3%vs.93%,P=0.012 for 100%support level;8%vs.104%,P=0.012 for 150%support level),ARDS(8%vs.29%,P=0.012 for 100%support level;16%vs.41%,P=0.017 for 150%support level),and post-operative patients(21%vs.35%,P=0.012 for 100%support level;15%vs.50%,P=0.017 for 150%support level).Improved support levels from 100%to 150%statistically increased total AI during PSP but not during PSN in patients with COPD or ARDS.Patients’inspiratory efforts for triggering and total inspiration were significantly lower during PSN than during PSP in patients with COPD or ARDS under both support levels(P<0.05).There was no difference in breathing patterns between PSN and PSP.Conclusions:PSN improves patient-ventilator synchrony and generates a respiratory pattern similar to PSP independently of any level of support in patients with different respiratory system mechanical properties.PSN,which reduces the trigger and total patient’s inspiratory effort in patients with COPD or ARDS,might be an alternative mode for PSP.Trial Registration:ClinicalTrials.gov,NCT01979627;https://clinicaltrials.gov/ct2/show/record/NCT01979627.

Hepatic Perfusion Alterations in Septic Shock Patients： Impact of Early Goal-directed Therapy

Background： Early goal-directed therapy （EGDT） has become an important therapeutic management in early salvage stage of septic shock. However, splenic organs possibly remained hypoperfused and hypoxic despite fluid resuscitation. This study aimed to evaluate the effect of EGDT on hepatic perfusion in septic shock patients. Methods： A prospective observational study was carried out in early septic shock patients who were admitted to Intensive Care Unit within 24 h after onset and who met all four elements of the EGDT criteria after treatment with the standard EGDT procedure within 6 h between December 1, 2012 and November 30, 2013. The hemodynamic data were recorded, and oxygen metabolism and hepatic functions were monitored. An indocyanine green clearance test was applied to detect the hepatic perfusion. The patients＇ characteristics were compared before treatment （TO）, immediately after EGDT （T 1 ）, and 24 h after EGDT （T2）. This study is registered at ClinicalTrials.org, NCT02060773. Results： Twenty-one patients were included in the study; however, the hepatic perfusion data were not included in the analysis for two patients： therefore, 19 patients were eligible for the study. Hemodynamics data, as monitored by pulse-indicator continuous cardiac output, were obtained from 16 patients. There were no significant differences in indocyanine green plasma disappearance rate （ICG-PDR） and 15-min retention rate （Rl 5） at TO （ 11.9 ±5.0%/min and 20.0 ±13.2%）, T1 （ 11.4 ± 5.1%/min and 23.6 ± 14.9%）, and T2 （ 11.0 ±4.5%/rain and 23.7 ± 15.3%） （all P 〉 0.05）. Both of the alterations of ICG-PDR and R l 5 showed no differences at TO, T1, and T2 in the patients of different subgroups that achieved different resuscitation goal numbers when elected （P 〉 0.05）.

Nursing staff capacity plays a crucial role in compliance to empiric antibiotic treatment within the first hour in patients with septic shock

To the Editor: Sepsis and septic shock are a leading cause of intensive care unit (ICU) admissions and induce significant morbidity and mortality.[1,2] Early propitiate antibiotics administration is significantly associated with improved survival in sepsis and septic shock[3,4] which is recommended by the international guidelines.[5] However, the compliance to sepsis protocols remains very low.[6] Nurses, who play a vital role in carrying out physician orders, are likely associated with the compliance to empiric antibiotic administration. Phua et al[7] showed that nurses occupy an essential and conscious position as brokers of doctors’ antibiotic decisions. In addition, other studies also demonstrated that nurse-led protocols were an effective, safe, and sustainable method for achieving early antibiotic administration in patients with suspected febrile neutropenia.[8] Therefore, we performed a retrospective cohort study to confirm the effect of nursing staff capacity on the compliance of nurses to empiric antibiotic treatment in patients with septic shock.

Role of immunodeficiency in Acinetobacter baumannii associated pneumonia in mice

Background: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.Methods: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.Results: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)-γlevel 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.Conclusion: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.

Symmetry restoring dynamics in a two-species bosonic Josephson junction by using occasional coupling

In this paper,by employing an occasionally coupling scheme in a two-species bosonic Josephson junction,it is found that for nonlocal measure synchronized states appearing in the two dynamic modes,known as 0-phase mode andπphase mode,their broken-symmetry can be restored.Nevertheless,there are dramatic differences for the results.For 0-phase mode,we can restore the broken symmetry by turning the nonlocal MS state into a conventional quasiperiodic MS state.However,for theπ-phase mode,the broken symmetry is restored accompanied by the appearance of chaotic MS states.