BACKGROUND: Severe stroke has high rates of mortality and morbidity. This study aimed to investigate the clinical course, causes of worsening, and outcomes of severe ischemic stroke. METHODS: This prospective, multicenter cohort study enrolled adult patients admitted ≤30 days after ischemic stroke from nine hospitals in China between September 2017 and December 2019. Severe stroke was defined as a score of ≥15 on the National Institutes of Health Stroke Scale (NIHSS). Clinical worsening was defined as an increase of 4 in the NIHSS score from baseline. Unfavorable functional outcome was defined as a modified Rankin scale score ≥3 at 3 months and 1 year after stroke onset, respectively. We performed Logistic regression to explore baseline features and reperfusion therapies associated with clinical worsening and functional outcomes. RESULTS: Among 4201 patients enrolled, 854 patients (20.33%) had severe stroke on admission. Of 3347 patients without severe stroke on admission, 142 (4.24%) patients developed severe stroke in hospital. Of 854 patients with severe stroke on admission, 33.95% (290/854) experienced clinical worsening (median time from stroke onset: 43 h, Q1-Q3: 20-88 h), with brain edema (54.83% [159/290]) as the leading cause; 24.59% (210/854) of these patients died by 30 days, and 81.47% (677/831) and 78.44% (633/807) had unfavorable functional outcomes at 3 months and 1 year respectively. Reperfusion reduced the risk of worsening (adjusted odds ratio [OR]: 0.24, 95% confidence interval [CI]: 0.12-0.49, P  <0.01), 30-day death (adjusted OR: 0.22, 95% CI: 0.11-0.41, P  <0.01), and unfavorable functional outcomes at 3 months (adjusted OR: 0.24, 95% CI: 0.08-0.68, P <0.01) and 1 year (adjusted OR: 0.17, 95% CI: 0.06-0.50, P  <0.01). CONCLUSIONS: Approximately one-fifth of patients with ischemic stroke had severe neurological deficits on admission. Clinical worsening mainly occurred in the first 3 to 4 days after stroke onset, with brain edema as the leading cause of worsening. Reperfusion reduced the risk of clinical worsening and improved functional outcomes. REGISTRATION ClinicalTrials.gov , NCT03222024.
Humans ; Male ; Female ; Prospective Studies ; Ischemic Stroke/mortality* ; Aged ; Middle Aged ; Aged, 80 and over ; Stroke ; Brain Ischemia

OBJECTIVE: To compare the effects of different chest compression rates (60-140 times/min) on hemodynamic parameters, return of spontaneous circulation (ROSC), resuscitation success, and survival in a porcine model of cardiac arrest (CA) followed by cardiopulmonary resuscitation (CPR). METHODS: Forty healthy male domestic pigs were randomly divided into five groups based on chest compression rate: 60, 80, 100, 120, and 140 times/min (n = 8). All animals underwent standard anesthesia and tracheal intubation. A catheter was inserted via the left femoral artery into the thoracic aorta to monitor aortic pressure (AOP), and another via the right external jugular vein into the right atrium to monitor right atrial pressure (RAP). In each group, animals were implanted with a stimulating electrode via the right external jugular vein to the endocardium, and ventricular fibrillation (VF) was induced by delivering alternating current stimulation, resulting in CA. After a 1-minute, manual chest compressions were performed at the assigned rate with a compression depth of 5 cm. The first defibrillation was delivered after 2 minutes of CPR. No epinephrine or other pharmacologic agents were administered during the entire resuscitation process. From 1 minute before VF induction to 10 minutes after ROSC, dynamic monitoring of AOP, coronary perfusion pressure (CPP), and partial pressure of end-tidal carbon dioxide (P_ETCO₂). Cortical ultrastructure was examined 24 hours post-ROSC using transmission electron microscopy. RESULTS: With increasing compression rates, both the total number of defibrillations and cumulative defibrillation energy significantly decreased, reaching their lowest levels in the 120 times/min group. The number of defibrillations decreased from (4.88±0.83) times in the 60 times/min group to (2.25±0.71) times in the 120 compressions/min group, and energy from (975.00±166.90)J to (450.00±141.42)J. However, both parameters increased again in the 140 times/min group [(4.75±1.04)times, (950.00±207.02)J], the differences among the groups were statistically significant (both P < 0.01). As compression frequency increased, P_ETCO₂, pre-defibrillation AOP and CPP significantly improved, peaking in the 120 times/min group [compared with the 60 times/min group, P_ETCO₂ (mmHg, 1 mmHg≈0.133 kPa): 18.69±1.98 vs. 8.67±1.30, AOP (mmHg): 95.13±7.06 vs. 71.00±6.41, CPP (mmHg): 14.88±6.92 vs. 8.57±3.42]. However, in the 140 times/min group, these values declined significantly again [P_ETCO₂, AOP, and CPP were (10.59±1.40), (72.38±11.49), and (10.36±4.57) mmHg, respectively], the differences among the groups were statistically significant (all P < 0.01). The number of animals achieving ROSC, successful resuscitation, and 24-hour survival increased with higher compression rates, reaching a peak in the 120 times/min group (compared with the 60 times/min group, ROSC: 7 vs. 2, successful resuscitation: 7 vs. 2, 24-hour survival: 7 vs.1), then decreased again in the 140 times/min group (the animals that ROSC, successfully recovered and survived for 24 hours were 3, 3, and 2, respectively). Transmission electron microscopy revealed that in the 60, 80, and 140 times/min groups, nuclear membranes in cerebral tissue were irregular and incomplete, nucleoli were indistinct, and mitochondria were swollen with reduced cristae and abnormal morphology. In contrast, the 100 times/min and 120 times/min groups exhibited significantly attenuated ultrastructural damage. CONCLUSIONS Among the tested chest compression rates of 60-140 times/min, a chest compressions frequency of 120 times/min is the most favorable hemodynamic profile and outcomes during CPR in a porcine CA model. However, due to the wide spacing between groups, further investigation is needed to determine the optimal compression rate range more precisely.
Animals ; Cardiopulmonary Resuscitation/methods* ; Swine ; Male ; Heart Arrest/therapy* ; Heart Massage/methods* ; Hemodynamics

Objective To investigate the independent risk factors for early neurological deterioration(END)associated with para-median pontine infarction(PPI),to construct a scoring model based on the independent risk factors,and to evaluate its predictive value in END.Methods A total of 163 patients with PPI were retrospectively included and divided into END group(n=35)and non-END group(n=128).After screening possible clinical factors and MRI features,a scoring model was established based on the predictive value,and the predictive efficacy of the model was evaluated.Results Taking END as the endpoint event,homocysteine(Hey)level,maximum infarct size,severe leukoaraiosis(LA),mean apparent diffusion coefficient(ADC)value and inferior pontine infarction were independent risk factors for PPI related END(P＜0.05).Scores were assigned according to odds ratio(OR)value,which were 1,1,3,1,4,respectively,and a scoring model was further established.The model predicted END with an area under the curve(AUC)value of 0.910 and sensitivity of 0.743 and specificity of 0.898 when the score was ≥6 points.Conclusion The scoring model based on Hcy and MRI features has good efficacy in predicting PPI related END,and can provide a basis for prognostic evaluation.

Chest compressions are a key component of cardiopulmonary resuscitation (CPR). The determination of the optimal compression point (OCP) in adult CPR is an indispensable critical factor for high quality chest compressions (CCs). At present, the OCP for adult CPR is still controversial, which still needs further research and discussion. To provide theoretical reference for determining the OCP, this paper reviews the research progress of the OCP of adult CPR from the development process of compression point and hemodynamic mechanism, so as to improve the quality of CCs and the outcome of cardiac arrest (CA) patients.

Based on the requirements of military professional education reform and in view of the problems existing in the operation and maintenance of first-aid medical equipment in grass-roots forces. We put forward a construction scheme of online course which named operation and maintenance of first-aid medical equipment in grass-roots forces, and then expound the scheme from teaching content construction and teaching mode construction. The teaching content construction consists of two parts: the management theory of conventional medical equipments and the operation and maintenance teaching of specific first-aid medical equipments. In the construction of teaching mode, we elaborate on the organization forms of teaching, answering questions, training and examination units in detail. The design scheme of the online course is in line with the learning characteristics and meets the demand of learning the knowledge of the operation and maintenance of first-aid medical equipment systematically, so as to improve the post competency of the grass-roots forces.

Objective:To analyze the dynamic changes of T lymphocytes in patients with COVID-19.Methods:Blood samples were collected from 40 COVID-19 cases and 40 healthy controls in Beihai People′s Hospital from January to February, 2020. The counts of CD4 + T and CD8 + T lymphocytes were detected by flow cytometry. Moreover, the T lymphocyte counts in 24 convalescent patients with two consecutive negative nucleic acid test results were also detected. Results:The leukocytes and lymphocytes in the patients with acute COVID-19 were significantly lower than those in the healthy controls [(4.71±1.54)×10 9 cell/L vs (6.26±1.44)×10 9 cell/L, (1.13±0.41)×10 9 cell/L vs (1.51±0.39)×10 9 cell/L; both P<0.05]. The counts of CD4 + T and CD8 + T lymphocytes in the patients with acute COVID-19 were significantly lower than those in the healthy controls [(447.15±144.42) cell/μl vs (592.83±146.76) cell/μl, (309.35±173.05) cell/μl vs (397.20±136.94) cell/μl; both P<0.05], while no significant difference was observed in the CD4 + /CD8 + T cell ratio ( P>0.05). In the 24 convalescent COVID-19 patients, the counts of CD4 + T and CD8 + T lymphocytes were higher during convalescence than in the acute phase [(598.08±138.71) cell/μl vs (420.67±147.38) cell/μl, (439.08±166.94) cell/μl vs (296.67±151.06) cell/μl; both P<0.05], but there was no significant difference in the T lymphocyte counts between the convalescent patients and the healthy controls ( P>0.05). Conclusions:A transient immune deficiency occurred in patients with acute COVID-19, but the impaired immune function could restore to normal level during recovery.

Objective: To explore the clinical effects of superior gluteal artery perforator island flap in repair of sacral pressure ulcer. Methods: From May 2012 to May 2017, 20 patients with sacral pressure ulcers (14 males and 6 females, aged 27 to 67 years) were admitted to our department. According to the consensus staging system of National Pressure Ulcer Advisory Panel in 2016, 6 cases were in 3 stages, 14 cases were in 4 stages, with the area of pressure ulcers ranging from 5.0 cm×4.0 cm to 10.0 cm×8.0 cm. After debridement and vacuum sealing drainage, the superior gluteal artery perforator island flaps were used to repair the pressure wounds, with the area of flaps ranging from 6 cm×5 cm to 13 cm×8 cm. The donor sites were sutured directly. The survival of flaps after operation, the healing of wounds, and the follow-up of patients were observed. Results: After surgery, flaps of 20 patients survived well without reoperation. The length of hospital stay of patients was 20 to 40 days, with an average of 25 days. Eighteen patients were followed up for 6 to 24 months, with an average of 12.2 months. The flaps were in good shape and elastic recovery. There were no complications such as seroma or hematoma in the donor sites. Both the patients and family members expressed satisfaction with the shape and texture of the flap and shape of hip. Conclusions The superior gluteal artery perforator island flap is reliable in blood supply and easy to rotate. The flap can carry a little muscle to increase the anti-infective ability. Moreover, the donor site can be directly sutured with slight damage. Thus, it is one of the good methods for repairing sacral pressure ulcers.

Objective: To investigate the feasibility of repairing soft tissue defects of extremities with the perforator flap based on the first perforating artery of profunda artery. Methods: From January 2015 to December 2018, 9 patients with soft tissue defects of extremities were treated in the Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University. 5 males and 4 females; aged 29-48 years, average 36 years old. The causes of injury were traffic accident injury (4 cases), heavy object crush injury (3 cases) and mechanical injury (2 cases). There were 3 cases of soft tissue defect of upper limb, 6 cases of soft tissue defect of lower extremity, 2 cases of tendon and nerve rupture, 2 cases of fracture, 1 case of tendon and 1 case of bone exposure. All soft tissue defects were repaired with the perforator flap based on the first perforating artery of Profunda artery. After debridement, The range of soft tissue defect was 10 cm×5 cm-16 cm×10 cm. The intraoperative flap area was 12 cm×6 cm-18 cm×11 cm. The vascular anastomosis was performed in the area, the flap covered the wound surface and the donor site directly pulled the suture or grafted skin. Results: All flaps survived completely and there were no complications such as vascular crisis. Follow-ups were performed in various forms for 6 to 12 months. These flaps were satisfactory in appearance and function and had a good texture. Conclusions The perforator flap based on the first perforating artery of profunda artery can repair the defects of the limbs in the soft group. The donor site of the flap is hidden, the amount of tissue available is relatively large and the repair effect is good.

Objective: To investigate the design of free perforator flap, and the efficacy of utilizing perforator flaps for Ⅳ degree Ischia-sacral ulcer treatment. Methods: From January 2010 to October 2016, 18 patients with Ⅳ degree ischia-sacral ulcer were treated. The surface area of the sacral tail ranged from 4 cm×5 cm to 8 cm ×12 cm.Doppler sonography was used to detect potential perforator.All defects were repaired with free perforator flaps, designed based on the size and shape of the wound. The flap size ranged from 6 cm×11 cm to 9 cm×15 cm. Results: One perforator flap went dehiscence after surgery, repaired by V-Y flap. All the rest of perforator flaps survived well, after 3-24 months follow-up. Flap texture and appearance was good, no ulcer reoccurred. Conclusions The free perforator flap is a simple technique.It does not need to tracethe trunk of vessels, and it does not cause major morbidities to the buttocks. Therefore, it is one of the ideal ways to repair Ⅳ degree Ischia-sacral ulcer.

Objective: To explore the effects of combined transplantation of the rat Schwann cells and fibroblasts (Fbs) on the nerve regeneration of denervated perforator flaps in rats and the mechanism. Methods: (1) Fbs were isolated from the trunk of 2 Sprague-Dawley (SD) rats embryos of 14-16 days′ pregnancy and cultured, and the morphology of the cells was observed. The third passage of cells were used for subsequent experiments. The protein expressions of fibronectin and Ephrin-B2 were observed by immunohistochemical method. The mRNA expression of Ephrin-B2 was detected by real-time fluorescent quantitative reverse transcription polymerase chain reaction (n=3). (2) Schwann cells were isolated from the bilateral sciatic nerves and brachial plexus nerves of 45 SD rats born for 1-3 days and cultured, and the morphology of the cells was observed. The third passage of cells were used for subsequent experiments. The rate of S100 positive cells was detected by immunofluorescence method and flow cytometer, with sample numbers of 9 and 3 respectively. (3) In Dulbecco′s modified Eagle medium (DMEM) high glucose medium, 1 mL Fbs and 1 mL Schwann cells both in the concentration of 1×10⁵ cells/mL were co-cultured as Schwann cells+ Fbs co-culture group, and 2 mL Schwann cells in the concentration of 1×10⁵ cells/mL were cultured alone as Schwann cells alone culture group, with 5 wells in each group. The clusters of Schwann cells in the two groups were observed and counted under inverted phase contrast microscope at post culture hour (PCH) 6 and 24 respectively. The clusters of Schwann cells in Schwann cells+ Fbs co-culture group were observed by immunofluorescence method at PCH 24 too. The protein expressions of EphB2, Sox2, and N-cadherin in Schwann cells of two groups at PCH 24 were detected by Western blotting (n=20). (4) Totally 100 8-week-old male SD rats were selected, and an in situ replanted peritoneal denervated perforator flap was made in each rat. According to the random number table, the rats were divided into simple flap group, Fbs alone transplantation group, Schwann cells alone transplantation group, Schwann cells+ Fbs co-transplantation group, with 25 rats in each group. Flaps of rats in Fbs alone transplantation group and Schwann cells alone transplantation group were injected with 0.4 mL Fb and 0.4 mL Schwann cells respectively (2×10⁶ cells each). Flaps of rats in Schwann cells+ Fbs co-transplantation group were injected with 0.4 mL Fbs and Schwann cells mixed cells (totally 2×10⁶ cells, cell number ratio: 1∶1), and flaps of rats of simple flap group were injected with the same volume of DMEM high glucose medium. On post injection day (PID) 2, 5, 7, 9, and 14, 5 rats in each group were selected respectively according to the random number table. The flap tissue was collected, and the number, diameter, and arrangement of regenerated nerves were observed by immunofluorescence method. Data were processed with completely random designed t test, analysis of variance for repeated measurement, t test, and Bonferroni correction. Results: (1) The third passage of cells isolated and cultured from the rat embryo trunks were uniform in size and shape, long spindle-shaped, with a large proportion of nuclei. Strong positive expressions of fibronectin and Ephrin-B2 protein in cells were observed, and the mRNA expression of Ephrin-B2 was 0.004 1±0.000 8. The cells were identified as Fbs. (2) After 5 days of culture, the primary cells isolated from the sciatic nerves and brachial plexus nerves of neonatal rats were elongated in cell bodies and grew in nest, fence, or vortex-like shape. The third passage of cells were detected by immunofluorescence method and flow cytometer, and the corresponding S100 positive cell rates were (95.9±1.0)% and (95.8±1.1)% respectively. The cells were identified as Schwann cells. (3) At PCH 6 and 24, the cluster numbers of Schwann cells in Schwann cells+ Fbs co-culture group were significantly higher than those of Schwann cells alone culture group (t=6.500, 10.614, P<0.01). At PCH 24, the Schwann cells in Schwann cells+ Fbs co-culture group aggregated into clusters, Fbs dispersed around the Schwann cell clusters, and the protein expressions of EphB2, N-cadherin, and Sox2 in Schwann cells were significantly higher than those in Schwann cells alone culture group (t=2.975, 19.717, 11.159, P<0.05 or P<0.01). (4) On PID 2, a small number of scattered, disordered, short, and thin nerve fibers were observed in the flap tissue of rats in the four groups. From PID 5 to 14, the number of nerve fibers in the flap tissue of rats of Schwann cells+ Fbs co-transplantation group increased gradually, and the nerve fibers were with long diameter and arranged orderly. The number of nerve fibers in the flap tissue of rats of Schwann cells alone transplantation group increased, but the nerve fibers were with short diameter and arranged disorderly, and the number was smaller than that of Schwann cells+ Fbs co-transplantation group. In simple flap group and Fbs alone transplantation group, the nerve fibers in the flap tissue of rats gradually degenerated with gradually decreased number or even disappeared. Conclusions The combined transplantation of Fbs and Schwann cells in rats can regulate Schwann cells migration and clustering by activating Ephrin/Eph-Sox2-N-cadherin signaling pathway, thus promoting the orderly nerve regeneration of denervated perforator flaps in rats.