Initial suction drainage decreases severe postoperative complications after pancreatic trauma:A cohort study

BACKGROUND Few studies have addressed the question of which drain types are more beneficial for patients with pancreatic trauma(PT).AIM To investigate whether sustained low negative pressure irrigation(NPI)suction drainage is superior to closed passive gravity(PG)drainage in PT patients.METHODS PT patients who underwent pancreatic surgery were enrolled consecutively at a referral trauma center from January 2009 to October 2021.The primary outcome was defined as the occurrence of severe complications(Clavien-Dindo grade≥Ⅲb).Multivariable logistic regression was used to model the primary outcome,and propensity score matching(PSM)was included in the regression-based sensitivity analysis.RESULTS In this study,146 patients underwent initial PG drainage,and 50 underwent initial NPI suction drainage.In the entire cohort,a multivariable logistic regression model showed that the adjusted risk for severe complications was decreased with NPI suction drainage[14/50(28.0%)vs 66/146(45.2%);odds ratio(OR),0.437;95%confidence interval(CI):0.203-0.940].After 1:1 PSM,44 matched pairs were identified.The proportion of each operative procedure performed for pancreatic injury-related and other intra-abdominal organ injury-related cases was comparable in the matched cohort.NPI suction drainage still showed a lower risk for severe complications[11/44(25.0%)vs 21/44(47.7%);OR,0.365;95%CI:0.148-0.901].A forest plot revealed that NPI suction drainage was associated with a lower risk of Clavien-Dindo severity in most subgroups.CONCLUSION This study,based on one of the largest PT populations in a single high-volume center,revealed that initial NPI suction drainage could be recommended as a safe and effective alternative for managing complex PT patients.

Early systemic anticoagulation reduces hospital readmission in acute necrotizing pancreatitis patients:A retrospective cohort study

Background:Early systemic anticoagulation(SAC)is a common practice in acute necrotizing pancreatitis(ANP),and its impact on in-hospital clinical outcomes had been assessed.However,whether it affects long-term outcomes is unknown.This study aimed to evaluate the effect of SAC on 90-day readmission and other long-term outcomes in ANP patients.Methods:During January 2013 and December 2018,ANP patients admitted within 7 days from the onset of abdominal pain were screened.The primary outcome was 90-day readmission after discharge.Cox proportional-hazards regression model and mediation analysis were used to define the relationship between early SAC and 90-day readmission.Results:A total of 241 ANP patients were enrolled,of whom 143 received early SAC during their hospitalization and 98 did not.Patients who received early SAC experienced a lower incidence of splanchnic venous thrombosis(SVT)[risk ratio(RR)=0.40,95%CI:0.26-0.60,P<0.01]and lower 90-day readmission with an RR of 0.61(95%CI:0.41-0.91,P=0.02)than those who did not.For the quality of life,patients who received early SAC had a significantly higher score in the subscale of vitality(P=0.03)while the other subscales were all comparable between the two groups.Multivariable Cox regression model showed that early SAC was an independent protective factor for 90-day readmission after adjusting for potential confounders with a hazard ratio of 0.57(95%CI:0.34-0.96,P=0.04).Mediation analysis showed that SVT mediated 37.0%of the early SAC-90-day readmission causality.Conclusions:The application of early SAC may reduce the risk of 90-day readmission in the survivors of ANP patients,and reduced SVT incidence might be the primary contributor.

High-mobility group box 1 protein and its role in severe acute pancreatitis

The high mobility group box 1(HMGB1),which belongs to the subfamily of HMG-1/-2,is a highly conserved single peptide chain consisting of 215 amino acid residues with a molecular weight of approximately 24894 Da.HMGB1 is a ubiquitous nuclear protein in mammals and plays a vital role in inflammatory diseases.Acute pancreatitis is one of the most common causes of acute abdominal pain with a poor prognosis.Acute pancreatitis is an acute inflammatory process of the pancreas(duration of less than six months),for which the severe form is called severe acute pancreatitis(SAP).More and more studies have shown that HMGB1 has a bidirectional effect in the pathogenesis of SAP.Extracellular HMGB1 can aggravate the pancreatic inflammatory process,whereas intracellular HMGB1 has a protective effect against pancreatitis.The mechanism of HMGB1 is multiple,mainly through the nuclear factor-κB pathway.Receptors for advanced glycation endproducts and toll-like receptors(TLR),especially TLR-2 and TLR-4,are two major types of receptors mediating the inflammatory process triggered by HMGB1 and may be also the main mediators in the pathogenesis of SAP.HMGB1 inhibitors,such as ethyl pyruvate,pyrrolidine dithiocarbamate and Scolopendra subspinipes mutilans,can decrease the level of extracellular HMGB1 and are the promising targets in the treatment of SAP.

A bird's eye view of the air pollution-cancer link in China

Air pollution in China comes from multiple sources,including coal consumption,construction and industrial dust,and vehicle exhaust.Coal consumption in particular directly determines the emissions of three major air pollutants:dust,sulfur dioxide(SO2),and nitrogen oxide(NOx).The rapidly increasing number of civilian vehicles is expected to bring NOx emission to a very high level.Contrary to expectations,however,existing data show that the concentrations of major pollutants[particulate matter-10(PM10),SO2,and nitrogen dioxide(NO2)]in several large Chinese cities have declined during the past decades,though they still exceed the national standards of ambient air quality.Archived data from China does not fully support that the concentrations of pollutants directly depend on local emissions,but this is likely due to inaccurate measurement of pollutants.Analyses on the cancer registry data show that cancer burden related to air pollution is on the rise in China and will likely increase further,but there is a lack of data to accurately predict the cancer burden.Past experience from other countries has sounded alarm of the link between air pollution and cancer.The quantitative association requires dedicated research as well as establishment of needed monitoring infrastructures and cancer registries.The air pollution-cancer link is a serious public health issue that needs urgent investigation.

Early versus delayed intervention in necrotizing acute pancreatitis complicated by persistent organ failure

Background:Current guidelines for the treatment of patients with necrotizing acute pancreatitis(NAP)recommend that invasive intervention for pancreatic necrosis should be deferred to 4 or more weeks from disease onset to allow necrotic collections becoming“walled-off”.However,for patients showing signs of clinical deterioration,especially those with persistent organ failure(POF),it is controversial whether this delayed approach should always be adopted.In this study,we aimed to assess the impact of differently timed intervention on clinical outcomes in a group of NAP patients complicated by POF.Methods:All NAP patients admitted to our hospital from January 2013 to December 2017 were screened for potential inclusion.They were divided into two groups based on the timing of initial interven-tion(within 4 weeks and beyond 4 weeks).All the data were extracted from a prospectively collected database.Results:Overall,131 patients were included for analysis.Among them,100(76.3%)patients were in-tervened within 4 weeks and 31(23.7%)underwent delayed interventions.As for organ failure prior to intervention,the incidences of respiratory failure,renal failure and cardiovascular failure were not signifi-cantly different between the two groups(P>0.05).The mortality was not significantly different between the two groups(35.0%vs.32.3%,P=0.83).The incidences of new-onset multiple organ failure(8.0%vs.6.5%,P=1.00),gastrointestinal fistula(29.0%vs.12.9%,P=0.10)and bleeding(35.0%vs.35.5%,P=1.00),and length of ICU(30.0 vs.22.0 days,P=0.61)and hospital stay(42.5 vs.40.0 days,P=0.96)were com-parable between the two groups.Conclusion:Intervention within 4 weeks did not worsen the clinical outcomes in NAP patients compli-cated by POF.

Effects of early enteral nutrition on immune function of severe acute pancreatitis patients

AIM:To investigate the effects of early enteral nutrition (EEN) on the immune function and clinical outcome of patients with severe acute pancreatitis (SAP).METHODS:Patients were randomly allocated to receive EEN or delayed enteral nutrition (DEN).Enteral nutrition was started within 48 h after admission in EEN group,whereas from the 8 th day in DEN group.All the immunologic parameters and C-reactive protein (CRP) levels were collected on days 1,3,7 and 14 after admission.The clinical outcome variables were also recorded.RESULTS:Sixty SAP patients were enrolled to this study.The CD4+ T-lymphocyte percentage,CD4+/CD8+ ratio,and the CRP levels in EEN group became significantly lower than in DEN group from the 7 th day after admission.In contrast,the immunoglobulin G(IgG) levels and human leukocyte antigen-DR expression in EEN group became significantly higher than in DEN group from the 7 th day after admission.No difference of CD8+ T-lymphocyte percentage,IgM and IgA levels was found between the two groups.The incidences of multiple organ dysfunction syndrome,systemic inflammatory response syndrome,and pancreatic infection as well as the duration of intensive care unit stay were significantly lower in EEN group than in DEN group.However,there was no difference of hospital mortality between the two groups.CONCLUSION:EEN moderates the excessive immune response during the early stage of SAP without leading to subsequent immunosuppression.EEN can improve the clinical outcome,but not decrease the hospital mortality of SAP patients.

Active and passive smoking with breast cancer risk for Chinese females: a systematic review and meta-analysis

Previous studies suggested that smoking and passive smoking could increase the risk of breast cancer, but the results were inconsistent, especially for Chinese females. Thus, we systematically searched cohort and case-control studies investigating the associations of active and passive smoking with breast cancer risk among Chinese females in four English databases(PubMed, Embase, ScienceDirect, and Wiley) and three Chinese databases(CNKI, WanFang, and VIP). Fifty-one articles(3 cohort studies and 48 casecontrol studies) covering 17 provinces of China were finally included in this systematic review. Among Chinese females, there was significant association between passive smoking and this risk of breast cancer [odds ratio(OR): 1.62; 95% confidence interval(CI): 1.39–1.85; I2 = 75.8%, P < 0.001; n = 26] but no significant association between active smoking and the risk of breast cancer(OR: 1.04; 95% CI: 0.89–1.20; I2 = 13.9%, P = 0.248; n = 31). The OR of exposure to husband's smoking and to smoke in the workplace was 1.27(95% CI: 1.07–1.50) and 1.66(95% CI: 1.07–2.59), respectively. The OR of light and heavy passive smoking was 1.11 and 1.41, respectively, for women exposed to their husband's smoke(< 20 and ≥ 20 cigarettes per day), and 1.07 and 1.87, respectively, for those exposed to smoke in the workplace(< 300 and ≥ 300 min of exposure per day). These results imply that passive smoking is associated with an increased risk of breast cancer, and the risk seems to increase as the level of passive exposure to smoke increases among Chinese females. Women with passive exposure to smoke in the workplace have a higher risk of breast cancer than those exposed to their husband's smoking.

Splanchnic vein thrombosis in necrotizing acute pancreatitis: Detection by computed tomographic venography

AIM: To assess the diagnostic accuracy of computed tomographic venography(CTV) for splanchnic vein thrombosis(SVT) detection in necrotizing acute pancreatitis(AP) patients.METHODS:Forty-three patients with necrotizing AP who underwent both CTV and digital subtraction angiography(DSA)within 3 d were analyzed in this retrospective comparative study.All CTV procedures were performed with a dual-source CT scanner.The presence and location of SVT were determined via blinded imaging data analyses.RESULTS:According to the DSA results,17(39.5%)of the total 43 patients had SVT.The sensitivity,specificity,positive and negative predictive values of CTV for SVT detection were 100%(95%CI:77.1%-100%),92.3%(95%CI:73.4%-98.7%),89.5%(95%CI:65.5%-98.2%)and 100%(95%CI:82.8%-100%),respectively.CONCLUSION:CTV is an effective examination for SVT detection in patients with necrotizing AP with high positive and negative predictive values.

Expert consensus on the diagnosis and treatment of thrombocytopenia in adult critical care patients in China

Thrombocytopenia is a common complication of critical care patients.The rates of bleeding events and mortality are also significantly increased in critical care patients with thrombocytopenia.Therefore,the Critical Care Medicine Committee of Chinese People’s Liberation Army(PLA)worked with Chinese Society of Laboratory Medicine,Chinese Medical Association to develop this consensus to provide guidance for clinical practice.The consensus includes five sections and 27 items:the definition of thrombocytopenia,etiology and pathophysiology,diagnosis and differential diagnosis,treatment and prevention.

Chinese expert consensus on diagnosis and treatment of coagulation dysfunction in COVID-19

Since December 2019,a novel type of coronavirus disease(COVID-19)in Wuhan led to an outbreak throughout China and the rest of the world.To date,there have been more than 1,260,000 COVID-19 patients,with a mortality rate of approximately 5.44%.Studies have shown that coagulation dysfunction is a major cause of death in patients with severe COVID-19.Therefore,the People’s Liberation Army Professional Committee of Critical Care Medicine and Chinese Society on Thrombosis and Hemostasis grouped experts from the frontline of the Wuhan epidemic to come together and develop an expert consensus on diagnosis and treatment of coagulation dysfunction associated with a severe COVID-19 infection.This consensus includes an overview of COVID-19-related coagulation dysfunction,tests for coagulation,anticoagulation therapy,replacement therapy,supportive therapy and prevention.The consensus produced 18 recommendations which are being used to guide clinical work.

Chinese expert consensus on diagnosis and treatment of trauma-induced hypercoagulopathy

Trauma-induced coagulopathy(TIC)is caused by post-traumatic tissue injury and manifests as hypercoagulability that leads to thromboembolism or hypocoagulability that leads to uncontrollable massive hemorrhage.Previous studies on TIC have mainly focused on hemorrhagic coagulopathy caused by the hypocoagulable phenotype of TIC,while recent studies have found that trauma-induced hypercoagulopathy can occur in as many as 22.2%–85.1%of trauma patients,in whom it can increase the risk of thrombotic events and mortality by 2-to 4-fold.Therefore,the Chinese People’s Liberation Army Professional Committee of Critical Care Medicine and the Chinese Society of Thrombosis,Hemostasis and Critical Care,Chinese Medicine Education Association jointly formulated this Chinese Expert Consensus comprising 15 recommendations for the definition,pathophysiological mechanism,assessment,prevention,and treatment of trauma-induced hypercoagulopathy.

Serum magnesium level as a predictor of acute kidney injury in patients with acute pancreatitis

BACKGROUND Decreased serum magnesium(Mg2+)is commonly seen in critically ill patients.Hypomagnesemia is significantly more frequent in patients with severe acute pancreatitis.Acute kidney injury(AKI)in patients with acute pancreatitis(AP)is associated with an extremely high mortality.The association underlying serum Mg2+and AKI in AP has not been elucidated.AIM To explore the association between serum Mg2+on admission and AKI in patients with AP.METHODS A retrospective observational study was conducted in a cohort of patients(n=233)with AP without any renal injury before admission to our center from August 2015 to February 2019.Demographic characteristics on admission,severity score,laboratory values and in-hospital mortality were compared between patients with and without AKI.RESULTS A total of 233 patients were included for analysis,including 85 with AKI.Compared to patients without AKI,serum Mg2+level was significantly lower in patients with AKI at admission[OR=6.070,95%CI:3.374-10.921,P<0.001].Multivariate logistic analysis showed that lower serum Mg2+was an independent risk factor for AKI[OR=8.47,95%CI:3.02-23.72,P<0.001].CONCLUSION Our analysis indicates that serum Mg2+level at admission is independently associated with the development of AKI in patients with AP and may be a potential prognostic factor.

Bioelectrical impedance analysis-guided fluid management promotes primary fascial closure after open abdomen:a randomized controlled trial

Background:Fluid overload(FO)after resuscitation is frequent and contributes to adverse outcomes among postinjury open abdomen(OA)patients.Bioelectrical impedance analysis(BIA)is a promising tool for monitoring fluid status and FO.Therefore,we sought to investigate the efficacy of BIA-directed fluid resuscitation among OA patients.Methods:A pragmatic,prospective,randomized,observer-blind,single-center trial was performed for all trauma patients requiring OA between January 2013 and December 2017 to a national referral center.A total of 140 postinjury OA patients were randomly assigned in a 1:1 ratio to receive either a BIA-directed fluid resuscitation(defined as BIA)protocol that included fluid administration with monitoring of hemodynamic parameters and different degrees of interventions to achieve a negative fluid balance targeting the hydration level(HL)measured by BIA or a traditional fluid resuscitation(TRD)in which clinicians determined the fluid resuscitation regimen according to traditional parameters during 30 d of intensive care unit(ICU)management.The primary outcome was the 30-day primary fascial closure(PFC)rate.The secondary outcomes included the time to PFC,postoperative 7-day cumulative fluid balance(CFB)and adverse events within 30 d after OA.The Kaplan–Meier method and the log-rank test were utilized for PFC after OA.A generalized linear regression model for the time to PFC and CFB was built.Results:A total of 134 patients completed the trial(BIA,n=66;TRD,n=68).The BIA patients were significantly more likely to achieve PFC than the TRD patients(83.33%vs.55.88%,P<0.001).In the BIA group,the time to PFC occurred earlier than that of the TRD group by an average of 3.66 d(P<0.001).Additionally,the BIA group showed a lower postoperative 7-day CFB by an average of 6632.80 ml(P<0.001)and fewer complications.Conclusions:Among postinjury OA patients in the ICU,the use of BIA-guided fluid resuscitation resulted in a higher PFC rate and fewer severe complications than the traditional fluid resuscitation strategy.

Maternal weight and its association with risk of overweight in offspring:a trajectory analysis from a birth cohort in China

Background Most studies on the association of maternal pregnancy weight with offspring weight trajectory have a short follow-up time.This study aimed to explore the associations of maternal prepregnancy body mass index(BMI)and gestational weight gain(GWG)with childhood weight trajectories in a 7-year birth cohort.Methods A total of 946 mother–child pairs(467 boys and 479 girls)from a longitudinal birth cohort in Tianjin City,China,were included in this study,ranging from pregnancy to offspring at 7 years.The outcome variable was defined as overweight or not overweight in offspring at the last round.A group-based trajectory model was applied to identify childhood BMI trajectory groups.Results Five discrete BMI trajectory groups were identified and characterized as constant underweight(25.2%),constant normal weight(42.8%),and high or increasing trajectory[at risk of overweight(16.9%),progressive overweight(11.0%)and progressive obesity(4.1%)].Maternal prepregnancy overweight was associated with 1.72(95%CI 1.14–2.60,P=0.01)to 4.02(95%CI 1.94–8.36,P<0.001)times the risk of all high or increasing trajectory groups,and excessive GWG was related to groups at risk of overweight[relative risk ratio(RRR)2.09,95%CI 1.27–3.46,P=0.004]and progressive obesity(RRR 3.33,95%CI 1.13–9.79,P=0.029).Children in all high or increasing trajectory groups were associated with greater overweight risk at the last round[risk ratios(RRs)ranged from 3.54(95%CI 2.53–4.95,P<0.001)to 6.18(95%CI 4.05–9.42,P<0.001)].Conclusion Maternal prepregnancy overweight and excessive gestational weight gain were associated with increasing or high-level childhood body mass index trajectories as well as a greater risk of overweight at 7 years.

Follow-up of N400 in the Rehabilitation of First-episode Schizophrenia

Background：The N400 component of event-related potentials （ERP） has recently drawn widespread attention at home and abroad.This study was to explore the relationship between N400 changes and risperidone treatment and rehabilitation in first-episode schizophrenia （FES）.Methods：ERP component N400 was recorded by Guangzhou Runjie W J-l ERP instruments,in 58 FES before and 6 months,15 months after risperidone treatment,and in 62 normal controls.The patients＇ syndromes were assessed by Positive and Negative Syndrome Scale （PANSS）.And the stimuli are Chinese sentences with matching （congruent） or mismatching （incongruent） ending words.Results：N400 latencies were prolonged,and amplitudes were decreased in Cz,Pz,Fz,C3,C4,in FES compared with in NC,before treatment.The prolonged N400 latencies and decreased amplitudes were negatively correlated with the patients＇ positive scale and total scale of PANSS.There are significant differences of N400 amplitudes and latencies in 6 months and 15 months follow-up after treatment.Before treatment,6 months and 15 months after treatment,N400 latencies are 446 ± 35 ms,440 ± 37 ms,414 ± 31 ms （F =9.72,P 〈 0.01） in incongruent situation;N400 amplitudes are 5.2 ± 4.6 μtⅤ,5.7 ± 4.8 μⅤ,7.3 ± 5.0 μⅤ （F =2.06,P 〉 0.05） in congruent situation,and 8.5 ± 5.9 μⅤ,10.1 ± 5.0 μⅤ,11.9 ± 7.0 μⅤ （F =3.697,P 〈 0.05） in incongruent situation.Conclusions：N400 could be used to predict the effects of treatment of schizophrenia to some degree.The linguistic and cognitive impairment in schizophrenia can be improved by antipsychotic drugs.

Intercostal artery damage and massive hemothorax after thoracocentesis by central venous catheter： A case report

Central venous catheters （CVCs） are widely used in various puncture and drainage operations in intensive care units （ICUs） in recent years. Compared to conventional operating devices, CVC was welcomed by clinicians because of the advantages of easy use, less damage to the body and convenient fixation pro- cess. We came across a patient with severe acute pancreatitis （SAP） who developed cardiac arrest due to thoracic cavity massive bleeding 24 h after thoracoceotesis with CVC. Thoracotomy surgery was carried out immediately, which confirmed an intercostal artery injury. The patient was discharged from hospital without any neurological complications two months later. Here we report this case to remind all the emergency department and ICU physicians to pay more attention to the complication of thoracic cavity bleeding following thoracocentesis conducted by CVC.