Objective To investigate the value of cluster cate forpatients with ventilator-associated pneumo-nia (VAP) in the intensive care unit. Method Three hundred fifty-four consecutive patients with mechanical ven-tilation support in the Emergency Intensive Care Unit of Nanjing First Hospital from January 2006 to September 2007 were included in this study. The cluster care included elevating patient's head and chest to at least 30 de-grecs to the horizontal level, intensiving frequency of oral-pharyngeal nursing with thorough suction, washing hands, changing ventialtor tube at shorter regular interval, closely observing temperature, sputmn, WBC count, pu-turn, white blood cell count, chest X-ray examination and respiratory tract bacterial culture etc. Another 398 me-chanical ventilated patients with conventional care in the Hospital from January 2004 to November 2005 were taken as control. The t -test and X2 -test were used for analysis. Results The morbidity of VAP was significantly de-creased after cluster care(16.6 % vs. 24.6% P<0.01), the length of intensive care unit stay (LOS) was shorter in patients with cluster care than those in patients of control [(10.75±5.86) d vs. (14.26±9.40) d, P <0.05]. Conclusions Pneumonia associated with mechanical ventilation can be effectively reduced by the cluster care.

Objective To investigate the diagnosis and operation treatment of primary intrahepatic cholangiocelhlar carcinoma (PICC), for improving the level of diagnosis and treament of PICC. Methods The clinical data of 18 cases with PICC confirmed by operation were analyzed retrospectively. Results In the early stage, no specific symptoms was found in all the 18 cases, the positive cases of AFP, CEA, CA199 and live cirrhosis were 2, 4, 3 and 4. The diagnostic rates of ultrasound examination, CT and MRI were 11.1%(2/18), 42.9%(6/14) and 45.5% (5/11 ). Seven cases were diagnosed as suffering from PICC and the others were misdiagnosed. Of all the 18 patients, 8 cases underwent radical resection and 10 cases received palliative excision. Conclusions PICC patients lack clinical features and serum tumor marker,the rato of misdiagnosis is high, but that of radical resection is low. Knowing its clinicopathological features well. Radicalresection is the best way for treatment of PICC.

Objective To study the effect of mechanical ventilation guided by esophageal pressure on hemodynamics and oxygen metabolism of severe acute pancreatitis (SAP) swine model with intra-abdominal hypertension (IAH) Methods By self-controlled study,SAP model was made by infusing sodium taurocholate (5％) into the pancreatic duct in 6 domestic swine.Mechanical ventilator mode was volumeassist control with tidal volume 10 ml/kg ; FiO2 40％ and PEEP 5 cm H2O (routine ventilation) given to SAP model swine.After 3 h ventilation,pneumo-peritoneum was made with N2 gas to increase the intraabdominal pressure (IAP) to 25 mm Hg in SAP swine.Three more hours later,PEEP was adjusted as the measurement of esophageal pressure (Pes guided ventilation) to such a level that trans-pulmonary pressure stayed above 0 cm H2O during end-expiratory occlusion.During the investigation period,heart rate (HR),cardiac output index (CI),central venous pressure (CVP),mean arterial pressure (MAP) and pulmonary arterial wedge pressure (PAWP) were continuously recorded with the aid of Swan-Ganz catheter and ECG monitor,and oxygen partial pressure of artery (PaO2) and carbon dioxide partial pressure of artery (PaCO2) were measured by blood-gas analysis.In addition,systemic oxygen delivery (DO2) and systemic oxygen consumption (VO2) were calculated by using the data of blood-gas analysis of arterial and central venous blood.Results No swine model was subjected to barotrauma.After routine mechanical ventilation,there were significant differences in HR,CI,MAP,CVP,PAWP,Ppeak,Pplat,Pes,pulmonary compliance (Cstat),PaO2,and DO2 between SAP and IAH in swine (all P ＜ 0.05).Compared with routine ventilation,however,PaO2 and Cstat improved significantly with lower CI and increased Pplat after PEEP adjusted according to measurements of esophageal pressure (all P ＜ 0.05).The lactate decreased significantly after esophageal pressure guided ventilation (all P ＜ 0.05).There were no significant changes in PaCO2,HR,MAP,CVP and PAWP in IAH swine after mechanical ventilation with routine parameters (all P ＞ 0.05).Conclusions There were remarkable effects on oxygen metabolism in response to mechanical ventilation guided by esophageal pressure.In case of clinical application of mechanical ventilation,the results of this study are in favor of setting transpulmonary pressure according to measurements of esophageal pressure in SAP patients with IAH in an early stage.

Objective To study the effects of diazepam and sodium valproate infusion with CRRT in treatment of patients with tetramethylene disulfotetramine poisoning. Methods Diazepam and sodium valproate were continuously infused to patients by infusion pump. Meanwhile, CRRT was used to eliminate tetramethylene disulfotetramine. Results Convulsion was effectively controlled within one hour in 7 patients. After treatment with CRRT for 1 to 4 times, all patients recovered. Conclusion CRRT with diazepam and sodium valproate infusion were effective in patients with tetramethylene disulfotetramine poisoning.

Objective To investigate the value of surgical biopsy with guidance of indwelling wire through stereotactic puncture in the diagnosis of occult breast cancer (OBC) and the clinical usage. Method Surgical biopsy was performed on 22 patients with suspected nonpalpable breast lesions. ResultsSurgical biopsy, including localization and resection of the lesion, under the guidance of a guide wire was successful with single procedure for all 22 lesions. The accuracy of qualitative diagnosis was 100%. Pathological examination showed malignant in 9 lesions and benign in 13 lesions. ConclusionThe surgical biopsy with the guidance of indwelling wire through stereotactic puncture is valuable technigue for the diagnosis of occult breast lesions.

Objective To investigate the effects of ischemic preconditioning on pneumocyte apoptosis and the expression of HSFT0 after lung isehemia-reperfusion(I/R) in rats and discuss its possible mechanism of extenu-ating ischemia-repedusion injury. Method Thirtysix male Sprague-Dawley rats were randomly divided into three groups [ sham operation(SO ) group, ischemia-teperfusion(L/R) group, and ischemic preconditioning(IP) group],twelve in each group. Lung croas-clamping was used to build the L/R model. In IP group, three cycles of 5-minute-ischemia + 5-minute-reperfusion were given to the pulmonary artery before the procedure. Sham operation rats had a thoracotomy only. Two hours(or five hours) reperfusion was given to both L/R and IP group. Tenninal-deoxynucleotidyl Transferase Mediated d-UTP Nick End Labeiing(TUNEL) was used to evaluate apoptosis. Expression of HSP/0 in lung was observed by immunohistochemical stain and image analysis. Index of quantitative assessment of histologic lung injury(IQA), wet to dry weight ratio(W/D) were measured. The pathological change of lung tissue was observed under both hght and electron microscopy. Statistical analysis was carried out by One-way Anova. Scheffe test was used for intragroup comparison. Results The apoptosis index and expression of HSP70、W/D,IQA of hng tissue in I/R group were higher than those in the sham operation group (P<0.01). Compared with the L/R group, the apoptosis index and expression of HSP70, W/D, IQA of lung tissue significantly decreased (P<0.01), the levels of expression of HSPTO increased significantly in IP group ( P<0.01 ). The pathological and ultrastructure change of lung tissue was better in IP group than those in I/R group. Condusions Ischemic preconditioning can extenuate lung I/R injury by the possible mechanism of increasing the expression of HSPT0 which inhibits the apoptosis during lung I/R injury.

Objective To evaluate the feasibility of Selective Portal Vein Embolization(SPVE)in rabbits with the mixture of ZT glue and Lipiodol.Methods Sixteen white New Zealand rabbits were randomly divided into 2 groups:Group A,ZT glue:Lipiodol(1:2)mixture and Group B Lipiodol group.SPVE of left branch was performed in each group under digital subtraction angiography.The distribution feature of the embolic agents and the histopathology of liver in each group were observed.The weight ratio of the right lobe to the whole liver at the 30th day after SPVE were recorded and analyzed.Results Permanent embolization were occurred in group A.Recanalization was appeared in group B.Atrophy of the embolized lobes and compensatory hypertrophy of none-embolized lohes was,observed..The weight ratio of the right lobe to the whole liver Was 69.41±5.10% in group A.There was statistical difference between these two groups(P＜0.05).Conclusion There were permanent embolization after SPVE with the mixture of ZT glue and lipiodol.SPVE induced atrophy of the embolized lobes of liver and compensatory hypertrophy of none-embolized lobes.

Objective To investigate the values of the APACHE O,APACHE-Ⅲ,Ranson and Balthazar CT(CTSI) scoring systems in predicting prognosis of severe acute pancreatitis.Methods Data were collected prospectively from 321 consecutive patients who were admitted into our hospital from 2005-01-01 to 2011-01-01 with acute pancreatitis (AP).The sensitivity,specificity and accuracy of the APACHE-O,APACHE-Ⅱ,Ranson,Balthazar CT scoring systems at different cut-off levels were calculated.The receiver-operating curves (ROC) for the prediction of severe AP in the early period were calculated using the APACHE-O,APACHE-Ⅱ,Ranson and Balthazar CT scores in different cut-off levels on hospital admission.The area under the curve (AUC) was used to compare the predictive accuracy.Using ROC curves,the values in predicting systemic complications,local complications and morbidities were also compared.Results At a cut-off point of 7,the APACHE O had a sensitivity of 95.4％,a specificity of 76.6％ and an overall accuracy of 79.4％.The Youden's index and the AUC of the APACHE-O score were 0.720 and 0.736,respectively.At a cut-off point of 8,the APACHE-Ⅱ had a sensitivity of 90.4％,a specificity of 81.0％ and an overall accuracy of 842.6％.The Youden's index and the AUC of the APACHE-Ⅱ were 0.714 and 0.699,respectively.At a cut-off point of 3,the Ranson had a sensitivity of 75.0％,a specificity of 78.1％ and an overall accuracy of 77.6％,respectively.The Youden’s index and the AUC of the Ranson were 0.531 and 0.703,respectively.At a cut-off point of 5,the CTSI had a sensitivity of 82.7％,a specificity of 91.4％ and an overall accuracy of 90.0％,respectively.The Youden's index and the AUC of the CTSI were 0.741 and 0.777,respectively.The CTSI system was the best in predicting local complications with a Youden’s index of 0.766,and an AUC of 0.777,respectively. At a cut-off point of 5,the CTSI had a sensitivity of 85.4％,a specificity of 91.2％ and an overall accuracy of 90.3％,respectively.The APACHE-O system was the best in predicting systematic complications with a Youden’s index of 0.789 and an AUC of 0.779,respectively.At a cut -off point of 8,the CTSI had a sensitivity of 91.1 ％,a specificity of 87.8％ and an overall accuracy of 88.2％,respectively.The CTSI system was the best in predicting local complications with a Youden’s index 0.952 and an AUC of 0.847,respectively.At a cut-off point of 8,the CTSI had a sensitivity of 100％,a specificity of 95.2％,and an overall accuracy of 95.3％,respectively.Conclusions The results suggested that the CTSI is the most useful system in predicting local complications and morbidities of severe AP in the early period.The APACHE-O is most useful in predicting systemic complications of severe AP.

Objective To explore the predictive values of the levels of procalcitonin (PCT) and thyroid hormone on the prognosis in patients with systemic inflammatory response syndrome (SIRS) complicated with euthyroid sick syndrome (ESS) and their values on differential diagnosis of ESS. Methods A total of 238 patients with SIRS hospitalized in the Emergency Department, Jiangsu Provincial Hospital of Integration of Chinese and Western Medicine, Jiangsu Branch of China Academy of Chinese Medical Sciences from July 2012 to December 2014 were divided into two groups: death group (31 cases) and survival group (207 cases), 182 patients being complicated with ESS and 56 patients without ESS. The differences in the levels of PCT, free triiodothyronine (FT3) and acute physiology and chronic health evaluation (APACHE Ⅱ) score in patients with different clinical outcomes were analyzed. The effects of the inflammatory mediators including levels of PCT, interleukin-6 (IL-6), C-reactive protein (CRP), and thyroid function such as free thyroxine (FT4) and thyroid stimulating hormone (TSH) on clinical outcomes and their predictive values on death of emergency patients with SIRS were also studied. Furthermore, the correlations between APACHEⅡscore and PCT, IL-6, CRP, thyroid hormone were analyzed. Results The level of PCT and APACHE Ⅱ score in death group were significantly higher than those in survival group [PCT (ng/L): 8.38 (13.88) vs. 1.04 (3.57), APACHEⅡscore:27.42±6.88 vs. 16.35±6.72, both P<0.01], while FT3 level was obviously lower in death group (pmol/L: 2.19±0.58 vs. 3.07±0.94, P < 0.05). No significant differences in levels of IL-6, CRP, FT4 and TSH were observed between the two groups (all P>0.05). The mortality was increased markedly in patients with higher PTC level and lower FT3 level compared with normal PCT level and normal FT3 level [18.8% (30/160) vs. 1.3% (1/78), 17.1%(31/181) vs. 0 (0/57), both P<0.05]. However, the abnormalities of IL-6, CRP, FT4 and TSH levels did not contribute to patient's mortality (all P>0.05). PCT was positively correlated with APACHEⅡscore (r>0.33, P<0.001), while FT3 was negatively correlated with APACHEⅡscore (r<-0.33, P<0.001). There were no correlations between IL-6 (r = 0.319, P < 0.001), CRP (r = 0.161, P < 0.05), FT4 (r = -0.170, P < 0.01), TSH (r = -0.057, P = 0.385), and APACHEⅡscore. The levels of PCT, IL-6 and CRP and APACHEⅡscore in patients with ESS were significantly higher than those in patients without ESS [PCT (ng/L):2.54 (5.90) vs. 0.20 (0.43), IL-6 (ng/L):98.62 (351.20) vs. 16.85 (33.60), CRP (mg/L):88.00 (110.50) vs. 25.50 (48.00), APACHEⅡscore:17.62±8.17 vs. 10.98±4.97, all P<0.01]. The cut-off values for predicting patient's death of these indexes showed by receiver operating characteristic curve (ROC curve) analysis were as follows: PCT: cut-off value ≥ 1.755 ng/L, sensitivity: 87.1%, specificity: 58.0%, area under the ROC curve (AUC): 0.802; FT3: cut-off value ≤ 2.92 pmol/L, sensitivity: 93.5%, specificity: 54.1%, AUC: 0.785;APACHE Ⅱ score: cut-off value ≥ 21.5, sensitivity: 83.9%, specificity: 88.4%, AUC: 0.920. Conclusions The levels of serum PCT, FT3 and APACHEⅡscore are prognostic factors in patients with SIRS. Meanwhile, the levels of serum PCT, IL-6, CRP and APACHE Ⅱ score should be taken into consideration in differential diagnosis of ESS in patients with SIRS.

Objective To investigate the effects of naloxone (Na) on pneumocyte apoptosis and expression of heme oxygenase-1 (HO-1) during ischemia reperfusion injury of lung in rats. Method Forty-two male Sprague-Dawley rats were made models of ischemia reperfusion injury of unilateral lung, and were randomly( random number) divided into three groups: sham operation group (Sh group), ischemia reperfusion group (IR group) and naloxone group (Na group). The hilus of lung was clamped for 45 minutes and the clamp was taken off to build the I/R model. After 3-6 hours reperfusion, naloxone in dose of 1 mg/kg was injected intra-peritoneally in rats of Na group. The rate of cell apoptosis in lung tissue was detected with the way of Annexin-V-PI in flow cy-tometer. The wet to dry weight ratio (W/D) of lung tissue was measured. The expression of HO-1 in lung was measured by using RT-PCR and the ultra-structure change of lung tissue was observed under electron microscope. Results The rate of pneumocyte apoptosis and W/D ratio of lung tissue were significantly higher in IR group than in Sh group (P < 0.01), and the rate of pneumocyte apoptosis and W/D ratio of lung tissue were negatively correlated with the expression of HO-1 mRNA in lung tissue. Compared with IR group, the rate of cell apoptosis and W/D ratio were lower and the expression of HO-1 mRNA was higher in Na group (P < 0.01). The ultra- structure changes of lung tissue were lessened in Na group than in IR group. Conclusions During early period of lung IR injury, HO-1 induced by naloxone can inhibit the cellular apoptosis and protect the lung tissue.