Objective To investigate the effects of direct hemoperfusion with polymixin B-immobilized fiber (DHP-PMX) in patients with sepsis. Methods We searched Pubmed, Embase, Web of Science databases and identified relevant randomized controlled trials (RCT) from January 1995 to May 2010. Meta-analysis of DHP-PMX on mortality and levels of endotoxin in patients with sepsis were conducted using the methods recommended by the Cochrane Collaboration. Results Eleven RCTs were included.Eight of them included the mortality of patients (sample size: 211 DHP-PMX and 178 conventional medical therapy). In total, the mortalities of patients with sepsis in DHP-PMX group and conventional group were 37.4% (79/211) and 68.5% (122/178) respectively. Compared with the conventional medical therapy,DHP-PMX appeared to significantly reduce mortality ( OR =0.24,95% CI 0.16-0.38 ,P ＜0.000 01 ). The results were similar when two RCTs enrolling patients with methicillin resistant staphylococcus aureus (MRSA) infections were excluded( OR =0. 27,95% CI 0. 17-0. 45, P ＜0. 000 01 ). When the analysis was limited to the nine studies that reported 28- to 30-day mortality, results were unchanged( OR =0. 29,95% CI 0.17-0.48 ,P ＜0.000 01 ). Six RCTs had the available data of endotoxin. The level of endotoxin decreased 31 ng/L(95% CI 22.46-39.55 ) after DHP-PMX therapy, and the decreasing was statistically significant (P＜0. 000 01 ) ,while the level of endotoxin in patients of conventional group did not change (P =0.94).Conclusions This study suggests a favorable effects of DHP-PMX on mortality and endotoxin decreasing in patients with sepsis. However, lack of enough cases and blinding need to be considered. Further investigation with large sample of high quality RCTs is needed.

ObjectiveTo evaluate the effects of ventilator circuit change frequency on ventilatorassociated pneumonia (VAP).MethodsMeta-analysis of effects of ventilator circuit change frequency on VAP was conducted with study-level data from 1995 to 2010 in Pubmed,Embase,Web of Science databases.ResultsNine articles were included (sample size:20 326 mechanically ventilated patients).Analysis of six articles showed that the incidence of VAP in ventilator circuit change every 2 or 3 days was 4.05％,while 3.65％ in ventilator circuit change every 7 days.Compared with change ventilator circuit every 2 or 3 days,the risk ratio (RR) of VAP in weekly changes was 0.77 [0.54,1.09] ( P =0.14 ).Analysis three articles showed that compared to ventilator circuit change every 7 days with 15.89％ incidence of VAP,the incidence of VAP in circuit change more than 14 days was 14.9％,and RR was 0.98 [0.69,1.39](P =0.91 ).ConclusionsRegular ventilator circuit change frequency in various intervals can't difference in the incidence of VAP in mechanical ventilation patients.

Objective To evaluate the effects of noninvasive positive pressure ventilation (NPPV)used after extubation on mortality and rate of reintubation in patients with acute respiratory failure (ARF).Method Pubmed, Embase, Web of Science databases were searched to collect data from randomized controlled trials (RCT) of the relevant subject from January 1995 to May 2010. Meta analysis of data about NPPV on mortality and rate of reintubation in patients after extubation carried out by using the methods recommended by the Cochrane Collaboration. Results Six RCTs included sample size of 381 NPPV and 379routine medical care. In total, the mortalities of patients in NPPV group and routine medical care group were 18.6% (62/334) vs. 21.6% (72/333), respectively, and the rates of reintubation of the two groups were 30.2% (115/381) vs. 33.5% (127/379), respectively. Compared with routine medical care, NPPV did not significantly reduce the mortality ( OR: 0.83, 95% CI =0.57 ～ 1.21 ,P =0.34) and rate of reintuation( OR: 0.83, 95% CI = 0.59 ～ 1.16, ( P = 0.27). When the analysis was focused to the four studies of them in which patients received NPPV as soon as extubation, the results were quite different. From these four studies, the mortalities of patients in NPPV group and routine medical care group were 12. 2% (22/181) vs.23.9% (44/184),(P=0.004), and the rate of reintubation of the two groups were 14.0% (32/228) vs.20.4% (47/230), (P =0.07). Compared with routine medical care, early application of NPPV to patients after extubation reduced the mortality. Conclusions This study suggests the favorable effects of early application of NPPV to patients after extubation on the mortality of acute respiratory failure.

Objective In order to analyze of poisoning causes,a new method was established utilizing hydrophilic liquid chromatography-tandem triple quadrupole mass spectrometer (HILIC-MS/MS) coupled with dispersive solid phase extraction for rapid qualitative and quantitative analysis of tetrodotoxin in nassarius and shellfish.Methods Sample (1.0 g) was extracted with 0.1％ acetic acid in boiling water bath,purified by dispersive solid phase extraction with 50 mg hydrophilic-lipophilic balance (HLB),5 mg graphitized carbon black (GCB) and protein precipitation with acetonitrile,and then filtered through a polytetrafluoroethylene (PTFE) membrane.The analytes were separated on a HILIC column,and detected in selected reaction monitoring (SRM) mode via positive electrospray ionization.The matrix matching and external standard method was used for quantification.Results Tetrodotoxin showed good linearity in the concentration range between 2.0 and 40.0 ng/ml,the correlation coefficient was higher than 0.999.The detection limit of tetrodotoxin in seafood was 10.0 pg/kg.The rates of recovery varied between 74.2％ and 87.9％ with relative standard deviations from 2.3％ to 9.1％ at spiked concentrations of 25,100 and 200 pg/kg.The proposed method was applied in the detection of tetrodotoxin in shellfish and nassarius from coastal cities of Zhejiang Province.Conclusion The method was accurate,fast,easy to operate,which could meet the requirements of public health emergency testing or routine testing.

Objective To determine whether urinary neutrophil gelatinase-associated lipecalin (uNGAL) and urinary intedeukin-18 (uIL-18) are early markers of acute kidney injury (AKI) in critically ill patients. Methods Ninety-two critically ill patients were studied for one week after their enrollment into our hospital. During the study, 46 patients who met the RIFLE criteria were selected as AKI group and the remaining 46 patients without AKI taken as a control group. The two groups were matched for age, gender and illness severity. Urine samples were collected daily for one week. The receiver operating characteristic curve was used to evaluate the early diagnostic value of uNGAL, uIL-18 and serum creatininc (SCr). Results As compared with the levels obtained 3 days before the diagnosis of AKI, the uNGAL levels in the AKI group increased significantly (P <0. 05), while uIL-18 and SCr levels did not change 2 days prior to the diagnosis of A KI (all P > 0. 05). uNGAL and uIL-18 levels increased significantly (all P < 0. 05), while SCr levels did not change 1 day prior to the diagnosis of AKI in the AKI group (P > 0. 05). The levels of uNGAL, uIL-18 and SCr did not change significantly in the control group during the study period (all P > 0. 05). Three days before the diagnosis of AKI, concentrations of uNGAL, uIL-18 and SCr were not the predictive of AKI. Two days before the diagnosis of AKI, the area under the curve (AUC) of uNGAL was 0. 840 (95% CI 0. 672-1. 009, P < 0. 05), which indicated that uNGAL was the predictive of AKI while uIL-18 and SCr were not. One day before the diagnosis of AKI, the AUC of uNGAL and ulL-18 were 0. 830 (95 % CI 0. 711-0. 950, P < 0. 05) and 0. 818 (95 % CI 0. 697-0. 938, P < 0. 05), indicating that uNGAL and uIL-18 were the predictive of AKI while SCr was not. Conclusion uNGAL and uIL-18 may be the early predictive markers of AKI in critically ill patients.

Objective To compare in vitro fertilization and embryo transfer( IVF-ET ) outcome of gonadotropin-releasing hormone( GnRH ) antagonist protocol and GnRH agonist long protocol in patients with polycystic ovary syndrome ( PCOS)and to provide reference for rational selection of ovulation stimulation protocol for PCOS patients. Methods One hundred and four patients with PCOS who underwent IVF-ET were randomly divided into two groups. In the study group,41 patients were subjected to the GnRH antagonist protocol;In the control group,63 patients were subjected to a long protocol of GnRH agonist. Doses and duration of gonadotropin therapy,the thickness of endometrium and the profile of hormone level on the day of HCG administration,the number of retrieved oocytes,the ratio of fertilization,the ratio of cleavage,the ratio of the good quantity embryos,implantation rate of embryo,pregnancy rate,the cycle cancellation rate and the incidence rate of ovarian hyperstimulation syndrome( OHSS)were recorded. Results The IVF-ET outcome of the two groups was similar with respects to the number of oocytes,the ratio of fertilization,the ratio of cleavage,implantation rate of embryo and the pregnancy rate( P﹥0. 05). Significant differences were found(P﹤0. 05)between the two groups regarding to the doses and duration of gonadotropin therapy,the levels of serum E2 and LH on the day of HCG administration,and the cycle cancellation rate. The incidence rate of OHSS was not significantly different ( 2. 44% vs. 12. 70%) between the two groups. Conclusion The duration of gonadotropins administration,the cycle cancellation rate,incidence of OHSS and the financial burdern are reduced in patients treated with GnRH antagonist. The growth of follicle,the ratio of fertilization,the ratio of cleavage,implantation rate of embryo and the pregnancy rate are not different between the two methods. The GnRH antagonist protocol is optimal for patients with PCOS.

Objective To evaluate the effects of sedation with propofol or dexmedetomidine on volume responsiveness in critically ill patients with acute circulatory failure. Methods Ninety?one critically ill patients with acute circulatory failure, aged 20-90 yr, weighing 40-80 kg, requiring sedation with propofol or dexmedetomidine, of Acute Physiology and Chronic Health Evaluation Ⅱ scores 12-47, of Sequential Organ Failure Assessment scores 1-18, and of NYHA Ⅰ or Ⅱ, were included. The patients were randomly divided into 2 groups using a random number table: propofol group ( n = 45 ) and dexmedetomidine group ( n=46) . Before and after propofol or dexmedetomidine sedation, when Richmond Agitation Sedation Scale score reached -2 or -1 ( BIS value 60-75) ( after sedation) , passive leg?raising (PLR) test was performed to evaluate volume responsiveness. An increase in cardiac index (ΔCI) ≥10% after PLR was considered to be a positive response, whereas ΔCI<10% after PLR was considered to be a negative response. The patients who presented with negative responses before sedation served as negative volume responsiveness subgroups ( N subgroups ) , that was PN subgroup and DN subgroup. Results The positive rates of volume responsiveness were 64% ( 14 cases) and 25% ( 5 cases) in PN and DN subgroups, respectively. The positive rates of volume responsiveness were significantly higher after sedation than before sedation in PN and DN subgroups. Compared with DN subgroup, the positive rates of volume responsiveness were significantly increased after sedation in PN subgroup. Conclusion For the critically ill patients with acute circulatory failure, both propofol and dexmedetomidine sedation can improve volume responsiveness, and propofol provides better efficacy than dexmedetomidine.

ObjectiveTo assess the efficacy of subglottic secretion drainage for preventing ventilatorassociated pneumonia.MethodsData of relevant randomized controlled trials (RCT) from January 1991 to June 2010 were collected,and data were split into two groups,namely draining group and non-draining group.Meta analysis of ventilator-associated pneumonia was carried out for finding the incidence and mortality in patients with mechanical ventilation using the methods recommended by the Cochrane Collaboration.ResultsSeven RCTs met the inclusion criteria and 1647 patients were enrolled.Subglottic secretion drainage reduced the incidence of ventilator-associated pneumonia ( OR =0.45,95％ confidence interval [CI]:0.32 - 0.63 ),primarily by reducing early-onset pneumonia.But the mortalities of ventilator associated pneumonia were not significantly different between the two groups ( OR =1.03,95％ confi dence interval [CI]:0.75 - 1.41 ).ConclusionsSubglottic secretion drainage appeared effective in preventing ventilator associated pneumonia among patients expected to require ＞48 hours of mechanical ventilation,but the mortality was unchanged.

Objective To assess the value of central venous-to-arterial carbon dioxide difference [ P( cv-a) CO2 ] in evaluation of disease severity and prognosis in patients with septic shock.Methods There were 45 consecutive resuscitated septic shock patients from April 2009 to October 2010 included immediately after their admission into our ICU.The patients were divided into low P(cv-a) CO2 group and high P(cv-a) CO2 group according to a threshold of 6 mm Hg ( 1 mm Hg=0.133 kPa).All patients were treated by early goal directed therapy (EGDT).The parameters of hemodynamics,lactate clearance rate,the Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ ) score,the sequential organ failure assessment (SOFA)score,6 h rate of EGDT achievement,the ICU mortality and 28 days in-hospital mortality were recorded for all patients.Results There were 30 patients in the low P(cv-a) CO2 group,and 15 in the high P(cv-a)CO2group.There were no significant differences between low P(cv-a) CO2 and high P(cv-a) CO2 patients in age,APACHE Ⅱ score and SOFA score (all P ＞ 0.05 ).Compared with the high P(cv-a)CO2 group,the low P(cv-a) CO2 group had higher cardiac index ( CI ) and 24 h CI,higher delivery O2 ( DO2 ) and 24 h DO2,higher central venous oxygen saturation ( ScvO2 ) [ (74 ± 9) ％ vs (67 ± 8) ％ ],lower lactate [ ( 3.4 ± 2.1 )mmol/L vs (5.7 ± 4.5 ) mmol/L] and higher △SOFA score [ (0.7 ± 1.8 ) vs ( - 0.4 ± 1.1 ) ],lower 24 h SOFA score [ (7.8 ± 2.0) vs (9.8 ± 2.0 ) ],higher 6 h rate of EGDT achievement ( 83.3％ vs 53.3 ％ )(P ＜ 0.05 ),however,there were no differences in 28 days mortality and ICU mortality between the two groups ( P ＞ 0.05 ).Conclusion P(cv-a) CO2 might be an indicator for predicting the severity of patients with septic shock and evaluating tissue perfusion.

Objective To investigate the effect of stress dose glucocorticoid on patients with acute respiratory distress syndrome (ARDS) combined with critical illness-related corticosteroid insufficiency (CIRCI).Methods All early ARDS patients combined with CIRCI were screened by an adrenal corticotrophic hormone (ACTH) test and randomly divided into treatment group (hydrocortisone 100 mg intravenous,3 times/day,consecutively for 7 days,n =12 ) and control group (equivalent normal saline,n =14 ).General clinical data,changes of arterial blood gas,hemodynamics and respiratory mechanics were observed and recorded at admission and at 7 days after treatment.Ventilator-free and shock-free days,ICU stay within 28 days after admission were recorded and 28-day mortality was used as judge prognosis index.Results CIRCI rate in 45 early ARDS patients was 57.8％ ( 26 patients),and the shock rate was markedly higher in ARDS patients with CIRCI than patients without CIRCI (46.2％ vs 5/19 ).There were no significant differences in baseline parameters,oxygenation and illness severity between the treatment and control groups,except for markedly lower lactic level in the treatment group [ 2.7 ( 1.2,3.9 ) mmol/L vs 4.6 ( 2.5,6.3 ) mmol/L,P ＜ O.05].After 7 days of treatment,PaO2/FiO2 markedly increased,while heart rate obviously decreased in the both groups.Compared with the control group,survival time of patients was significantly longer and shock rate of the patients was markedly lower in treatment group within 28 days (5/12 vs 10/14,P ＜ 0.05).The 28-day mortality,which were adjusted by baseline arterial lactic,was lower in the treatment group (2.6/12 ) than in the control group (5.8/14) while with no significant difference ( P ＞ 0.05 ).There was no significant difference in complication incidence between the two groups.Conclusion Stress dose glucocorticoid could reduce shock incidence and prolong survival time,and has a tendency of lower 28-day mortality in early ARDS patients combined with CIRCI.