Assessing the impact of early progressive mobilization on moderate-to-severe traumatic brain injury: a randomized controlled trial

INTRODUCTION

Traumatic brain injury (TBI) is a major cause of neurodisability worldwide, with notably high disability rates among moderately severe TBI cases. Extensive previous research emphasizes the critical need for early initiation of rehabilitation interventions for these cases. However, the optimal timing and methodology of early mobilization in TBI remain to be conclusively determined. Therefore, we explored the impact of early progressive mobilization (EPM) protocols on the functional outcomes of ICU-admitted patients with moderate to severe TBI.

METHODS

This randomized controlled trial was conducted at a trauma ICU of a medical center; 65 patients were randomly assigned to either the EPM group or the early progressive upright positioning (EPUP) group. The EPM group received early out-of-bed mobilization therapy within seven days after injury, while the EPUP group underwent early in-bed upright position rehabilitation. The primary outcome was the Perme ICU Mobility Score and secondary outcomes included Functional Independence Measure motor domain (FIM-motor) score, phase angle (PhA), skeletal muscle index (SMI), the length of stay in the intensive care unit (ICU), and duration of ventilation.

RESULTS

Among 65 randomized patients, 33 were assigned to EPM and 32 to EPUP group. The EPM group significantly outperformed the EPUP group in the Perme ICU Mobility and FIM-motor scores, with a notably shorter ICU stay by 5.9 days (p < 0.001) and ventilation duration by 6.7 days (p = 0.001). However, no significant differences were observed in PhAs.

CONCLUSION

The early progressive out-of-bed mobilization protocol can enhance mobility and functional outcomes and shorten ICU stay and ventilation duration of patients with moderate-to-severe TBI. Our study's results support further investigation of EPM through larger, randomized clinical trials. Clinical trial registration ClinicalTrials.gov NCT04810273 . Registered 13 March 2021.

Efficacy and safety of enteral supplementation with high-dose vitamin D in critically ill patients with vitamin D deficiency

BACKGROUND

Vitamin D deficiency is associated with mortality and morbidity in critically ill patients. This study investigated the safety and effectiveness of enteral high-dose vitamin D supplementation in intensive care unit (ICU) patients in Asia.

METHODS

This was a multicenter, prospective, randomized-controlled study. Eligible participants with vitamin D deficiency were randomly assigned to the control or vitamin D supplementation group. In the vitamin D supplementation group, the patients received 569,600 IU vitamin D. The primary outcome was the serum 25(OH)D level on day 7.

RESULTS

41 and 20 patients were included in the vitamin D supplementation and control groups, respectively. On day 7, the serum 25(OH)D level was significantly higher in the vitamin D supplementation group compared to the control group (28.5 [IQR: 20.2-52.6] ng/mL and 13.9 [IQR: 11.6-18.8] ng/mL, p < 0.001). Only 41.5% of the patients achieved serum 25(OH)D levels higher than 30 ng/mL in the supplementation group. This increased level was sustained in the supplementation group on both day 14 and day 28. There were no significant adverse effects noted in the supplementation group. Patients who reached a serum 25(OH)D level of >30 ng/mL on day 7 had a significantly lower 30-day mortality rate than did those who did not (5.9% vs 37.5%, p < 0.05).

CONCLUSIONS

In our study, less than half of the patients reached adequate vitamin D levels after the enteral administration of high-dose vitamin D. A reduction in 30-day mortality was noted in the patients who achieved adequate vitamin D levels. TRIAL REGISTRATION CLINICALTRIALS.

GOV ID

NCT04292873, Registered, March 1, 2020.

Association Between Adequate Serum 25(OH)D Levels and Atherogenic Dyslipidemia in Young Adults

AIM

This study aimed to investigate the association between vitamin D deficiency and novel biomarkers of atherogenic dyslipidemia among young adults.

METHOD

A total of 976 young adults were recruited between 2011 and 2019. Their serum 25(OH)D levels were measured, and lipid profile markers, including low-density lipoprotein cholesterol (LDL-C), low-density lipoprotein triglyceride (LDL-TG), and small-dense low-density lipoprotein cholesterol (sdLDL-C), were assessed as novel biomarkers of atherogenic dyslipidemia. Multivariable linear regression was used to analyze the association between vitamin D levels and lipid profile markers. Odds ratios were calculated to assess the risk of atherogenic dyslipidemia in individuals with serum 25(OH)D levels below 30 ng/mL compared to those with levels above 30 ng/mL. Structural equation modeling (SEM) was employed to explore potential mediation pathways.

RESULTS

The study found a significant association between vitamin D levels and lower levels of LDL-C, LDL-TG, sdLDL-C, non-high-density lipoprotein cholesterol (non-HDL-C), triglycerides, and total cholesterol. Individuals with serum 25(OH)D levels below 30 ng/mL exhibited significantly higher odds ratios for developing atherogenic dyslipidemia in a dose-response pattern compared to those with vitamin D levels above 30 ng/mL. Notably, structural equation modeling (SEM) analysis revealed that vitamin D did not affect atherogenic lipid markers through the mediation of insulin resistance markers or high-sensitivity C-reactive protein.

CONCLUSION

This study provides evidence of an association between vitamin D deficiency and atherogenic dyslipidemia in young adults. It further highlights that individuals with serum 25(OH)D levels below 30 ng/mL are at a significantly higher risk of developing atherogenic dyslipidemia in a dose-response manner compared to those with higher vitamin D levels. These findings underscore the potential role of vitamin D in dyslipidemia management and emphasize the importance of maintaining sufficient vitamin D levels for cardiovascular health in young adults.

Fermented rape pollen powder can alleviate benign prostatic hyperplasia in rats by reducing hormone content and changing gut microbiota

Benign prostatic hyperplasia (BPH) can cause urethral compression, bladder stone formation, and renal function damage, which may endanger the life of patients. Therefore, we aimed to develop plant-based preparations for BPH treatment with no side effects. In this study, the Lactiplantibacillus plantarum 322Hp, Lactobacillus acidophilus 322Ha, and Limosilactobacillus reuteri 322Hr were used to ferment rape pollen. The fermented rape pollen was subsequently converted into fermented rape pollen powder (FRPP) through vacuum freeze-drying technology. After fermenting and drying, the bioactive substances and antioxidant capacity of FRPP were significantly higher than those of unfermented rapeseed pollen, and FRPP had a longer storage duration, which can be stored for over one year. To investigate the therapeutic effect of FRPP on BPH, a BPH rat model was established by hypodermic injection of testosterone propionate. The BPH rats were treated differently, with the model group receiving normal saline, the positive control group receiving finasteride, and the low, medium, and high dose FRPP group receiving FRPP at doses of 0.14 g/kg/d, 0.28 g/kg/d, and 0.56 g/kg/d, respectively. The results indicate that medium dose FRPP reduced the levels of hormone such as testosterone, dihydrotestosterone, and oestradiol in rats with BPH by about 32%, thus bringing the prostate tissue of BPH rats closer to normal. More importantly, medium dose FRPP treatment had a significant effect on the composition of gut microbiota in rats with BPH, increasing the levels of beneficial genera (such as Coprococcus and Jeotgalicoccus), and decreasing the levels of harmful pathogens (such as Turicibacter and Clostridiaceae_Clostridium) in the gut. This study showed that medium dose FRPP reduced the hormone level and regulated the unbalanced gut microbiota in BPH rats, thereby alleviating BPH.

SERS-based rapid susceptibility testing of commonly administered antibiotics on clinically important bacteria species directly from blood culture of bacteremia patients

Bloodstream infections are a growing public health concern due to emerging pathogens and increasing antimicrobial resistance. Rapid antibiotic susceptibility testing (AST) is urgently needed for timely and optimized choice of antibiotics, but current methods require days to obtain results. Here, we present a general AST protocol based on surface-enhanced Raman scattering (SERS-AST) for bacteremia caused by eight clinically relevant Gram-positive and Gram-negative pathogens treated with seven commonly administered antibiotics. Our results show that the SERS-AST protocol achieves a high level of agreement (96% for Gram-positive and 97% for Gram-negative bacteria) with the widely deployed VITEK 2 diagnostic system. The protocol requires only five hours to complete per blood-culture sample, making it a rapid and effective alternative to conventional methods. Our findings provide a solid foundation for the SERS-AST protocol as a promising approach to optimize the choice of antibiotics for specific bacteremia patients. This novel protocol has the potential to improve patient outcomes and reduce the spread of antibiotic resistance.

[Spatial and temporal distribution characteristics of seasonal A(H3N2) influenza in China, 2014-2019]

Objective: To analyze the spatial and temporal distribution characteristics of seasonal A(H3N2) influenza [influenza A(H3N2)] in China and to provide a reference for scientific prevention and control. Methods: The influenza A(H3N2) surveillance data in 2014-2019 was derived from China Influenza Surveillance Information System. A line chart described the epidemic trend analyzed and plotted. Spatial autocorrelation analysis was conducted using ArcGIS 10.7, and spatiotemporal scanning analysis was conducted using SaTScan 10.1. Results: A total of 2 603 209 influenza-like case sample specimens were detected from March 31, 2014, to March 31, 2019, and the influenza A(H3N2) positive rate was 5.96%(155 259/2 603 209). The positive rate of influenza A(H3N2) was statistically significant in the north and southern provinces in each surveillance year (all P<0.05). The high incidence seasons of influenza A (H3N2) were in winter in northern provinces and summer or winter in southern provinces. Influenza A (H3N2) clustered in 31 provinces in 2014-2015 and 2016-2017. High-high clusters were distributed in eight provinces, including Beijing, Tianjin, Hebei, Shandong, Shanxi, Henan, Shaanxi, and Ningxia Hui Autonomous Region in 2014-2015, and high-high clusters were distributed in five provinces including Shanxi, Shandong, Henan, Anhui, and Shanghai in 2016-2017. Spatiotemporal scanning analysis from 2014 to 2019 showed that Shandong and its surrounding twelve provinces clustered from November 2016 to February 2017 (RR=3.59, LLR=9 875.74, P<0.001). Conclusion: Influenza A (H3N2) has high incidence seasons with northern provinces in winter and southern provinces in summer or winter and obvious spatial and temporal clustering characteristics in China from 2014-2019.

Deep Learning-Assisted Surface-Enhanced Raman Scattering for Rapid Bacterial Identification

Bloodstream infection (BSI) is characterized by the presence of viable microorganisms in the bloodstream and may induce systemic immune responses. Early and appropriate antibiotic usage is crucial to effectively treating BSI. However, conventional culture-based microbiological diagnostics are time-consuming and cannot provide timely bacterial identification for subsequent antimicrobial susceptibility test (AST) and clinical decision-making. To address this issue, modern microbiological diagnostics have been developed, such as surface-enhanced Raman scattering (SERS), which is a sensitive, label-free, and quick bacterial detection method measuring specific bacterial metabolites. In this study, we aim to integrate a new deep learning (DL) method, Vision Transformer (ViT), with bacterial SERS spectral analysis to build the SERS-DL model for rapid identification of Gram type, species, and resistant strains. To demonstrate the feasibility of our approach, we used 11,774 SERS spectra obtained directly from eight common bacterial species in clinical blood samples without artificial introduction as the training dataset for the SERS-DL model. Our results showed that ViT achieved excellent identification accuracy of 99.30% for Gram type and 97.56% for species. Moreover, we employed transfer learning by using the Gram-positive species identifier as a pre-trained model to perform the antibiotic-resistant strain task. The identification accuracy of methicillin-resistant and -susceptible Staphylococcus aureus (MRSA and MSSA) can reach 98.5% with only 200-dataset requirement. In summary, our SERS-DL model has great potential to provide a quick clinical reference to determine the bacterial Gram type, species, and even resistant strains, which can guide early antibiotic usage in BSI.

[Association between urinary arsenic level and serum testosterone in Chinese men aged 18 to 79 years]

Objective: To investigate the association between the urinary arsenic level and serum total testosterone in Chinese men aged 18 to 79 years. Methods: A total of 5 048 male participants aged 18 to 79 years were recruited from the China National Human Biomonitoring (CNHBM) from 2017 to 2018. Questionnaires and physical examinations were used to collect information on demographic characteristics, lifestyle, food intake frequency and health status. Venous blood and urine samples were collected to detect the level of serum total testosterone, urine arsenic and urine creatinine. Participants were divided into three groups (low, middle, and high) based on the tertiles of creatinine-adjusted urine arsenic concentration. Weighted multiple linear regression was fitted to analyze the association of urinary arsenic with serum total testosterone. Results: The weighted average age of 5 048 Chinese men was (46.72±0.40) years. Geometric mean concentration (95%CI) of urinary arsenic, creatinine-adjusted urine arsenic and serum testosterone was 22.46 (20.08, 25.12) μg/L, 19.36 (16.92, 22.15) μg/L and 18.13 (17.42, 18.85) nmol/L, respectively. After controlling for covariates, compared with the low-level urinary arsenic group, the testosterone level of the participants in the middle-level group and the high-level group decreased gradually. The percentile ratio (95%CI) was -5.17% (-13.14%, 3.54%) and -10.33% (-15.68%, -4.63). The subgroup analysis showed that the association between the urinary arsenic level and testosterone level was more obvious in the group with BMI<24 kg/m² group (P_interaction<0.05). Conclusion: There is a negative association between the urinary arsenic level and serum total testosterone in Chinese men aged 18-79 years.

Functional mobility effects of progressive early mobilization protocol on people with moderate-to-severe traumatic brain injury: A pre-post intervention study

BACKGROUND: Brain plasticity evoked by environmental enrichment through early mobilization may improve sensorimotor functions of patients with moderate-to-severe traumatic brain injury (TBI). Increasing evidence also suggests that early mobilization increases verticalization, which is beneficial to TBI patients in critical care. However, there are limited data on early mobilization interventions provided to patients with moderate-to-severe TBI. OBJECTIVE: We investigated the possible enhancing effects of revised progressive early mobilization on functional mobility and the rate of out-of-bed mobility attained by patients with moderate-to-severe TBI. METHODS: This is a quantitative study with a retrospective and prospective pre–post intervention design. We implemented a revised progressive early mobilization protocol for patients with moderate-to-severe TBI admitted to the trauma intensive care unit (ICU) within the previous seven days. The outcome parameters were the rate of patients attaining early mobilization (sitting on the edge of the bed) and the Perme ICU Mobility Score at discharge from the ICU. The outcome parameters in the intervention cohort were compared with those from a historical control cohort who received standard medical care a year previously. Differences in the Perme ICU Mobility Score between the two cohorts were assessed using univariate analysis of covariance. RESULTS: Forty-two patients were included in the progressive early mobilization program and were compared with 44 patients who underwent standard medical care. In the intervention cohort, 100% and 57.2% of the patients completed early rehabilitation and early mobilization, respectively, compared to 0% in the control cohort. The intervention cohort at ICU discharge showed significantly improved the Perme ICU Mobility Scores. CONCLUSIONS: The implementation of the revised progressive early mobilization program for patients with moderate-to-severe TBI resulted in significantly improved mobility at ICU discharge; however, the length of overall stay in the ICU may be not affected.

The adaptation to freezing tolerance of hydrated lettuce seeds: effects of regional climate and of seed characteristics

BACKGROUND

With global warming, soil seed banks at high altitudes face dual challenges, excessive water absorption and thinner snow cover that increase underground temperature. A better understanding of freezing tolerance of hydrated seeds provides insights for conservation in natural soil seed banks.

OBJECTIVE

To understand the adaptation mechanisms of seed freezing tolerance under various climates, in relation to cooling rate and seed size.

MATERIALS AND METHODS

Twelve ecotypes of lettuce (Lactuca sativa) seeds were collected from different geographical locations around the world. Seeds were fully hydrated and tested for their freezing tolerance using programmed cooling methods.

RESULTS

The size of seeds from different climate regions varied, and was correlated with the freezing tolerance of the hydrated seeds (P < 0.05). Larger seeds showed poorer freezing tolerance. The local climates of maternal plants were also well correlated to seed freezing tolerance (P < 0.05), especially under slow cooling conditions. The seeds collected in regions with high spring rainfall exhibited greater freezing tolerance.

CONCLUSION

Freezing tolerance of hydrated seeds is affected by the climate of maternal plants and by seed size. Our data revealed the existence of an adaptation mechanism of freezing tolerance among various ecotypes of lettuce seeds. doi.org/10.54680/fr22410110412.

An antibiotic concentration gradient microfluidic device integrating surface-enhanced Raman spectroscopy for multiplex antimicrobial susceptibility testing

Antimicrobial susceptibility testing (AST) is a key measure in clinical microbiology laboratories to enable appropriate antimicrobial administration. During an AST, the determination of the minimum inhibitory concentration (MIC) is an important step in which the bacterial responses to an antibiotic at a series of concentrations obtained in separate bacterial growth chambers or sites are compared. However, the preparation of different antibiotic concentrations is time-consuming and labor-intensive. In this paper, we present a microfluidic device that generates a concentration gradient for antibiotics that is produced by diffusion in the laminar flow regime along a series of lateral microwells to encapsulate bacteria for antibiotic treatment. All the AST preparation steps (including bacterium loading, antibiotic concentration generation, buffer washing, and isolated bacterial growth with an antibiotic) can be performed in a single chip. The viable bacterial cells in each microwell after the antibiotic treatment are then quantified by their surface-enhanced Raman scattering (SERS) signals that are acquired after placing a uniform SERS-active substrate in contact with all the microwells. For proof-of-concept, we demonstrated the AST performance of this system on ampicillin (AMP)-susceptible and -resistant E. coli strains. Compared with the parameters for conventional AST methods, the AST procedure based on this chip requires only 20 μL of bacteria solution and 5 h of operation time. This result indicates that this integrated system can greatly shorten and simplify the tedious and labor-intensive procedures required for current standard AST methods.

Prevalence of Vitamin D Deficiency and Associated Factors in Critically Ill Patients: A Multicenter Observational Study

Background: Vitamin D deficiency is common in the general population worldwide, and the prevalence and severity of vitamin D deficiency increase in critically ill patients. The prevalence of vitamin D deficiency in a community-based cohort in Northern Taiwan was 22.4%. This multicenter cohort study investigated the prevalence of vitamin D deficiency and associated factors in critically ill patients in Northern Taiwan. Methods: Critically ill patients were enrolled and divided into five groups according to their length of stay at intensive care units (ICUs) during enrolment as follows: group 1, <2 days with expected short ICU stay; group 2, <2 days with expected long ICU stay; group 3, 3-7 days; group 4, 8-14 days; and group 5, 15-28 days. Vitamin D deficiency was defined as a serum 25-hydroxyvitamin D (25(OH)D) level < 20 ng/ml, and severe vitamin D deficiency was defined as a 25(OH)D level < 12 ng/ml. The primary analysis was the prevalence of vitamin D deficiency. The exploratory analyses were serial follow-up vitamin D levels in group 2, associated factors for vitamin D deficiency, and the effect of vitamin D deficiency on clinical outcomes in critically ill patients. Results: The prevalence of vitamin D deficiency was 59% [95% confidence interval (CI) 55-62%], and the prevalence of severe vitamin D deficiency was 18% (95% CI 15-21%). The median vitamin D level for all enrolled critically ill patients was 18.3 (13.7-23.9) ng/ml. In group 2, the median vitamin D levels were <20 ng/ml during the serial follow-up. According to the multivariable analysis, young age, female gender, low albumin level, high parathyroid hormone (PTH) level, and high sequential organ failure assessment (SOFA) score were significantly associated risk factors for vitamin D deficiency. Patients with vitamin D deficiency had longer ventilator use duration and length of ICU stay. However, the 28- and 90-day mortality rate were not associated with vitamin D deficiency. Conclusions: This study demonstrated that the prevalence of vitamin D deficiency is high in critically ill patients. Age, gender, albumin level, PTH level, and SOFA score were significantly associated with vitamin D deficiency in these patients.

Enhancement of the anticoagulant capacity of polyvinyl chloride tubing for cardiopulmonary bypass circuit using aluminum oxide nanoscale coating applied through atomic layer deposition

For cardiopulmonary bypass, the polyvinyl chloride (PVC) circuit which can initiate the activation of platelets and the coagulation cascade after blood cell contacting is the possible detrimental effect. Surface coating of the PVC tubing system can be an effective approach to enhance circuit's hemocompatibility. In this study, aluminum oxide (Al₂ O₃ ) thin films were deposited through thermal atomic layer deposition (T-ALD) or plasma-enhanced ALD (PE-ALD) on PVC samples, and the anticoagulation of the Al₂ O₃ -coated PVC samples was demonstrated. The results revealed that Al₂ O₃ deposition through ALD increased surface roughness, whereas T-ALD had a relative hydrophilicity compared with blank PVC and PE-ALD. Whole blood immersion tests showed that blood clots formed on blank PVC and that a large amount of red blood cells was found on PE-ALD substrates, whereas less blood cells were noted in T-ALD samples. Both T-ALD and PE-ALD Al₂ O₃ films did not cause activation of blood cells, as evidenced in CD3⁺ /CD4⁺ /CD8⁺ , CD61⁺ /CD62P⁺ , and CD45⁺ /CD42b⁺ populations. Analysis of serum coagulation factors showed that a lower amount of prothrombin was absorbed on T-ALD Al₂ O₃ samples than that on blank PVC. For albumin and fibrinogen immersion tests, immunostaining and scanning electron microscopy further revealed that a thin albumin layer was absorbed on T-ALD Al₂ O₃ substrates but not on PVC samples. This study revealed that deposition of Al₂ O₃ films by T-ALD can improve anticoagulation of the PVC tubing system.

A microfluidic microwell device operated by the automated microfluidic control system for surface-enhanced Raman scattering-based antimicrobial susceptibility testing

Bloodstream infection (BSI) is a serious public health issue worldwide. Timely and effective antibiotics for controlling infection are crucial towards patient outcomes. However, the current culture-based methods of identifying bacteria and antimicrobial susceptibility testing (AST) remain labor-intensive and time-consuming, and are unable to provide early support to physicians in critical hours. To improve the effectiveness of early antibiotic therapy, Surface-enhanced Raman scattering (SERS) technology, has been used in bacterial detection and AST based on its high specificity and label-free features. To simplify sample preparation steps in SERS-AST, we proposed an automated microfluidic control system to integrate all required procedures into a single device. Our preliminary results demonstrated the system can achieve on-chip reagent replacement, bacteria trapping, and buffer exchange. Finally, in-situ SERS-AST was performed within 3.5 h by loading isolates of ampicilin susceptible and resistant E. coli and clear discrimination of two strains under antibiotic treatment was demonstrated. Overall, our system can standardize and simplify the SERS-AST protocol and implicate parallel bacterial detection. This prototypical integration demonstrates timely microbiological support to optimize early antibiotic therapy for fighting bacteremia.

Association between Vitamin D Deficiency and High Serum Levels of Small Dense LDL in Middle-Aged Adults

Recent studies suggested a potential link between vitamin D deficiency and cardiovascular risk factors, including dyslipidemia. This study aimed to investigate the association between serum 25(OH)D levels and atherogenic lipid profiles, specifically, that of small dense low-density lipoprotein-cholesterol (sdLDL-C). From 2009 to 2011, a total of 715 individuals aged 35–65 without evident cardiovascular disease (CVD) were enrolled. Their levels of serum 25(OH)D and lipid profiles were measured. Vitamin D deficiency was found to be more common in females, smokers, alcohol drinkers, individuals at a younger age, and those who do not exercise regularly. The analysis of lipid profiles revealed that high sdLDL-C levels were associated with low serum vitamin D levels and were more common among cigarette smokers; alcohol drinkers; individuals with hypertension; individuals with high BMI; and those with high levels of fasting blood glucose, triglycerides, LDL-C, and VLDL-C. The use of multivariate logistic regression verified a strong negative correlation between low vitamin D status (serum 25(OH)D < 15 ng/mL) and the three identified biomarkers of atherogenic dyslipidemia: high serum levels of sdLDL-C, triglycerides, and VLDL-C. This study provides strong evidence that vitamin D deficiency is associated with atherogenic dyslipidemia, and in particular, high sdLDL-C levels in middle-aged adults without CVD.

Rapid antibiotic susceptibility testing of bacteria from patients' blood via assaying bacterial metabolic response with surface-enhanced Raman spectroscopy

Blood stream infection is one of the major public health issues characterized with high cost and high mortality. Timely effective antibiotics usage to control infection is crucial for patients’ survival. The standard microbiological diagnosis of infection however can last days. The delay in accurate antibiotic therapy would lead to not only poor clinical outcomes, but also to a rise in antibiotic resistance due to widespread use of empirical broad-spectrum antibiotics. An important measure to tackle this problem is fast determination of bacterial antibiotic susceptibility to optimize antibiotic treatment. We show that a protocol based on surface-enhanced Raman spectroscopy can obtain consistent antibiotic susceptibility test results from clinical blood-culture samples within four hours. The characteristic spectral signatures of the obtained spectra of Staphylococcus aureus and Escherichia coli—prototypic Gram-positive and Gram-negative bacteria—became prominent after an effective pretreatment procedure removed strong interferences from blood constituents. Using them as the biomarkers of bacterial metabolic responses to antibiotics, the protocol reported the susceptibility profiles of tested drugs against these two bacteria acquired from patients’ blood with high specificity, sensitivity and speed.

[Significance of microRNA 216a, 324-5p and 29a expression in peripheral blood in patients with acute pancreatitis and their correlation with liver injury]

Objective: To investigate the significance of microRNA (miR)-216a, miR-324-5p, miR-29a expression in peripheral blood in patients with acute pancreatitis (AP) and their correlation with liver injury. Methods: It was a case-control study design. To select 130 AP patients admitted from June 2017 to May 2019 in the First People's Hospital of Shangqiu, and the patients were divided into mild AP group (MAP group) and moderately severe AP group (SAP group) according to the disease severity, or 54 patients in the liver injury group (20 were MAP and 34 were SAP) and 76 in the non-liver injury group(all were MAP) according to liver injury. And another 40 healthy volunteers were selected as the healthy group. The expressions of miR-216a, miR-324-5p and miR-29a in peripheral blood of MAP group, SAP group, healthy group and liver injury group, non-liver injury group were compared, and the correlation between the miRNA levels and clinical indexes was analyzed. The predictive value of miRNA levels in peripheral blood for AP complicated with liver injury was analyzed by receiver operating characteristic (ROC) curve. Results: The levels of miR-216a and miR-29a in MAP group and SAP group were higher than those in healthy group, and the level of miR-324-5p was lower than that in healthy group (all P<0.01). The levels of miR-216a and miR-29a in SAP group were higher than those in MAP group, and the level of miR-324-5p was lower than that in healthy group (all P<0.01). Balthazar CT Score, acute physiology and chronic health evaluations (APACHE Ⅱ) score, C-reactive protein level, length of hospital stay were positively correlated with the levels of miR-216a and miR-29a in peripheral blood (all P<0.05), and negatively correlated with the levels of miR-324-5p (P<0.05). The levels of miR-216a and miR-29a in the peripheral blood in the liver injury group were higher than those in the non-liver injury group, and they were higher inSAP patients than those in MAP patients in the liver injury group (all P<0.05). The level of miR-324-5p in the peripheral blood in the liver injury group was lower than that in the non-liver injury group, and it was lower in SAP patients than that in MAP patientsin the liver injury group (all P<0.05). The area under ROC curve of miR-216a, miR-324-5p, and miR-29a in peripheral blood to predicate the AP complicated with liver damage was 0.694, 0.750 and 0.814, respectively. Conclusions: The levels of miR-216a and miR-29a increase in peripheral blood and the level of miR-324-5p decreases in patients with AP, and they are closely related to Balthazar CT score, APACHEⅡ score, C-reactive protein and length of hospital stay. The levels of miR-216a, miR-324-5p, miR-29a has certain predictive value for AP with liver injury, of which miR-29a has the highest predictive value.

Field-Driven Quantum Criticality in the Spinel Magnet ZnCr_{2}Se_{4}

We report detailed dc and ac magnetic susceptibilities, specific heat, and thermal conductivity measurements on the frustrated magnet ZnCr_{2}Se_{4}. At low temperatures, with an increasing magnetic field, this spinel material goes through a series of spin state transitions from the helix spin state to the spiral spin state and then to the fully polarized state. Our results indicate a direct quantum phase transition from the spiral spin state to the fully polarized state. As the system approaches the quantum criticality, we find strong quantum fluctuations of the spins with behaviors such as an unconventional T^{2}-dependent specific heat and temperature-independent mean free path for the thermal transport. We complete the full phase diagram of ZnCr_{2}Se_{4} under the external magnetic field and propose the possibility of frustrated quantum criticality with extended densities of critical modes to account for the unusual low-energy excitations in the vicinity of the criticality. Our results reveal that ZnCr_{2}Se_{4} is a rare example of a 3D magnet exhibiting a field-driven quantum criticality with unconventional properties.

TNFα-activated mesenchymal stromal cells promote breast cancer metastasis by recruiting CXCR2+ neutrophils

Mesenchymal stromal cells (MSCs) tend to infiltrate into tumors and form a major component of the tumor microenvironment. Our previous work demonstrated that tumor necrosis factor α (TNFα)-activated MSCs significantly promoted tumor growth. However, the role of TNFα-treated MSCs in tumor metastasis remains elusive. Employing a lung metastasis model of murine breast cancer, we found that TNFα-activated MSCs strikingly enhanced tumor metastasis compared with normal MSCs. We analyzed the chemokine profiles and found that the expression of CCL5, CCR2 and CXCR2 ligands were enhanced in TNFα-activated MSCs. Using genetic or pharmacological strategies to inhibit CCL5 or CCR2, we demonstrated that CCL5 and CCR2 ligands were indispensable in supporting TNFα-activated MSCs to promote tumor metastasis. Analysis of immune cells revealed that CXCR2 ligands (CXCL1, CXCL 2 and CXCL5) expressed by TNFα-activated MSCs efficiently recruited CXCR2⁺ neutrophils into tumor. These neutrophils were responsible for the pro-metastatic effect of MSCs since inhibition of this chemotaxis abolished increased neutrophil recruitment and tumor metastasis. The interaction between neutrophils and tumor cells resulted in markedly elevated metastasis-related genes by tumor cells, including CXCR4, CXCR7, MMP12, MMP13, IL-6 and TGFβ. Importantly, in IL8^high human breast cancer samples, we also observed similar alterations of gene expression. Collectively, our findings demonstrate that TNFα-activated MSCs promote tumor metastasis via CXCR2⁺ neutrophil recruitment.

[Clinical value of serum presepsin (SCD14-ST) concentration measurement in patients with pesticide poisoning]

OBJECTIVE

To investigate the value of serum presepsin concentration measurement in the clinical diagnosis and treatment of patients with pesticide poisoning patients.

METHODS

A total of 160 patients with pesticide poisoning were enrolled as study subjects and divided into moderate organophosphate pesticide poisoning group (40 patients) , severe organophosphate pesticide poisoning group (40 patients) , abamectin pesticide poisoning group (40 patients) , and paraquat poisoning group (40 patients). A total of 20 healthy volunteers were enrolled as the control group. All the patients with poisoning received conventional treatment of pesticide poisoning immediately after admission, and serum presepsin concentration was measured on days 1 (within 24 hours after poisoning) , 3, and 7 of admission, and biochemical and radiological parameters related to the patient's condition were also examined. The patients with a Presepsin concentration of >800 pg/ml on day 1 of admission were randomly divided into conventional treatment group and ulinastatin treatment group, and the treatment outcome was compared between the two groups.

RESULTS

Compared with the healthy control group, the groups with pesticide poisoning showed significant increases in serum Presepsin concentrations, with the highest degree of increase on day 1 (P <0.05). The serum Presepsin concentration was positively correlated with alanine aminotransferase, aspartate aminotransferase, creatine kinase, creatine kinase MB, lactate dehydrogenase, serum creatinine, blood urea nitrogen, interleukin-18, and white blood cell count, but negatively correlated with cholinesterase. In the conventional treatment group and ulinastatin treatment group, the overall response rate was 68% and 78.8%, respectively, with a significant difference between the two groups (P<0.05). In 40 patients with paraquat poisoning, 32 experienced an increase in serum presepsin concentration, and among these 32 patients, 27 (83%) experienced exudation on lung CT.

CONCLUSION

Serum Presepsin concentration measurement can assist early diagnosis, evaluation of disease severity, and guidance for clinical medication in patients with pesticide poisoning, especially in those with severe pesticide poisoning and a tendency to multiple organ failure.

TonEBP modulates the protective effect of taurine in ischemia-induced cytotoxicity in cardiomyocytes

Taurine, which is found at high concentration in the heart, exerts several protective actions on myocardium. Physically, the high level of taurine in heart is maintained by a taurine transporter (TauT), the expression of which is suppressed under ischemic insult. Although taurine supplementation upregulates TauT expression, elevates the intracellular taurine content and ameliorates the ischemic injury of cardiomyocytes (CMs), little is known about the regulatory mechanisms of taurine governing TauT expression under ischemia. In this study, we describe the TonE (tonicity-responsive element)/TonEBP (TonE-binding protein) pathway involved in the taurine-regulated TauT expression in ischemic CMs. Taurine inhibited the ubiquitin-dependent proteasomal degradation of TonEBP, promoted the translocation of TonEBP into the nucleus, enhanced TauT promoter activity and finally upregulated TauT expression in CMs. In addition, we observed that TonEBP had an anti-apoptotic and anti-oxidative role in CMs under ischemia. Moreover, the protective effects of taurine on myocardial ischemia were TonEBP dependent. Collectively, our findings suggest that TonEBP is a core molecule in the protective mechanism of taurine in CMs under ischemic insult.

Atomic-layer-deposited silver and dielectric nanostructures for plasmonic enhancement of Raman scattering from nanoscale ultrathin films

Plasmonic silver nanostructures and a precise ZnO cover layer prepared by capacitively coupled plasma atomic layer deposition (ALD) were exploited to enhance the Raman scattering from nanoscale ultrathin films on a Si substrate. The plasmonic activity was supported by a nanostructured Ag (nano-Ag) layer, and a ZnO cover layer was introduced upon the nano-Ag layer to spectrally tailor the localized surface plasmon resonance to coincide with the laser excitation wavelength. Because of the optimized dielectric environment provided by the precise growth of ZnO cover layer using ALD, the intensity of Raman scattering from nanoscale ultrathin films was significantly enhanced by an additional order of magnitude, leading to the observation of the monoclinic and tetragonal phases in the nanoscale ZrO2 high-K gate dielectric as thin as ∼6 nm on Si substrate. The excellent agreement between the finite-difference time-domain simulation and experimental measurement further confirms the so-called [absolute value]E(->)[absolute value](4) dependence of the surface-enhanced Raman scattering. This technique of plasmonic enhancement of Raman spectroscopy, assisted by the nano-Ag layer and optimized dielectric environment prepared by ALD, can be applied to characterize the structures of ultrathin films in a variety of nanoscale materials and devices, even on a Si substrate with overwhelming Raman background.

Prognostic Factors of Survival From Intractable Oronasal Bleeding After Successful Transarterial Embolization

PURPOSE

To evaluate the prognostic factors that influence the survival of patients with traumatic intractable oronasal bleeding treated by transarterial embolization (TAE).

MATERIALS AND METHODS

Patients who received TAE for intractable oronasal bleeding in the National Taiwan University Hospital from 2002 through 2013 were included in the study. Retrospective reviews were undertaken to collect relevant clinical and neuroradiologic data that might be correlated with patients' survival. The Wilcoxon rank-sum test or Fisher exact test was adopted to analyze differences between the survival group and the mortality group. Odds ratios were estimated by univariate logistic regression.

RESULTS

TAE successfully controlled the bleeding in 24 of 26 patients (92.3%) who had severe craniofacial injury in the 12-year period. Of the 24 patients with successful TAE, 13 patients were discharged alive from the hospital. The overall survival rate was 50% (13 of 26). Significantly higher initial Glasgow Coma Scale (GCS) score (P = .01) and lower Injury Severity Score (ISS; P < .01) were present in the survival group than in the mortality group by the Wilcoxon rank-sum test. Moreover, patients with an ISS of at least 30, a GCS score lower than 9, initial hemoglobin level lower than 10 g/dL, and computed tomographic (CT) findings of a brain midline shift had statistically higher odds ratios predicting mortality than their counterparts as estimated by univariate logistic regression.

CONCLUSIONS

The results of this study showed that the combination of diagnostic angiography and therapeutic embolization is effective treatment for intractable oronasal bleeding in patients with severe craniofacial injury. The prognosis in patients who were rescued with successful TAE was statistically correlated with the severity of trauma and concomitant brain injury. An ISS of at least 30, a GCS score lower than 9, an initial hemoglobin level lower than 10, and CT findings of a brain midline shift were strong predictors for mortality.

Enhancement of light emission from silicon by precisely tuning coupled localized surface plasmon resonance of a nanostructured platinum layer prepared by atomic layer deposition

Plasmonic enhancement of photoluminescence from bulk silicon was achieved by spectrally tailoring coupled localized surface plasmon resonance (LSPR) in the Al2O3 cover/nanostructured platinum (nano-Pt)/Al2O3 spacer/silicon multilayer structures prepared by atomic layer deposition (ALD). Agreement between the simulation and experimental data indicates that the plasmonic activity originates from absorption enhancement due to coupled LSPR. Because of the optimized dielectric environment deposited by ALD around the nano-Pt layer, absorption of the multilayer structure was enhanced by the precise tuning of coupled LSPR to coincide with the excitation wavelength. This accurate plasmonic multilayer structure grown by ALD with high precision, tunability, uniformity, and reproducibility can be further applied in efficient light-emitting devices.

Evaluation of anatomical landmark position differences between respiration-gated MRI and four-dimensional CT for radiation therapy in patients with hepatocellular carcinoma

OBJECTIVE

To measure the accuracy of position differences in anatomical landmarks in gated MRI and four-dimensional CT (4D-CT) fusion planning for radiation therapy in patients with hepatocellular carcinoma (HCC).

METHODS

From April to December 2009, gated MR and planning 4D-CT images were obtained from 53 inoperable HCC patients accrued to this study. Gated MRI and planning 4D-CT were conducted on the same day. Manual image fusions were performed by matching the vertebral bodies. Liver volumes and three specific anatomical landmarks (portal vein conjunction, superior mesenteric artery bifurcation, and other noticeable points) were contoured from each modality. The points chosen nearest the centre of the four landmark points were compared to measure the accuracy of fusion.

RESULTS

The average distance differences (±standard deviation) of four validation points were 5.1 mm (±4.6 mm), 5.6 mm (±6.2 mm), 5.4 mm (±4.5 mm) and 5.1 mm (±4.8 mm). Patients who had ascites or pulmonary disease showed larger discrepancies. MRI-CT fusion discrepancy was significantly correlated with positive radiation response (p<0.05).

CONCLUSIONS

Approximately 5-mm anatomical landmark positional differences in all directions were found between gated MRI and 4D-CT fusion planning for HCC patients; the gap was larger in patients with ascites or pulmonary disease.

ADVANCES IN KNOWLEDGE

There were discrepancies of approximately 5 mm in gated MRI-CT fusion planning for HCC patients.

Kidney function decline after a non-dialysis-requiring acute kidney injury is associated with higher long-term mortality in critically ill survivors

Introduction

The adverse consequences of a non-dialysis-requiring acute kidney injury (AKI) are unclear. This study aimed to assess the long-term prognoses for critically ill patients experiencing a non-dialysis-requiring AKI.

Methods

This retrospective observational cohort study investigated non-dialysis-requiring AKI survivors in surgical intensive care units between January 2002 and June 2010. All longitudinal post-discharge serum creatinine measurements and information regarding end-stage renal disease (ESRD) and death were collected. We assessed the long-term outcomes of chronic kidney disease (CKD), ESRD and all-cause mortality beyond discharge.

Results

Of the 922 identified critically ill patients with a non-dialysis-requiring AKI, 634 (68.8%) patients who survived to discharge were enrolled. A total of 207 patients died after a median follow-up of 700.5 days. The median intervals between the onset of the AKI and the composite endpoints "stage 3 CKD or death", "stage 4 CKD or death", "stage 5 CKD or death", and "ESRD or death" were 685, 1319, 1743, and 2048 days, respectively. This finding shows a steady long-term decline in kidney function after discharge. Using the multivariate Cox proportional hazard model, we found that every 1 mL/min/1.73 m² decrease from baseline estimated glomerular filtration rate (eGFR) of individuals who progressed to stage 3, 4, and 5 CKD increased the risks of long-term mortality by 0.7%, 2.3%, and 4.1%, respectively (all p < 0.05). This result indicates that the mortality risk increased significantly in a graded manner as kidney function declined from the baseline eGFR to advanced stages of CKD during the follow-up period.

Conclusions

In critically ill patients who survive a non-dialysis-requiring AKI, there is a need for continuous monitoring and kidney function protection beyond discharge.

Effect of diuretic use on 30-day postdialysis mortality in critically ill patients receiving acute dialysis

BACKGROUND

The impact of diuretic usage and dosage on the mortality of critically ill patients with acute kidney injury is still unclear.

METHODS AND RESULTS

In this prospective, multicenter, observational study, 572 patients with postsurgical acute kidney injury receiving hemodialysis were recruited and followed daily. Thirty-day postdialysis mortality was analyzed using Cox's proportional hazards model with time-dependent covariates. The mean age of the 572 patients was 60.8±16.6 years. Patients with lower serum creatinine (p = 0.031) and blood lactate (p = 0.033) at ICU admission, lower predialysis urine output (p = 0.001) and PaO(2)/FiO(2) (p = 0.039), as well as diabetes (p = 0.037) and heart failure (p = 0.049) were more likely to receive diuretics. A total of 280 (49.0%) patients died within 30 days after acute dialysis initiation. The analysis of 30-day postdialysis mortality by fitting propensity score-adjusted Cox's proportional hazards models with time-dependent covariates showed that higher 3-day accumulated diuretic doses after dialysis initiation (HR = 1.449, p = 0.021) could increase the hazard rate of death. Moreover, higher time-varying 3-day accumulative diuretic doses were associated with hypotension (p<0.001) and less intense hemodialysis (p<0.001) during the acute dialysis period.

BACKGROUND AND SIGNIFICANCE

Higher time-varying 3-day accumulative diuretic dose predicts mortality in postsurgical critically ill patients requiring acute dialysis. Higher diuretic doses are associated with hypotension and a lower intensity of dialysis. Caution should be employed before loop diuretics are administered to postsurgical patients during the acute dialysis period.

Preoperative proteinuria is associated with long-term progression to chronic dialysis and mortality after coronary artery bypass grafting surgery

AIMS

Preoperative proteinuria is associated with post-operative acute kidney injury (AKI), but whether it is also associated with increased long-term mortality and end-stage renal disease (ESRD) is unknown.

METHODS AND RESULTS

We studied 925 consecutive patients undergoing CABG. Demographic and clinical data were collected prospectively, and patients were followed for a median of 4.71 years after surgery. Proteinuria, according to dipstick tests, was defined as mild (trace to 1+) or heavy (2+ to 4+) according to the results of the dipstick test. A total of 276 (29.8%) patients had mild proteinuria before surgery and 119 (12.9%) patients had heavy proteinuria. During the follow-up, the Cox proportional hazards model demonstrated that heavy proteinuria (hazard ratio [HR], 27.17) was an independent predictor of long-term ESRD. There was a progressive increased risk for mild proteinuria ([HR], 1.88) and heavy proteinuria ([HR], 2.28) to predict all-cause mortality compared to no proteinuria. Mild ([HR], 2.57) and heavy proteinuria ([HR], 2.70) exhibited a stepwise increased ratio compared to patients without proteinuria for long-term composite catastrophic outcomes (mortality and ESRD), which were independent of the baseline GFR and postoperative acute kidney injury (AKI).

CONCLUSION

Our study demonstrated that proteinuria is a powerful independent risk factor of long-term all-cause mortality and ESRD after CABG in addition to preoperative GFR and postoperative AKI. Our study demonstrated that proteinuria should be integrated into clinical risk prediction models for long-term outcomes after CABG. These results provide a high priority for future renal protective strategies and methods for post-operative CABG patients.

Effects of fish oil on inflammatory modulation in surgical intensive care unit patients

BACKGROUND

The benefit of ω-3 fatty acids in fat emulsion remains controversial. This study evaluated the effect of ω-3 fatty acids on immune and inflammatory modulation in surgical intensive care unit (SICU) patients.

METHODS

Thirty-eight patients admitted to the SICU after major surgery were enrolled in this prospective controlled study and randomized to receive parenteral nutrition (PN) with equal volume and calories from glucose, nitrogen, and fat but different lipid components for 7 postoperative days. Group A (n = 12) received a mixture of soybean and medium-chain triglyceride oils; group B (n = 18) received a fat emulsion with part of the lipid replaced by fish oil. Blood tests, including lipid profile, routine biochemistry, inflammatory cytokines, and lymphocyte subpopulations, were evaluated preoperatively and on postoperative days 4 and 7.

RESULTS

Both lipid regimens were well tolerated. There was a trend toward reduced serum inflammatory cytokines in group B vs group A with significant differences regarding interleukin (IL)-1, IL-8, and interferon (IFN)-γ on postoperative day 4 (P < .05) and IL-1, IL-8, IFN-γ, IL-6, and tumor necrosis factor-α on postoperative day 7 (P < .05). There was a reduction in postoperative liver dysfunction (A vs B: 50% vs 33.3%) and infection rate (A vs B: 41.7% vs 27.8%) in group B, although this was not statistically significant. There was no mortality in either group.

CONCLUSION

This study suggests that supplementation of parenteral ω-3 fatty acids in PN is safe and may improve immune and hyperinflammatory response for SICU patients after major surgery.

Impact of timing of renal replacement therapy initiation on outcome of septic acute kidney injury

INTRODUCTION

Sepsis is the leading cause of acute kidney injury (AKI) in critical patients. The optimal timing of initiating renal replacement therapy (RRT) in septic AKI patients remains controversial. The objective of this study is to determine the impact of early or late initiation of RRT, as defined using the simplified RIFLE (risk, injury, failure, loss of kidney function, and end-stage renal failure) classification (sRIFLE), on hospital mortality among septic AKI patients.

METHODS

Patient with sepsis and AKI requiring RRT in surgical intensive care units were enrolled between January 2002 and October 2009. The patients were divided into early (sRIFLE-0 or -Risk) or late (sRIFLE-Injury or -Failure) initiation of RRT by sRIFLE criteria. Cox proportional hazard ratios for in hospital mortality were determined to assess the impact of timing of RRT.

RESULTS

Among the 370 patients, 192 (51.9%) underwent early RRT and 259 (70.0%) died during hospitalization. The mortality rate in early and late RRT groups were 70.8% and 69.7% respectively (P > 0.05). Early dialysis did not relate to hospital mortality by Cox proportional hazard model (P > 0.05). Patients with heart failure, male gender, higher admission creatinine, and operation were more likely to be in the late RRT group. Cox proportional hazard model, after adjustment with propensity score including all patients based on the probability of late RRT, showed early dialysis was not related to hospital mortality. Further model matched patients by 1:1 fashion according to each patient's propensity to late RRT showed no differences in hospital mortality according to head-to-head comparison of demographic data (P > 0.05).

CONCLUSIONS

Use of sRIFLE classification as a marker poorly predicted the benefits of early or late RRT in the context of septic AKI. In the future, more physiologically meaningful markers with which to determine the optimal timing of RRT initiation should be identified.

Neglected esophageal injury presenting with spontaneously shrunken retroesophageal pocket

Cervical stab wounds with a thoracic-inlet esophageal injury are extremely rare. A 30-year-old man presented with dysphagia and stridor. He had attempted suicide by stabbing his neck with a screwdriver followed by jumping from a building 10 days previously, when a cervical tracheal injury was found and surgically repaired. Physical examination was unremarkable. Lateral cervical radiography revealed an air-fluid level within an extensive retropharyngeal pocket. Follow-up radiography showed that the retropharyngeal lesion had shrunk spontaneously. Contrast esophagography demonstrated an extravasation at the thoracic inlet. The patient underwent surgical exploration of the esophagus via a lower neck incision. A thoracic-inlet esophageal slit was found and primary repair was performed. He resumed oral intake uneventfully on the 8th postoperative day. This was a rare case of esophageal injury secondary to cervical stabbing wounds, presenting with delayed occurrence and spontaneously shrunken retroesophageal pocket. Esophageal perforation can be easily missed if tracheal lesion is found. Both bronchoscopy and esophagoscopy are mandatory. In patients highly suspected to have esophageal injury but with a negative esophagoscopy result, contrast esophagography is indicated and can decrease the incidence of false-negative results.

Clinical outcome of severe head injury in different protocol-driven therapies

In the past 5 years cerebral perfusion pressure (CPP) management has become mainstream in the treatment of severe head injuries. The American Association of Neurological Surgeons guidelines (2000) suggest that CPP should be maintained at least 70 mmHg; however, there is still debate about optimal CPP level. The purpose of this study is to evaluate the effectiveness of three widely used therapies: intracranial pressure (ICP)-targeted therapy, CPP-targeted therapy with CPP > 70 mmHg, and modified CPP-targeted therapy with CPP > 60 mmHg. The clinical procedures, complications, and patient outcomes are compared. Data including patient age, sex, initial Glasgow Coma Score (GCS), ICP, CPP, fluid status, amount of mannitol and vasopressor used, daily intake and output, complications, and clinical results were collected from 213 patients with severe head injuries over a 12-year period. Patients were categorized into three groups (ICP, CPP, modified CPP [mCPP]) according to treatment protocol used. Retrospective data collection was by chart review. The mortality rate was 28.6%, 14.3%, and 13.5% in groups ICP, CPP, and mCPP, respectively. Highest intake/output ratio, amount of vasopressor used, and pulmonary complication rates were seen in group CPP patients. Group mCPP patients showed the best clinical outcome and lowest complication rate. Though CPP-targeted therapy is the most recommended therapeutic protocol, our data showed that the outcome is as good in the mCPP-targeted group with CPP > 60 mmHg as in the CPP-targeted group, but complications are fewer in the mCPP group.

Clinical experience of hydroxyethyl starch (10% HES 200/0.5) in cerebral perfusion pressure protocol for severe head injury

BACKGROUND

The present study was undertaken to evaluate 10% hydroxyethyl starch (HES 200/0.5) with regard to its clinical outcome and safety in the treatment of severe head injury.

METHODS

Retrospective review of patient data from a prospectively designed standard treatment protocol for severe head injury. The standard protocol included (1) cerebral perfusion pressure higher than 60 mm Hg, (2) colloid solution (10% HES 200/0.5) 1000 mL/d in combination with crystalloid solution, (3) stepwise management of intracranial hypertension. Renal function, coagulation function, and electrolytes were evaluated every other day. The data of intracranial pressure, mean arterial pressure, cerebral perfusion pressure, intake, output, mannitol, complications, and outcome were recorded and analyzed.

RESULTS

There were 78 patients, aged 45.61 +/- 21.80 years, in this study. The initial Glasgow Coma Scale score was 6.35 +/- 1.38. Seventy-three patients received operations with intracranial pressure monitoring. Blood transfusion was surgery related (days 1 and 2); otherwise, it was rarely used (P<.05). Prolonged prothrombin time was shown only 7 (2.65%) times of 234 of blood sampling. There was no anaphylactic reaction, pulmonary complications, or renal function deterioration in the course of our observation. The chart review of the patients at 6 months revealed the following: favorable outcome, 55.1%; unfavorable outcome, 33.3%; and mortality, 11.6%.

CONCLUSIONS

The 10% HES (200/0.5) can be used in the treatment protocol of severe head injury. There is no definite bleeding complications documented by current dosage of HES. Besides, balanced fluid management can be achieved without causing serious pulmonary complications. However, a further randomized, prospective study is needed to define the actual benefit of HES in fluid management and clinical outcome.

Clinical outcome of severe head injury using three different ICP and CPP protocol-driven therapies

In the past 5 years, cerebral perfusion pressure (CPP) management has become the standard in the treatment of severe head injuries. Guidelines published in 2000 suggest that CPP should be at least 70 mmHg; however, there is still debate about the optimal CPP. The purpose of the present study was to evaluate the effectiveness of these three widely used therapies: (i) intracranial pressure (ICP) targeted; (ii) CPP-targeted with CPP >70 mmHg; and (iii) modified CPP-targeted (mCPP) therapy with CPP >60 mmHg. The clinical procedures, complications and outcomes of patients in the different groups were compared. Data, including patient age, sex, initial Glasgow Coma Scale, ICP, CPP, fluid status, amount of mannitol and vasopressor used, daily fluid intake and output, complications and clinical results, were collected from 213 patients with severe head injuries over a 12-year period. Patients were categorized into three groups (ICP, CPP, mCPP) according to the treatment protocol used. Retrospective data collection was performed by chart review. The mortality rate was 28.6%, 14.3% and 13.5% in the ICP, CPP, and mCPP groups, respectively. Highest intake/output ratio, amount of vasopressor used and pulmonary complications were seen in the CPP patients. The mCPP patients showed the best clinical outcome and lowest complication rate. Although CPP-targeted therapy is the most recommended therapeutic protocol, our data show that patients treated with modified CPP-target therapy with CPP >60 mmHg have better clinical outcomes and fewer complications.

Efficacy and safety of hypertonic saline solutions in the treatment of severe head injury

BACKGROUND

The present study was undertaken to evaluate the efficacy and safety of hypertonic saline (HS) in the treatment of intracranial hypertension after severe head injury.

METHODS

This prospective, observational study was performed in an 11-bed neurosurgery intensive care unit of a teaching hospital. From February 2002 to September 2004, 18 severely head-injured patients with elevated intracranial pressure (ICP) and Glasgow Coma Scale scores of 5 to 8 (mean, 5.9 +/- 1.2) were admitted to the unit and treated according to a standard protocol. One dose per day of 3% saline was administered by rapid infusion (300 mL/20 min) when ICP values exceeded 20 mm Hg. After infusion, cerebral blood flow, ICP, blood pressure, end-tidal carbon dioxide, and heart rate were monitored continuously for 60 minutes and recorded. Serum osmolarity, sodium, potassium, chloride, arterial carbon dioxide pressure, arterial oxygen pressure, hemoglobin, lactic acid, and pH were measured immediately before infusion (zero time) and 20 and 60 minutes after infusion. Mean arterial pressure, cerebral perfusion pressure (CPP), mean flow velocity (MFV), and pulsatility index (PI) were also recorded and analyzed.

RESULTS

Intracranial pressure fell immediately after initiation of infusion with further significant decreases observed at 20 and 60 minutes (30.4 +/- 8.5, 24.3 +/- 7.4, and 23.8 +/- 8.3 mm Hg, respectively; P < .01). At these respective times CPP increased significantly (78.7 +/- 8.7, 83.2 +/- 7.8, and 87.2 +/- 12.8 mm Hg), PI dropped rapidly (1.51 +/- 0.42, 1.38 +/- 0.32, and 1.34 +/- 0.33) and MFV increased (66.26 +/- 25.91, 71.92 +/- 28.13, and 68.74 +/- 28.44). Serum sodium increased from 141.3 +/- 7.2 to 146.3 +/- 7.2 mmol/L after 20 minutes and returned to 144.3 +/- 7.36 mmol/L at 60 minutes. Potassium concentrations decreased significantly from 3.9 +/- 0.39 to 3.55 +/- 0.35 mmol/L after 20 minutes (P < .01). Lactic acid values at 0, 20, and 60 minutes were 1.6 +/- 0.5, 1.47 +/- 0.48, and 1.38 +/- 0.53 mmol/L, respectively (P < .01).

CONCLUSION

Rapid infusion of single dose daily of HS is a safe alternative for the treatment of elevated ICP in severe head injury. Further evaluations of long-term consequences and complications and of maximal tolerance to this treatment are required.

Delayed diagnosis of esophageal perforation following intraoperative transesophageal echocardiography during valvular replacement--a case report

A 62 year-old man sustained esophageal perforation following intra-operative transesophageal echocardiography (TEE) in a valvular replacement surgery. Septic shock developed on the 12th postoperative day (POD) and the esophageal perforation was diagnosed with chest CT. Emergent operation together with intensive care saved the patient's life. We speculate that the mechanism of perforation was not due to manipulation of the probe, but rather due to ischemia of the esophagus resulting from the combination of probe compression, non-pulsatile flow and the distension of the atria during a lengthy procedure. It is advisable that in patients with operative risk factors, such as distension of atria, long cardiac procedure and likely ischemia of organs due to cardiopulmonary bypass, the monitoring probe of TEE should not constantly rest in the esophagus and be withdrawn when it is idle or not in actual use. In addition, if resistance has been met during the intraoperative manipulation of the probe in a patient without previous history of esophageal disease, perforation might suspected if he or she sustains postoperative fever with positive chest X-ray findings.

Supplementing transesophageal echocardiography with transthoracic echocardiography for monitoring transcatheter closure of atrial septal defects with attenuated anterior rim: a case series

The use of transesophageal echocardiography (TEE) for guidance of transcatheter closure of secundum-type atrial septal defect (ASD) is increasingly becoming a routine procedure. ASD with attenuated anterior superior (SA) rim is a variant of secundum-type ASD and is suitable for transcatheter closure. The success rate of TEE guidance for device deployment in these patients is not known. Therefore, we assessed 124 consecutive patients with ASD (57 secundum-type, 67 with attenuated SA rim) closed with an Amplatzer Septal Occluder under TEE guidance. Our results show that the TEE was successful in depicting all 4 corners and corresponding edges of each Amplatzer disk, as well as the septal rims of all 57 secundum-type ASDs. However, in 6 of 67 ASDs (9%) with attenuated SA rim in which TEE failed to visualize the adequate placement of occluder on the anterior inferior (IA) rim, the additional use of transthoracic echocardiography helped to resolve this inadequacy. Four of these six patients had the unusual morphology of the IA rim tissue. Two had severe right axis deviation of the heart with large Q angle (>90 degrees ). The SA rim was absent in 35 of 67 ASDs with attenuated SA rim and in these cases TEE demonstrated the anterior surface of the disk against the wall of the aorta but without distortion. We conclude that TEE can be useful for confirming successful deployment of the occluder in most patients with ASDs. In a small number of ASDs with attenuated SA rim who have unusual IA morphology, supplemental transthoracic echocardiography is required to verify successful deployment of the occluder when TEE visualization fails to reliably diagnose adequate placement of the occluder.

IMPLICATIONS

Transesophageal echocardiography can be useful for confirming successful deployment of the occluder in the majority of patients with atrial septal defect. In a small number of atrial septal defects with attenuated anterior superior rim which have unusual anterior inferior morphology, supplemental transthoracic echocardiography is required to verify successful deployment of the occluder when transesophageal echocardiography visualization fails to reliably diagnose adequate placement of the occluder.

The analgesic effect of oral morphine or pentazocine for extracorporeal shock wave lithotripsy

BACKGROUND

Extracorporeal shock wave lithotripsy (ESWL) in these days is usually carried out on ambulatory or outpatient basis. With the application of a lithotriptor of modern version an appropriate yet cost-effective analgesia with minimal side effects for ESWL is mandatory.

METHODS

The analgesic effect of oral morphine (30 mg) was compared with that of pentazocine (100 mg) in a prospective study comprising 100 patients undergoing ESWL with a lithotripter of improved version for urinary tract stones. All patients received orally lorazepam 1 mg as sedative together with the appointed tested drug 30 min before the procedure. The analgesic effects of both drugs were assessed having recourse to the pain scale and efficacy scale.

RESULTS

There were 94% of patients in the pentazocine (mixed agonist-antagonist) group who felt satisfied with the regimen and stood the procedure well without resort to supplemental drug, as compared with the morphine (potent mu-agonist) group in which only 70% of patients did so. Although the adverse effect such as dizziness was found in the pentazocine group, the degree of sleepiness produced by its deeper sedation effect was to the advantage of patients during the lithotripsy procedure. There were no significant changes in intergroup mean blood pressure (MBP), but heart rate (HR) was higher and O2 saturation (SpO2) was lower in the pentazocine group after treatment. Both narcotics did not induce renal colic in our study. Also, pentazocine 100 mg plus lorazepam 1 mg given orally did not induce psychotomimetic reaction intraoperatively or postoperatively.

CONCLUSIONS

We concluded that oral pentazocine at 100 mg plus lorazepam 1 mg, could offer satisfactory analgesia in patients undergoing ESWL for urinary tract stones with a lithotripter of improved version.

An evidence-based review on the use of corticosteroids in peri-operative and critical care

With complex and extensive pharmacological effects, corticosteroids are widely used in many clinical situations. A survey conducted to define the role of corticosteroids in various settings of peri-operative and critical care gave strong evidence to support that the use of corticosteroid is absolutely indicated in patients with adrenal insufficiency, asthma, anaphylaxis, acute spinal cord injury, and increased ICP resulting from brain tumors. As the benefits of corticosteroids are much in evidence, their uses are recommended to extend to postoperative antiemesis, acute respiratory failure (such as ARDS, COPD, and fat embolism), increased ICP associated with brain abscess, thyroid storm, and refractory hypothermia. Beneficial effect could be expected in septic shock with high-dose corticosteroids. Despite extensive reports on their versatile usefulness, evidence-based review did not recommend the use of corticosteroids in increased ICP associated with traumatic head injury and cerebral infarct, cardiac arrest, post-extubation airway edema, and aspiration pneumonia due to poor effectiveness let alone further worsening of the conditions. Great caution must be taken in clinical situations where administration of corticosteroids is considered contraindicated such as systemic fungal infection, hypersensitivity to the drug, intramuscular injection in idiopathic thrombocytopenia purpura, vaccination with live virus.

Successful resuscitation of acute massive pulmonary embolism with extracorporeal membrane oxygenation and open embolectomy

Acute massive pulmonary embolism is usually fatal if not treated aggressively, but the management is not standardized. Open pulmonary embolectomy retains a role in the treatment of this disastrous disease. Extracorporeal membrane oxygenation has been used for cardiopulmonary support in some patients with life-threatening pulmonary embolism. This article details our experience of a 58-year-old woman suffering from acute cardiopulmonary collapse caused by massive pulmonary embolism. Under extracorporeal membrane oxygenation support, the patient received pulmonary angiography and underwent open embolectomy for a definitive treatment.