Management of regional citrate anticoagulation for continuous renal replacement therapy:guideline recommendations from Chinese emergency medical doctor consensus

Continuous renal replacement therapy(CRRT)is widely used for treating critically-ill patients in the emergency department in China.Anticoagulant therapy is needed to prevent clotting in the extracorporeal circulation during CRRT.Regional citrate anticoagulation(RCA)has been shown to potentially be safer and more effective,and is now recommended as the preferred anticoagulant method for CRRT.However,there is still a lack of unified standards for RCA management in the world,and there are many problems in using this method in clinical practice.The Emergency Medical Doctor Branch of the Chinese Medical Doctor Association(CMDA)organized a panel of domestic emergency medicine experts and international experts of CRRT to discuss RCA-related issues,including the advantages and disadvantages of RCA in CRRT anticoagulation,the principle of RCA,parameter settings for RCA,monitoring of RCA(mainly metabolic acid-base disorders),and special issues during RCA.Based on the latest available research evidence as well as the paneled experts'clinical experience,considering the generalizability,suitability,and potential resource utilization,while also balancing clinical advantages and disadvantages,a total of 16 guideline recommendations were formed from the experts'consensus.

Acute arterial mesenteric ischemia and reperfusion:Macroscopic and MRI findings, preliminary report

AIM:To explore the physiopathology and magnetic resonance imaging(MRI)findings in an animal model of acute arterial mesenteric ischemia(AAMI)with and without reperfusion.METHODS:In this study,8 adult Sprague-Dawley rats underwent superior mesenteric artery(SMA)ligation and were then randomly divided in two groups of 4.In groupⅠ,the ischemia was maintained for 8 h.In groupⅡ,1-h after SMA occlusion,the ligation was removed by cutting the thread fixed on the back of the animal,and reperfusion was monitored for 8 h.MRI was performed using a 7-T system.RESULTS:We found that,in the case of AAMI without reperfusion,spastic reflex ileus,hypotonic reflex ileus,free abdominal fluid and bowel wall thinning are present from the second hour,and bowel wall hyperintensity in T2-W sequences are present from the fourth hour.The reperfusion model shows the presence of early bowel wall hyperintensity in T2-W sequences after 1 h and bowel wall thickening from the second hour.CONCLUSION:Our study has shown that MRI can assess pathological changes that occur in the small bowel and distinguish between the presence and absence of reperfusion after induced acute arterial ischemia.

Diabetes and COVID-19:Diseases of racial,social and glucose intolerance

Diabetes and coronavirus disease 2019(COVID-19)are worldwide pandemics that have had a major impact on public health throughout the globe.Risk factors for developing diabetes and having adverse outcomes of COVID-19 appear to be similar;metabolic factors(such as obesity),non-White ethnicity and poorer socioeconomic status appear to be risk factors for both.Diabetes and COVID-19 have a significant effect on populations adversely affected by health inequality.Whilst we hope that COVID-19 will be mitigated by widespread use of vaccines,no such prospect exists for mitigating the pandemic of diabetes.In this brief opinion review,I compare risk factors for diabetes and adverse outcomes of COVID-19 and argue that tackling health and social inequality is likely to play a major role in solving the global diabetes pandemic and improve outcomes of COVID-19.

Evidence-based approach to providing informed consent for hip fracture surgery during the COVID-19 era

BACKGROUND Hip fractures are the most common reason for inpatient orthopaedic trauma admission.Urgent surgical intervention for hip fractures has remained a clinical priority throughout the coronavirus disease 2019(COVID-19)pandemic.Despite this,there is a paucity of clinical guidance addressing the informed consent process for hip fracture surgery in COVID-19 positive patients.This is of paramount medicolegal importance in a high-risk patient population.AIM To quantify the additional perioperative risks for COVID-19 positive patients undergoing hip fracture surgery and provide clinicians with an evidence-based framework to establish an informed consent process.METHODS Two hundred and fifty nine consecutive patients undergoing surgical intervention for hip fractures in four hospitals in the United Kingdom were recruited.51 patients were confirmed positive for COVID-19.Predefined outcomes were analyzed over a 30-d postoperative period.COVID-19 positive and COVID-19 negative patients were compared after adjustment for confounding factors.RESULTS COVID-19 positive patients had more intensive care admissions(27%vs 5%,P<0.001),longer inpatient stays(median 23 d vs 9 d,P<0.001)and a higher 30-d mortality(29%vs 10%,P=0.001)than COVID-19 negative patients.Postoperative complications were evident in 74.5%of COVID-19 positive patients.35.3%of COVID-19 positive patients suffered postoperative lower respiratory tract infections with 13.7%developing acute respiratory distress syndrome(ARDS)and 9.8%experiencing symptomatic thromboembolic events.CONCLUSION The COVID-19 pandemic has created uncertainty in the medical community worldwide and poses unique challenges in providing informed consent for surgery.COVID-19 positive patients undergoing hip fracture surgery should be consented for the additional risk of postoperative complications(including lower respiratory tract infection,ARDS,deep vein thrombosis and pulmonary embolism),increased requirement for intensive care admission,longer inpatient stay and higher risk of mortality.Further,clinicians must be transparent about the potential for unknown risks as research into the long-term surgical outcomes of COVID-19 positive patients continues to evolve.

Management, Triage and Outcomes of 378 Patients Presenting to the Emergency Department with Chest Pain of Acute Onset： A Single Centre Observational Study

Chest pain accounts for 700,000 hospital attendances in the UK each year. Prompt risk assessment and diagnosis both improves outcomes and reduces unnecessary admissions. Data on patients who presented to the ED with chest pain was collected retrospectively. Patients were then followed up via hospital records and telephone. 70% of the authors＇ patients were triaged as low risk chest pain. Three represented within 30 d with non ischaemic chest pain. 1 patient had MACE. The authors＇ triage pathway safely managed those presenting with chest pain.

Diagnosis and management of laryngeal cleft: a single centre experience and a novel endoscopic technique

AIM： To examine the presentation, diagnosis and out-comes of patients with laryngeal cleft.METHODS： An 18 mo （from mid-2012 to 2013） pro-spective longitudinal study was performed at the Barts Children’s and Royal London Hospital, a tertiary referral centre. Chart review was performed for all patients including data extraction of demographics, outpatient clinic review documentation, speech therapy findings, medication list, operative findings alongside technique and follow up. A systematic review of contemporary English medical literature was also reviewed to compare series. The study was approved and registered by the hospital clinical governance and audit board. Biosta-tistician review was not required.RESULTS： Twenty-two children aged 1 to 72 mo （mean age 23.5 mo） with a 7：4 male-female ratio. Twenty had Benjamin-Evans type 1 clefts and 2 had a type 2 cleft. All were symptomatic despite medical management including anti-reflux therapy. Patients presented with dyspnoea （81%）, feeding diffculty （63%）, stridor （54%） and recurrent pneumonia （36%）. Several patients had concomitant aerodigestive abnormalities including 7 with laryngomalacia, 4 subglottic stenosis, 2 subglottic webs and 1 tracheo-oesophageal fstula. To date, 18 patients have undergone endoscopic repair, all of whom have shown radiological and/or clinical signs of improvement. All endoscopic repairs were performed with the novel use of a Negus knot pusher, with Baby Benjamin rigid suspension, to more reliably and easily suture at depth.CONCLUSION： This is a significant single unit series demonstrating the strong association of laryngeal cleft with combined aerodigestive symptoms and other laryngeal abnormalities. Endoscopic management of type 1 and 2 laryngeal clefts is successful. We recommend the use of a Negus knot pusher to facilitate endoscopic repair.

克罗恩病患者使用低聚果糖的临床、微生物学和免疫学效果

Background and aims: The intestinal microbiota play a pivotal role in the inflammation associated with Crohn’s disease through their interaction with the mucosal immune system. Some bifidobacteria species are immunoregulatory and induce increased dendritic cell interleukin 10 (IL- 10) release in vitro. Fructo-oligosaccharides (FOS) increase faecal and mucosal bifidobacteria in healthy volunteers. The aim of this study was to assess the effect of FOS administration on disease activity, bifidobacteria concentrations, and mucosal dendritic cell function in patients with moderately active Crohn’s disease. Patients and methods: Ten patients with active ileocolonic Crohn’s disease received 15 g of FOS for three weeks. Disease activity was measured using the Harvey Bradshaw index. Faecal and mucosal bifidobacteria were quantified by fluorescence in situ hybridisation, and mucosal dendritic cell IL- 10 and Toll-like receptor (TLR) expression were assessed by flow cytometry of dissociated rectal biopsies. Results: FOS induced a significant reduction in the Harvey Bradshaw index from 9.8 (SD 3.1) to 0.9 (3.4) (p < 0.01). There was a significant increase in faecal bifidobacteria concentration from 8.8 (0.9) log10 to 9.4 (0.9)- log10 cells/g dry faeces (p < 0.001). The percentage of IL- 10 positive dendritic cells increased from 30 (12)% to 53 (10)% (p = 0.06). Finally, the percentage of dendritic cells expressing TLR2 and TLR4 increased from 1.7 (1.7)% to 36.8 (15.9)% (p = 0.08) and from 3.6 (3.6)% to 75.4 (3.4)% (p < 0.001), respectively. Conclusions: FOS supplementation increases faecal bifidobacteria concentrations and modifies mucosal dendritic cell function. This novel therapeutic strategy appears to decrease Crohn’s disease activity in a small open label trial and therefore warrants further investigation.

伴有对称性脂膜炎的惠普尔病

Specific cutaneous involvement in Whipple’s disease is extremely ra re. The condition usually runs a chronic course, with symptoms preceding diagnosis by ye ars or even decades. We report a 44-year-old man who presented with a rapid onset of progressive, extensive, symmetrical plaques of panniculitis affecting t he inner thighs and forearms. He had accompanying large joint arthritis and was profoundly anaemic. Biopsy of the subcutis revealed a florid septal panniculitis with infiltration of the septa by foamy macrophages containing intracellular granules that stained strongly wit h periodic acid-Schiff reagent. A similar but more intense infiltrate was seen in the small bowel lamina propria, and a diagnosis ofWhipple’s disease was ma de. Symmetrical panniculitis has not previously been reported as a manifestation of Whipple’s disease.

COVID-19:长期佩戴FFP3口罩与皮肤损伤

Sayburn指的是英格兰公共卫生指南,该指南建议,在气溶胶生成和含气溶胶高风险区域执行公务时,佩戴FFP3口罩'。因此,医护人员应在COVID-19患者特护病房工作时佩戴FFP3口罩,意味着持续佩戴几个小时。最近,我被调往COVID-19患者特护病房,我的许多同事在长时间佩戴FFP3口罩后,皮肤感觉不适并有压力性损伤,特别在鼻梁上。