The amount of superoxide anions released by polymorphonuclear leukocytes (PMNs)and malonyldialdehyde (MDA) level in plasma,lung homoge-nate and bronchoalveolar lavage fluid (BALF) were determined in pigs after they were inflicted with gunshot wounds of steel-ball pellets.It was found that the amount of superoxide anions released spontaneously and after the stimulation of zymosa was increased and reached the peak in the 4th and 8th hour after injury respectively,and then returned to the preinjury level gradually.The changes of plasma MDA level was similar to those of superoxide anions released by PMNs.MDA level of lung homogenate and BALF was also significantly increased in the 24th hour postinjury.In addition,the relationship between PMNs function and lipid peroxidation in the plasma and the lungs was discussed.

The morphological and pathophysiological manifestations of theheart after abdominal gun-shot wound created by a model-53 smooth bore gun of 6.35 mm in caliber with 1.03 g steel ball were observed in 15 pigs,which were randomized into 3 groups.Five animals of the first group were killed immediately after wounding and all the animals showed small spotty flat hemorrhages on the endocardium of the left ventricle under gross inspection.Focal or small flat hemorrhages on the myocardium and under the endocardium were found under optical microscopy.Under electron microscopy,myofibrilla gaps were widened and filled with fluid,and mitochondrial swelling or vacuolar degeneration in the myocardium could be seen.7 animals of the second group were infused and monitored until they were killed 72 hours after wounding.It was found that there were varying degrees of functional disorder of the left ventricle in every animal.The serum level of creatine kinase isozyme MB increased significantly.The 3 pigs of the third group were killed with large andrapid blood-shedding without gun-shot wound and showed no similar pathological changes.

Objective To improve the diagnosis and treatment of Q fever endocarditis.Methods From 2008 to 2013,four cases of Q fever endocarditis were diagnosed in Peking Union Medical College Hospital.Clinical features,laboratory test,management and prognosis were analyzed with literature review.Result All four cases had long period of fever and heart murmur.Two patients represented with respiratory symptom and one with non-specific rash.General laboratory tests including complete blood cell count,ESR,C-reactive protein(CRP),liver function and radiology of lung did not show specific abnormalities.Signs of endocarditis were shown by ultrasound and important for diagnosis.Repeated blood culture was negative.All of the diagnoses were confirmed by serum antibody detection and the patients recovered well with treatment based on doxycycline or minocycline.Conclusions Endocarditis is the most common form of chronic Q fever,which is easily misdiagnosed because its blood culture is negative and may accompanied with varied manifestation such as pneumonia and liver injury.For the patients with chronic fever and blood culture negative endocarditis,chronic Q fever should be considered as differential diagnosis.The confirmatory method for diagnosis is serum antibody detection.Early and sufficient treatment may improve the prognosis.

From March 2000 to March 2003,15 cases of post internal fixation of fractures and arthroplasty infection were selected from Department of Traumatic Orthopedics,Tianjin Hospital,including 6 males and 9 females.The average age of re-operation was 56 years old.The average time from the primary surgery to diagnosis of infection was 0-19 months.Of the 15 cases,4 of arthroplasty infection underwent prosthesis extraction and temporary fixation with bone cement containing antibiotic and underwent another arthroplasty 6 months later.Of 11 cases of infection following internal fixation,the internal fixation was effective in 2 cases,and the fixation was removed after fracture healing,and ineffective in 9 cases.The fixation was removed primarily and focus of infection was cleared,lavaged with antibiotic solution,and another internal fixation was performed.The pus samples of 15 cases showed positive.Eleven cases(73.3%) had chronic infection including 9 occurring following fracture fixation and 2 following arthroplasty.Four cases(26.7%) had acute infection,including 2 occurring following arthroplasty and 2 following fracture fixation.No infection caused by blood circulation was found.The Gram-positive bacteria,staphylococcus aurens,staphylococcus epidermidis,and enterococcus occupied the most part of the infections in spite of the location and type of the infections,and Gram-positive bacteria-staphylococcus aurens was the most common.The order of the antibiotics sensitivity was Vancomycin,Rifampicin,Gentamicin,and Cephazoline.In addition,antibiotics sensitivity was varied in different infections.In samples of 15 cases,2 cases were sensitive to two bacteria at the same time following fracture fixation.The staphylococcus aurens,staphylococcus epidermidis,and enterococus are the high risk of injection following internal fixation of fractures and arthroplasty.The sensitive antibiotics and long-term medication are effective methods to treat the infection.

Objective:To explore whether prophylactic anti-viral therapy is needed for hepatitis B virus (HBV) infection resolvers with high titer of hepatitis B surface antibody (anti-HBs) receiving rituximab treatment.Methods:This study was a prospective cohort study. Nine patients with hepatitis B surface antigen(HBsAg) negative/hepatitis B core antibody (anti-HBc) positive/anti-HBs positive receiving rituximab treatment in Chinese Academy of Medical Science, Peking Union Medical College Hospital from June 2017 to June 2018 were enrolled. Patients were divided into two groups according to baseline anti-HBs titers. Patients with anti-HBs≥100 mIU/mL did not receive prophylactic treatment after informed consent. Patients with anti-HBs<100 mIU/mL were prescribed with entecavir before the treatment of rituximab. All patients were followed up every month after the first use of rituximab. Liver function, HBV DNA and HBV serology markers were tested. Descriptive statistical analysis was used.Results:Of the nine patients, six patients were diagnosed with diffuse large B cell lymphoma (DLBCL), one with Waldenstrom′s macroglobulinemia, one with indolent B-cell lymphoma, and one with membranous nephropathy. There were seven patients with anti-HBs≥100 mIU/mL who did not receive prophylactic anti-HBV therapy, and two patients with anti-HBs<100 mIU/mL who received entecavir (0.5 mg/d) prophylactic treatment before chemotherapy. The anti-HBs titer of the patient with indolent B cell lymphoma decreased from 21.27 mIU/mL to 6.33 mIU/mL during the third course of rituximab treatment. After the fourth course of treatment, the anti-HBs titer of one patient with DLBCL decreased from 172.25 mIU/mL to 57.76 mIU/mL. One patient with membranous nephropathy was followed up for one year and the anti-HBs titer increased from 141.47 mIU/mL to 328.98 mIU/mL.No significant changes of anti-HBs titer were observed in other patients. No HBV reactivation occurred in all patients and HBV DNA remained negative during the follow-up.Conclusions:The anti-HBs titer may drop after rituximab treatment in resolved HBV patients. High titer of anti-HBs may protect resolved HBV patients from HBV reactivation. Patients with high titer of anti-HBs may not need prophylactic anti-viral therapy.

Objective To summarize and analyze the dynamic change of HBsAg levels in patients with chronic Hepatitis B (CHB) after receiving nucleos(t)ide analogues (NAs) as antiviral treatment.Methods Patients who were performed quantitative Hepatitis B surface antigen(qHBsAg) from July 30, 2012 to December 30,2016 in Peking Union Medical College Hospital were retrospectively enrolled.qHBsAg, HBV DNA, HBeAg were collected and analyzed at baseline and at 192-week follow-up every 24 weeks.qHBsAg and HBeAg were assessed with chemiluminesent microparticle immuno assay(CMIA).HBV DNA was assessed with PCR and COBAS Amplicor.Results 60 patients were included.Patients in HBeAg-positive group had higher HBV DNA than that in HBeAg-negative group (P<0.05)at baseline and the two groups both were under detection limit after 48 weeks.BaselineqHBsAg in HBeAg positive-group and negative-group were (3.43±0.73) log10 IU/mL, (3.08±0.47) log10 IU/mL respectively.qHBsAg in HBeAg-positive group was higher than that in HBeAg negative-group on all follow-ups(P<0.05) except 48weeks.However on 168 weeks and 192 weeks, difference between the two groups was statistically significant(P<0.05).In HBeAg-positive group,quantitative HBeAg dropped significantly during antiviral treatment.Conclusions HBV replication can be suppressed in the process of long-term NAs treatment in CHB patients.However qHBsAg decline is not so obvious, which indicates that HBsAg cleavence is difficult,and long-term NAs therapy is still necessary.

A 28-year-old woman with multiple abscesses for 2 month and fever for 1 month was admitted in Peking Union Medical College Hospital.The skin abscesses gradually developed at skull,face,abdominal wall and pelvis.Laboratory examinations related to inflammatory reactions were strongly high including erythrocyte sedimentation rate 99 mm/1 h,C-reactive protein160.28 mg/L and ferritin 1 584 μg/L.Multiple nodules and cavities were detected in lungs.And vesico-cervical fistula was found during exploratory laparotomy.The pathological tests of abdominal tissues demonstrated necrosis and granuloma.Evidence of infectious diseases was not definite.Positive anti-proteinase 3 (PR3) antibody confirmed the diagnosis of granulomatosis with polyangiitis.After treated with glucocorticoid and immunosuppressants,the patient's symptoms improved remarkably.This case suggested that systemic vasculitis should be considered as a differential diagnosis of multiple abscesses which are not explained by infections.

Objective To analyze the epidemiology and clinical characteristics of patients with Brucella endocarditis in order to improve the understanding and treatment of Brucella endocarditis.Methods The clinical data including demographic characteristics,clinical features,laboratory data,echocardiography,treatment and clinical outcome of 6 patients with Brucella endocarditis were collected and analyzed.Results In our database consisting of 211 brucellosis patients with positive blood culture,6 patients (2.8％) with Brucella endocarditis were selected from May 2007 to December 2016 in Peking Union Medical College Hospital.The age range was 25-55 years,among whom 5 patients were men.The majority were farmers and all patients reported the history of closely contact with livestock.All of them had fever and 3 of them had arthralgia.Four patients had aortic involvement (4/6) and 2 of them presented with symptoms of left ventricular failure at admission.Blood culture of Brucella and serum agglutination test of Brucella were positive in all of them.Combined antibiotics treatments were given to all patients.Valve replacement surgery was performed in four patients,among them,three patients well recovered,one lost.Among all the patients,four were followed up continually and other two were lost.Conclusions Brucella endocarditis has a predominance of aortic involvement and is prone to left ventricular failure.Early antibiotic treatment combined with valve-replacement surgery is effective to improve the prognosis.

Objective To study the injury factors, pathogenic process and clinical features of delay two-phase multiple organ dysfunction syndrome (MODS) in severe burned patients and to replicate a standardized animal model that would accurately imitate the clinical features of MODS.Methods Forty-five human patients with burn size larger than 30% total body surface area (TBSA) were analyzed. All of them underwent severe burn shock in early stage and sepsis in late stage. Thirty-two goats were randomly divided into three groups: 1) hemorrhagic shock (group H, n=6); 2) endotoxemia (group E, n=6); and 3) hemorrhagic shock plus endotoxemia (group M, n=20). Hemorrhagic shock was produced according to the method of Wigger (6.7 kPa for an hour, 1 kPa=7.5 mmHg). Endotoxin (E. coli O111 B4) was given via the portal vein 24 hours after the resuscitation of hemorrhagic shock, in a dose of 30 ng/kg/min for 5 consecutive days. During the observation period of 10 days, all animals were hemodynamically monitored, given standard metabolic support and due cardiac and pulmonary support according to human intensive care.Results All the patients showed burn shock at 1-3 days and hyperdynamic circulation, hypermetabolism and systemic inflammatory responses over two weeks post-injury. Thirteen cases were found to develop MODS according to the prevailing diagnostic criteria, and 10 of them died with a mortality of 77%. Eighteen animals died in group M with a mortality of 90%, 12 of the 18 developed MODS, with overall incidence of 60%. Most animals in group M showed changes similar to that observed in human cases. The experimentation proved that in the pathogenic process of MODS, there was a two-hit phenomenon in the dvelopment of the syndrome. To prevent the development of MODS, it therefore was imperative to blunt the first hit or the second hit, so that an excessive inflammatory response was alleviated. This postulation has been verified in the treatment of extensive burns. Two patients with burn extent reaching 100% TBSA survived with only mild acute respiratory distress syndrome (ARDS) and renal dysfunction after comprehensive treatment of burn shock, including adequate fluid resuscitation, drugs to remove oxygen free radicals, rapid restoration of pHi, and early extensive excision of burn eschars.Conclusion Both in human patients or animal experimentation, the typical delay two-phase MODS is shown to be produced by two successive insults in the forms of hypovolemic shock and sepsis. This postulation is helpful in formulating the prevention and treatment modality of MODS.

Fever and abdominal pain are common symptoms and could be main manifestations in patients with autoinflammatory diseases.A 48-year-old female patient was admitted with recurrent fever and abdominal pain for 9 years.Serum level of inflammatory markers synchronously fluctuated with fever,and returned to normal when fever subsided.The periodic episodes of fever occurred every 1 to 4 months and failed to respond to empirical antibiotics.Whole exome sequencing showed heterozygous mutation of NOD2 gene q902k,leading to the final diagnosis of autoinflammatory disease.Corticosteroid and tripterygiumglycosides were effective for the disease remission.