Subacute liver and respiratory failure after segmental hepatectomy for complicated hepatolithiasis with secondary biliary cirrhosis: A case report

BACKGROUND Despite being a benign disease, hepatolithiasis has a poor prognosis because of its intractable nature and frequent recurrence. Nonsurgical treatment is associated with high incidences of residual and recurrent stones. Consequently, surgery via hepatic lobectomy or segmental hepatectomy has become the main treatment modality. Clinical management and resolution of complicated hepatolithiasis with bilateral or diffuse intrahepatic stones remain very difficult and challenging. Repeated cholangitis and calculous obstruction may result in secondary biliary cirrhosis, a limiting factor in the treatment of hepatolithiasis.CASE SUMMARY A 53-year-old woman with a 5-year history of intermittent abdominal pain and fever was admitted to the hepatopancreatobiliary surgery department following worsening symptoms over a 3-d period. Blood tests revealed elevated transaminases, alkaline phosphatase, γ-glutamyl transpeptidase, and total bilirubin, as well as anemia. Magnetic resonance cholangiopancreatography showed dilatation of the intrahepatic, left and right hepatic, common hepatic, and common bile ducts, and multiple short T2 signals in the intrahepatic and common bile ducts. Abdominal computed tomography showed splenomegaly and splenic varices. The diagnosis was bilateral hepatolithiasis and choledocholithiasis with cholangitis. Surgical treatment included hepatectomy of segments Ⅱ and Ⅲ, cholangioplasty, left hepaticolithotomy, second biliary duct exploration, choledocholithotomy, T-tube drainage, and accretion lysis. Surgical and pathological findings confirmed secondary biliary cirrhosis. Liver-protective therapy and anti-infectives were administered. The patient developed liver and respiratory failure, severe abdominal infection, and septicemia. Eventually, her family elected to discontinue treatment.CONCLUSION Liver transplantation, rather than hepatectomy, might be a treatment option for complicated bilateral hepatolithiasis with secondary liver cirrhosis.

Melatonin intervention to prevent delirium in hospitalized patients: A meta-analysis

BACKGROUND Evaluation of the effectiveness of melatonin is necessary to prevent the development of delirium in hospitalized patients.Melatonin(N-acetyl-5-methoxytryptamine)is a hormone produced by the pineal gland of the brain from the amino acid tryptophan.Synthetic melatonin supplements have been used for various medical conditions,especially sleep-related diseases,and have proved to be successful.AIM To determine the effect of melatonin on the prevention of delirium in hospitalized patients.METHODS A literature search of the CNKI,Wanfang Database,VIP Database,China Biomedical Literature Database,PubMed,Embase,Cochrane Library,Web of Science,and other databases was conducted.The CNKI,Wanfang Database,VIP Database(VIP),and China Biomedical Literature Database were searched for Chinese studies,and PubMed,Embase,Cochrane Library,Web of Science and other databases were searched for international studies.It will be established in June 2021 in a randomized controlled trial(RCT)whether melatonin treatment for 6 mo prevents delirium in hospitalized patients.Literature screening,quality review,and data extraction were carried out using the Cochrane Manual 5.1.0 systematic evaluation method, and Stata 15.0 software and Review Manager 5.3 were used formeta-analysis and processing.RESULTSA total of 18 new RCT articles and 18 experimental subjects were identified. The results of themeta-analysis showed that following the occurrence of delirium, melatonin reduced the incidenceof delirium in patients (RR = 0.69, 95%CI: 0.60-0.80), which is of significance, but heterogeneitywas significant I2 = 62%. Subgroup analysis was performed to examine the source of heterogeneity,and it was found that different patient types were the source of heterogeneity;the research onsubgroup analysis was of high quality and homogeneous. To determine the reliability androbustness of the research results, a sensitivity analysis was carried out. The results showed thatafter excluding individual studies one by one, the effect size was still within 95%CI, whichstrengthened the reliability of the original meta-analysis results. Melatonin has a significantpreventive effect on delirium in hospitalized medical patients [RR = 0.60, 95%CI: 0.47-0.76), P <0.001].CONCLUSIONMelatonin can reduce the rate of delirium in medical patients, and the role of melatonin inreducing the incidence of delirium in surgical patients and critical care unit patients requiresfurther study.

Self-Appraisal of Clinical Competence in Echocardiography of Chinese Intensivists Post Basic Echocardiography Training

Objectives To learn the echocardiography skills of intensivists after receiving a basic critical care echocardiography training course,and investigate factors that may influence their performance.Methods We completed a web-based questionnaire that assessed the skills in ultrasound scanning techniques of intensivists who took a training course on basic critical care echocardiography held in 2019 and 2020.MannWhitney test was used to analyze the factors which might affect their performance on image acquisition,recognizing clinical syndrome,and measuring the diameter of inferior vena cava,left ventricular ejection fraction and left ventricular outflow tract velocity-time integral.Results We enrolled 554 physicians from 412 intensive care units across China.Among them,185(33.4%)reported that they had 10%-30%chance of being misled by critical care echocardiography when making therapeutic decision,and 34(6.1%)reported that the chance was greater than 30%.Intensivists who performed echocardiography under the guidance of a mentor and finished ultrasound scanning more than 10 times per week reported significant higher scores in image acquisition,clinical syndrome recognition,and quantitative measurement of inferior vena cava diameter,left ventricular ejection fraction and left ventricular outflow tract velocity-time integral than those without mentor and performing echocardiography 10 times or less per week respectively(all P 0.05).Conclusion The skills in diagnostic medical echocardiography of Chinese intensivists after a basic echocardiographic training course remain low,and further quality assurance training program is clearly warranted.

Lopinavir/Ritonavir in the Treatment of COVID-19:A Systematic Review and Meta-Analysis

Objective:To systematically evaluate the efficacy and safety of lopinavir/ritonavir(LPV/r)in the treatment of COVID-19.Methods:PubMed,Embase,Ovid,CNKI,CBM,Wanfang,and VIP databases were searched to obtain the clinical studies of LPV/r in the treatment of COVID-19 from December 2019 to July 2020.The literatures were screened according to the inclusion and exclusion criteria.Their qualities were evaluated according to the Newcastle-Ottawa Scale(NOS)and RevMan 5.3 software was used for meta-analysis.Results:A total of 688 patients were included in five studies,involving China and France.Compared with patients in the control group,who was only treated with routine treatment,there were no significant differences of the 7-day nucleic acid negative conversion rate and 14-day nucleic acid negative conversion rate in the treatment group.However,the use of LPV/r increased the incidence of adverse reactions in the treatment group compared to the control group.Conclusion:There is no available evidence to support the use of Lopinavir/ritonavir in the treatment of COVID-19.

Protective effects of tanshinoneⅡA on sepsis-induced multiple organ dysfunction:a literature review

TanshinoneⅡA(TanⅡA)is a noteworthy lipophilic diterpene compound derived from the dried roots of the Traditional Chinese Medicine Danshen(Radix Salviae Miltiorrhizae)that has various pharmacological properties,including anti-inflammatory,antibacterial,and antioxidative effects.Sepsis is a life-threatening organ dysfunction induced by a dysregulated host response to infection.Recently,increasing attention has been paid to sepsis-induced dysfunction of the intestine,cardiovascular system,lungs,kidneys,liver,and other organs.Experimental studies have shown that TanⅡA has therapeutic potential for sepsis-induced organ dysfunction owing to its anti-inflammatory,anti-apoptotic and regulatory effects on multiple signalling pathways.The purpose of this article is to evaluate the potential multiorgan protective effects of TanⅡA in sepsis.

Expert consensus on the glycemic management of critically ill patients

Introduction The incidence of hyperglycemia is 40-60%in critically ill patients and is up to 60-80%in those who have undergone car-diac surgery.[1]The results of an epidemiological study in the United States showed that 28.6%of diabetic patients and 9.3%of non-diabetic patients had elevated mean daily glucose on the day of ICU admission.[2]In critically ill patients,elevated blood glucose is primarily the result of stress,and stress-induced hy-perglycemia is an independent risk factor associated with prog-nosis,regardless of a previous diagnosis of diabetes.Nutritional therapy has become an integral treatment option for patients in the ICU,[3,4]though nearly 30%of patients with enteral nu-trition and 44-50%with parenteral nutrition(PN)experience elevated glucose.[5,6]Intensive insulin therapy(IIT)is an impor-tant treatment for controlling hyperglycemia in critically ill pa-tients,but it also carries a corresponding risk of hypoglycemia.