[Expert consensus on late stage of critical care management]

We wished to establish an expert consensus on late stage of critical care (CC) management. The panel comprised 13 experts in CC medicine. Each statement was assessed based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) principle. Then, the Delphi method was adopted by 17 experts to reassess the following 28 statements. (1) ESCAPE has evolved from a strategy of delirium management to a strategy of late stage of CC management. (2) The new version of ESCAPE is a strategy for optimizing treatment and comprehensive care of critically ill patients (CIPs) after the rescue period, including early mobilization, early rehabilitation, nutritional support, sleep management, mental assessment, cognitive-function training, emotional support, and optimizing sedation and analgesia. (3) Disease assessment to determine the starting point of early mobilization, early rehabilitation, and early enteral nutrition. (4) Early mobilization has synergistic effects upon the recovery of organ function. (5) Early functional exercise and rehabilitation are important means to promote CIP recovery, and gives them a sense of future prospects. (6) Timely start of enteral nutrition is conducive to early mobilization and early rehabilitation. (7) The spontaneous breathing test should be started as soon as possible, and a weaning plan should be selected step-by-step. (8) The waking process of CIPs should be realized in a planned and purposeful way. (9) Establishment of a sleep-wake rhythm is the key to sleep management in post-CC management. (10) The spontaneous awakening trial, spontaneous breathing trial, and sleep management should be carried out together. (11) The depth of sedation should be adjusted dynamically in the late stage of CC period. (12) Standardized sedation assessment is the premise of rational sedation. (13) Appropriate sedative drugs should be selected according to the objectives of sedation and drug characteristics. (14) A goal-directed minimization strategy for sedation should be implemented. (15) The principle of analgesia must be mastered first. (16) Subjective assessment is preferred for analgesia assessment. (17) Opioid-based analgesic strategies should be selected step-by-step according to the characteristics of different drugs. (18) There must be rational use of non-opioid analgesics and non-drug-based analgesic measures. (19) Pay attention to evaluation of the psychological status of CIPs. (20) Cognitive function in CIPs cannot be ignored. (21) Delirium management should be based on non-drug-based measures and rational use of drugs. (22) Reset treatment can be considered for severe delirium. (23) Psychological assessment should be conducted as early as possible to screen-out high-risk groups with post-traumatic stress disorder. (24) Emotional support, flexible visiting, and environment management are important components of humanistic management in the intensive care unit (ICU). (25) Emotional support from medical teams and families should be promoted through"ICU diaries"and other forms. (26) Environmental management should be carried out by enriching environmental content, limiting environmental interference, and optimizing the environmental atmosphere. (27) Reasonable promotion of flexible visitation should be done on the basis of prevention of nosocomial infection. (28) ESCAPE is an excellent project for late stage of CC management.

Bone marrow mesenchymal stem cell-derived exosomal MiR-338-3p represses progression of hepatocellular carcinoma by targeting ETS1

The present study aims to explore the function of human bone marrow mesenchymal stem cell (BMSC)-derived exosomal micro ribonucleic acid (miR)-338-3p in hepatocellular carcinoma (HCC) and further investigate its effect on HCC cell functions. Firstly, BMSCs were co-cultured with HCC cells, and BMSC-derived exosomes were identified. Next, Transwell assay and methyl thiazolyl tetrazolium (MTT) experiments were carried out to detect the effects of miR-338-3p and E26 transformation specific-1 (ETS1) on the viability, invasion, migration, and apoptosis of HCC cells through the exosomes derived from BMSCs. Furthermore, the targeting relationship between miR-338-3p and EST1 was verified via bioinformatics study and dual-luciferase reporter gene analysis. Additionally, Western blotting (WB) was carried out to measure the expression levels of EST1 and other proteins in HCC cells. It was found that BMSCs inhibited HCC cell proliferation, invasion and migration, and induced cell apoptosis, while the inhibitors of exosomes played the opposite roles. In addition, the up-regulation of exosomal miR-338-3p or the silencing of EST1 restrained HCC cell proliferation, invasion and migration, and induced cell apoptosis. In conclusion, BMSC-derived exosomal miR-338-3p delays the development of HCC by down-regulating EST1, providing a new promising treatment target for HCC.

Fetal growth at different gestational periods and risk of impaired childhood growth, low childhood weight and obesity: a prospective birth cohort study

OBJECTIVE

To examine the longitudinal associations of fetal growth with adverse child growth outcomes and to assess whether maternal metabolic factors modify the associations.

DESIGN

Prospective cohort study.

SETTING

Born in Guangzhou Cohort Study, China.

POPULATION

A total of 4818 mother-child pairs.

METHODS

Fetal growth was assessed according to estimated fetal weight (EFW) from 22 weeks of gestation until birth and the measurement of the birthweight. Fetal growth Z-scores were computed from random effects in the multilevel linear spline models to represent fetal size in early pregnancy (22 weeks of gestation) and growth in mid-pregnancy (22-27 weeks of gestation), early third trimester (28-36 weeks of gestation) and late third trimester (≥37 weeks of gestation).

MAIN OUTCOME MEASURES

Z-scores for childhood stunting, low weight, overweight or obesity, length/height for age (LAZ/HAZ), weight for age (WAZ) and body mass index for age (BMIZ) at the age of 3 years. Adjusted associations were examined using multiple Poisson or linear regression models.

RESULTS

Increased Z-scores of fetal size in early pregnancy and growth in mid-pregnancy and early third trimester were associated with a higher risk of childhood overweight or obesity (risk ratios 1.25-1.45). Fetal growth in each period was negatively associated with stunting and low weight, with the strongest associations observed for fetal size in early pregnancy and growth in mid-pregnancy. The results for continuous outcomes (LAZ/HAZ, WAZ and BMIZ) were similar. The associations of fetal growth with overweight or obesity in childhood were stronger among mothers who were underweight and who were overweight or obese than among mothers of normal weight.

CONCLUSIONS

Accelerated fetal growth before 37 weeks of gestation is associated with children who are overweight or obese, whereas the critical period for stunting and low weight occurs before 28 weeks of gestation.

TWEETABLE ABSTRACT

Fetal growth during different periods is differentially associated with childhood stunting, underweight and overweight or obesity.

[Role and mechanism of the regulation of nuclear factor-κB by heparin binding-epidermal growth factor-like growth factor in the induction of paclitaxel resistance of ovarian cancer]

Objective: To investigate the role and mechanism of the regulation of nuclear factor-κB (NF-κB) by heparin binding-epidermal growth factor-like growth factor (HB-EGF) in paclitaxel resistance of ovarian cancer in vitro and in vivo. Methods: (1) The detection of NF-κB expression: parental (A2780) and paclitaxel-resistant (A2780/Taxol) ovarian carcinoma cells were divided into four groups, named A2780 group, A2780+cross-reacting material 197 (CRM197, HB-EGF inhibitor) group, A2780/Taxol group and A2780/Taxol+CRM197 group. Among four groups, the expression level HB-EGF and epidermal growth factor receptor (EGFR) were examined by immunofluorescence double staining on confocal microscopy. Western blot was used to detect the expression level of NF-κB. In vivo, A2780 and A2780/Taxol cells were injected intraperitoneally to nude mouse to determine the expression level of NF-κB of the tumors from these four groups by immunohistochemistry method. (2) The detection on the function of NF-κB: A2780/Taxol cells were divided into four groups, named transfected with empty vector+saline group, NF-κB small interference RNA (siRNA)+saline group, empty vector+CRM197 group and NF-κB siRNA+CRM197 group respectively. Among four groups, the 50% inhibitory concentrations (IC(50)) of A2780/Taxol cells to paclitaxel, the expression level of plasma membrane glycoprotein (P-gp) and the effect of intracellular rhodomine123 (Rh123) accumulation were detected. Results: (1) The detection of NF-κB expression: the expression scores of HB-EGF protein among four groups were 5.6±1.3, 2.1±1.2, 11.7±3.5 and 6.2±1.4; the expression scores of EGFR protein were 5.1±1.6, 2.8±0.6, 10.4±3.1 and 5.6±1.9, respectively. The expression levels of NF-κB protein in the cells of the group named A2780, A2780+CRM197, A2780/Taxol and A2780/Taxol+CRM197 group were 1.89±0.23, 0.74±0.12, 3.45±0.16 and 1.31±0.08, respectively; the expression scores of NF-κB protein in the tissue tumors from four groups were 3.3±1.1, 1.4±0.4, 8.7±2.3 and 3.6±1.2, respectively. The expression level of HB-EGF, EGFR and NF-κB protein between A2780 and A2780/Taxol groups in vivo and in vitro were higher than these in A2780+CRM197 and A2780/Taxol+CRM197 group, while the expression level of HB-EGF, EGFR and NF-κB protein in A2780 group were lower than those in A2780/Taxol groups in vivo and in vitro (P<0.05). (2) The examination of NF-κB function: the IC(50) of A2780/Taxol cells to paclitaxel in groups transfected with empty vector+saline, NF-κB siRNA+saline, empty vector+CRM197 and NF-κB siRNA+CRM197 group were respectively (39.4±0.8), (7.6±0.6), (6.7±0.5) and (4.2±0.4) μmol/L, while the expression levels of P-gp protein among four groups were respectively 3.11±0.23,1.45±0.16, 1.73±0.21 and 0.68±0.14, the cellular Rh123 accumulation among four groups were respectively 110±15, 246±19, 231±22 and 296±24. The expression levels of IC(50) and P-gp protein in groups transfected with NF-κB siRNA+saline, empty vector+CRM197 and NF-κB siRNA+CRM197 group were significantly higher than those in group transfected with empty vector+saline group (P<0.01), while the cellular Rh123 accumulation among three groups were significantly lower than that in group transfected with empty vector+saline (P<0.01). Conclusions: The expression of NF-κB may contributes to the paclitaxel resistance to ovarian cancer. HB-EGF may induce the paclitaxel resistance of ovarian cancer by the regulation of EGFR/NF-κB/P-gp pathway.

The expression of the BRM and MMP2 genes in thoracic aortic aneurysm and aortic dissection

OBJECTIVE

To study the expression, roles, and clinical significance of Brahma (BRM) and matrix metalloproteinase 2 (MMP2) in the thoracic aortic aneurysm and aortic dissection.

PATIENTS ND METHODS

Arterial specimens from 20 cases of thoracic aortic dissection and 38 cases of thoracic aortic aneurysm, as well as normal tissue were collected, paraffin-embedded, sectioned, and stained with anti-BRM and MMP2 monoclonal antibodies. Sections were analyzed by immunofluorescence, and the distribution and expression of BRM and MMP2 in the aortic wall were determined. Reverse transcriptase-polymerase chain reaction (RT-PCR) was used to measure the expression of BRM and MMP2 mRNA in the thoracic aortic aneurysm, thoracic aortic dissection, and normal tissues. The expression of MMP2 and BRM protein in these tissues was analyzed by Western blot. SPSS 17.0 statistical software was used for data analysis.

RESULTS

MMP2 and BRM (mRNA and protein) were expressed in arterial tissue from thoracic aortic aneurysms and aortic dissections. Immunofluorescence also showed that BRM and MMP2 were expressed in the thoracic aortic aneurysm and aortic dissection tissue. The expression was very high in thoracic aortic aneurysm tissue. The differences in expression of BRM and MMP2 in the different arterial tissues were statistically significant (p<0.01).

CONCLUSIONS

Expression of BRM and MMP2 in the thoracic aortic aneurysm and aortic dissection is very high, indicating that BRM and MMP2 may play important roles in the occurrence and development of thoracic aortic aneurysm and aortic dissection. They may represent potential targets for the treatment of thoracic aortic aneurysm and aortic dissection and provide a new basis for clinical diagnosis.

[Reverse of the resistance to paclitaxel of the heparin binding-epidermal growth factor-like growth factor inhibitor in ovarian cancer]

Objective: To investigate the effect and mechanism of CRM197, the heparin binding-epidermal growth factor-like growth factor (HB-EGF) inhibitor, on the reverse of the resistance of ovarian cancer to paclitaxel. Methods: (1)The effect of CRM197 on the 50% inhibitory concentrations (IC(50)) of human ovarian carcinoma cell line A2780 and paclitaxel-resistant ovarian carcinoma cell line A2780/Taxol was tested by methyl thiazolyl tetrazolium (MTT) assay. Western blot was used to detect the effect of CRM197 on the expression of HB-EGF, epidermal growth factor receptor (EGFR) and plasma membrane glycoprotein (P-gp) protein in A2780 and A2780/Taxol cells. Real-time PCR was used to examine the MDR1 mRNA expression in these cells. (2) A2780/Taxol cells were divided into 4 groups, including the cells transfected with empty vector and saline treatment (empty vector group), MDR1 small interference RNA (siRNA) vector and saline treatment (MDR1 siRNA group), empty vector and CRM197 treatment (empty vector+CRM197 group) and MDR1 siRNA vector and CRM197 treatment (MDR1 siRNA+CRM197 group), respectively. Flow cytometry was used to detecte the effect of intracellular rhodomine 123 (Rh123) accumulation, and caspase-3 activity assay was used to test the effect of apoptosis in four groups of A2780/Taxol cells. (3) In experiments in vivo, A2780/Taxol cells were inoculated to nude mouse subcutaneously to determine the EGFR and P-gp protein expression following CRM197 treatment by immunohistochemistry. Results: (1) In vitro, MTT examination showed that the IC(50) of A2780/Taxol cells to paclitaxel in A2780/Taxol+CRM197 group [(6.4±0.3) μmol/L] was significantly lower than the IC(50) in A2780/Taxol group [ (34.1±0.5) μmol/L, P<0.01], and the reveral fold of CRM197 was 5.3. The expression level of HB-EGF protein in A2780/Taxol+CRM197 group (1.44±0.29) was significantly lower than HB-EGF protein in A2780/Taxol group (2.72±0.32), respectively (P<0.05). The expression level of EGFR protein (0.71±0.25) and P-gp protein (0.82±0.19) in A2780/Taxol+CRM197 group was significantly lower than EGFR protein (1.87±0.31) and P-gp protein (1.84±0.27) of A2780/Taxol group (P<0.05). Compared with A2780/Taxol group (1.78±0.27) , MDR1 mRNA was significantly down-regulated in A2780/Taxol+CRM197 group (0.79±0.13, P<0.05). (2) The fluorescence intensity of Rh123 of the A2780/Taxol cells in empty vector group, MDR1 siRNA group,empty vector+CRM197 group, MDR1 siRNA+CRM197 group was 33.4±1.6, 56.3±3.3, 43.5±3.1,100.4±7.4, and the pNA of the A2780/Taxol cells was (11.4±1.2) , (52.8±0.9) , (71.2±3.6) , (82.7±3.8) μmol/L. The expression levels in MDR1 siRNA+CRM197 group were both higher than the expression levels in empty vector+CRM197 group, and the expression levels in empty vector+CRM197 group, MDR1 siRNA group were both higher than the expression levels in empty vector group (P<0.05). (3) In vivo, the expression scores of EGFR protein in A2780/Taxol+CRM197 tumors (4.4±1.4) were lower than that in A2780/Taxol tumors (10.2±3.1, P<0.05). The expression scores of P-gp protein in A2780/Taxol+CRM197 tumors (3.8±1.1) were lower than that in A2780/Taxol tumors (8.8±2.7, P<0.05). Conclusion: CRM197 reverses the resistance of ovarian cancer to paclitaxel by increasing caspase-3 activity to advance apoptosis via EGFR/MDR1/P-gp pathway.

Visceral artery aneurysm: risk factor analysis and therapeutic opinion

OBJECTIVES

To identify independent risk factors for visceral artery aneurysms.

METHODS

Retrospective medical record review over 10 years.

RESULTS

There were 26 men and 15 women, median age of 54 (range 22 to 85), and median follow-up was 20.6 months (range 0 to 94 months). There were 11 splenic, 17 hepatic, 8 gastroduodenal, 6 pancreatoduodenal, 5 superior mesenteric, and two inferior mesenteric artery aneurysms. Thirteen patients (13/41, 31.7%) were treated surgically without adjuvant endovascular intervention. Nineteen patients (19/41, 46.3%) were treated exclusively using endovascular procedures. Five patients (5/41, 12.2%) received second endovascular or surgical treatment as salvage procedure after the first procedure failed. Concomitant malignancy was positive predictors for in-hospital death. Renal failure, chronic lung disease, liver cirrhosis, previous abdominal surgery and concomitant malignancy were positive predictors of 2-year mortality. With the intention to treat in the whole cohort, less than 10% (2/21) of the endovascular treatments failed, compared to 18.5% (3/16) in the surgical group. Patients treated by surgery without aid of endovascular intervention, have lower 2-year mortality. In hospital-death rate was 9.8%, while overall mortality rate was 21.9%.

CONCLUSIONS

The endovascular intervention provides compatible, even better early postoperative outcomes for visceral artery aneurysms to surgery. Concomitant malignancy was the major determinant of visceral artery aneurysms, both in-hospital death and survival.

Modified neodymium-YAG laser in rigid bronchoscopy

The use of laser bronchoscopy in the treatment of tracheobronchial stenosis has been reported in the past. It is generally safe and effective; however, the complications of haemorrhage, airway perforation, or airway fire are relatively frequent among less experienced surgeons. We illustrate a modified technique of laser probe location to simplify the laser ablation procedure.

What we see is not what we get in catamenial haemoptysis

Catamenial haemoptysis is rare entity, a part of thoracic endometriosis syndrome. We present a young woman who was timely diagnosed, successfully treated using video-assisted thoracoscopic surgery and pathologically confirmed the case. The change in lung parenchyma over time in the computed tomography is highlighted.

[Structure characterization of melanin in black sesame by GC/MS]

Black sesame melanin, a kind of biopolymer was degraded by alkali fusion to study structure characterization. The degraded products were derivatized with bis-(trimethylsilyl) trifloroacetamide in a sealed tube at 125 degrees C for 30 min. The silylanization derivatives of degradation products were analyzed by GC/MS. Catechol, 1,4-dihydroxy benzene and catechuic acid were detected. This method can be used to characterize the structure type of black sesame melanin.

[Long-term results of modified Majer-Piquet's operation in the treatment of advanced glottic type laryngeal carcinoma]

OBJECTIVE

To investigate the long term results of modified Majer-Piquet's operation in the treatment of advanced glottic type of laryngeal carcinoma.

METHOD

A series of 21 cases treated were analysed, of whom, 11 were T3N0M0, 6 were T3N1M0, 4 were T4N0M0.

RESULT

3 years and 5 years survival rate were 100% and 85.7% respectively. Decannulation rate were 95.2%. All the patients could speak after decannulated, and could take food through mouth without inspiration.

CONCLUSION

This operation could be used in the treatment of some advanced glottic type laryngeal carcinoma effectively.

Genetic differences in the development of physical dependence upon diazepam in Lewis and Fischer 344 inbred rat strains

The purpose of the present study was to investigate physical dependence upon diazepam systematically in two inbred strains of rats, Lewis (LEW) and Fischer 344 (F344). Rats were chronically fed food containing diazepam on an escalating drug dosage schedule, from 1 and 2 to 12 mg/g of food, over a period of 30 days. During treatment, the growth curve in LEW and F344 rats was suppressed compared with the respective controls. Motor incoordination was evaluated by a rotarod performance test. The ranking of the motor incoordination during the final concentration of diazepam was as follows: F344 greater than LEW. After substitution of normal food for the diazepam-admixed food, various signs of diazepam withdrawal occurred 16-120 h later. These signs included vocalization, irritability, muscle rigidity, ear-twitching, Straub's tail, piloerection, fascicular twitch, tremor, convulsion, and death. The incidences of vocalization, ear-twitching, piloerection, and tremor in F344 were significantly higher than those in LEW rats. Furthermore, two of six F344 rats showed spontaneous convulsions and one rat died of convulsions. Overall withdrawal scores were significantly greater in F344 (16.0) than in LEW (6.3) rats. These results suggest that diazepam withdrawal severity is strongly influenced by genetic factors, and F344 rats are highly susceptible to dependence upon benzodiazepines.