Objective To investigate the effectiveness of different dose dexmedetomidine ( DEX) combined with video laryngoscopy during orotracheal Intubation for patients with spontaneous breathing. Methods A total of 87 emergency or intensive care unit ( ICU) patients with spontaneous breathing was in-cluded (age range:18 to 75 years).The patients were randomly divided into three groups with 29 cases each:midazolam combined with fentanyl group ( A) , low dose DEX group ( B) , and high dose DEX group (C).Mean arterial pressure (MAP),heart rate (HR), and SpO2 were detected before injecting different dosage drugs (T0), during intubation (T1),after intubation immediately (T2), at 3 min after intubation ( T3 ) .The amount of intubation time and side effects in each group were assessed.Results Compared to A group, the changes of hemodynamics in group B and C were more stable after injecting drugs.The doctors spend less time for intubation in group B and C.The rate of significant bradycardia in group C was higher than other groups.Conclusions If you can assess indications, doses and timings strictly, it was safety and availability to control intubation response in the patients with spontaneous breathing by injected of DEX.

Primary immune thrombocytopenia ( ITP) is an organ-specific autoimmune hemorrhagic disease. The etiology of ITP is still unclear, but loss of immune tolerance to platelet surface antigens is con-sidered as a fundamental cause of ITP. Therapeutic strategies that prevent the activation and proliferation of autoreactive cells have been suggested, which includes clearance of autoreactive cells ( apoptosis) , receptor editing, induction of anergy and extrinsic cellular suppression. Failure at any of these steps may lead to the production of autoantibodies against platelet and megakaryocyte glycoproteins. An improved understanding of the mechanisms for autoantibody production will provide theoretical basis for optimal diagnosis and treatment of ITP.

Using a series of purification methods including silica gel， Sephadex LH-20 and preparative high performance liquid chromatography， secondary metabolites of Myrothecium sp. were purified from the ethyl acetate extract of the solid fermentation product. Based on structure characterization and investigation on the physical and chemical properties a， twelve monomeric compounds were identified as 3''-hydroxyverrucarin A (1), verrucarin A (2), verrucarin L acetate (3), verrucarin J (4), verrucarin K (5), roridin A (6), roridin D (7), roridin H (8), roridin J (9), verrol 4-acetate (10), (3S, 3aS, 6α, 6aR)-dihydrosporothrioride (11) and 4,6-dihydroxy-1(3H)-isobenzofuranone (12). Compounds 1, 5 and 9 -12 were isolated from Myrothecium sp. for the first time.Compounds 2, 3, 4, 7 and 8 exhibited strong inhibitory effects on Candida albicans, with a minimal inhibitory concentration （MIC50） of 0.318, 0.218, 0.047, 0.569 and 0.558 μg/mL, respectively.

Objective To report and analyze the renal function improvement in a case with ad-vanced bilateral renal cell carcinoma after targeted therapy. Methods The patient was a 60-year-old man who complained of lower back pain for 1 month. Ultrasound and CT scan detected bilateral renal masses, left lesion was 11.0 cm×9.4 cm×8.5 cm, and the right one was 3.5 cm×4.3 cm×4.1 cm. X-ray examination showed metastatic lesions in liver and lower right lung. GFR was 20.39 ml/min of left kidney, 25.40 ml/min of right kidney. The renal biopsy confirmed renal clear cell carcinoma. Sorafenib was administrated 400 mg twice or once daily for 12 weeks. Results After the targeted therapy, the decreased bilateral kidney tumor sizes were identified by CT scan. There was liquid nec-rosis in the tumor, and no new metastatic lesion detected. The kidney function was improved as well. The total GFR increased to 71.38 ml/min. Left kidney GFR increased to 31.57 ml/min, right kidney GFR increased to 39.81 ml/min, respectively. Conclusion Targeted therapy could improve renal function in advanced renal cell carcinoma cases by controlling tumor development.

Objective To study the prognostic factors of survival in patients with metastatic renal cell carcinoma (mRCC) treated with sunitinib.Methods From May 2008 to Dec 2012,the clinical data of 82 cases with mRCC adminstered by sunitinib were reviewed retrospectively.The study included 60 male patients and 22 female patients,whose age ranged from 29 to 82 years [mean (56.1±11.3) years].Among them,52 cases presented hematuria,flank pain and palpable mass.The size of renal tumor ranged from 2.0 to 18.0 cm [mean (8.0±3.0) cm].The location of tumor included 41 in left kidney,37 in right kidney and 4 in bilateral kidney.The pathological tissue obtained from the operation in 69 cases and from biopsy in 13 cases.The pathological results demonstrated renal cell carcinoma in 75 cases,papillary cell carcinoma in 2 cases,chromophobe cell carcinoma in 2 cases,sarcomatoid carcinoma in 2 cases,collecting duct carcinoma in one case.The site of metastasis included lung in 50 cases,liver in 11 cases,bone in 14 cases,pancrease in 3 cases,retroperitoneal lymph node in 31 cases.In 52 cases,the ECOG scores ranged from 1 to 2.The others scores were more than 3.The average level of hemoglobin,AKP,LDH and leukocyte were (132±24)g/L,(90±65) U/L,(168±114) U/L and (6.4±2.0)×109/L,respectively.Before treatment,the abnormal cases in those parameters were 59,9,6 and 2,respectively.According to the MSKCC risk model,14 cases were classified into the high risk group and 68 cases into medium risk group.74 cases were accepted the sunitinb therapy within one year after diagnosis and 8 cases were accepted same therapy until one year after diagnosis.The overall survival (OS) rates were calculated by Kaplan-Meier method and Cox regression model was used to analyze the relationship between the influencing factors and the prognosis.Results The average OS was (21.6± 14.1) months (ranged 2.8 to 64.1 months).The survival rate at 1 st,2nd and 3rd year were 71％,64％ and 58％,respectively.Single factor analysis showed that significant prognostic factors were as follows:ECOG performance status ≥ 2 (P =0.005),clinical symptom during first clinic visiting (P =0.031),without nephrectomy (P =0.012),the number of metastatic sites ≥ 2 (P =0.015),hemoglobin before treatment (P=0.005),serum AKP level before treatment (＞126 U/L) (P=0.007),MSKCC score≥ 3 (P =0.000),the presence of liver metastases (P =0.000) and bone metastases (P =0.000) and relative dose intensity in the first month (1M-RDI) of sunitinib ≥ 50％ (P=0.000).Cox regression model showed that the beneficial predictive factors were ECOG performance status＜2 (P=0.136),no symptom during the first clinic visiting (P=0.801),serum AKP ＜126 U/L (P=0.618) before treatment,the absence of bone (P =0.068) and pancreas metastases (P =0.265).Sunitinib 1M-RDI ≥ 50％ was the independent predictive factor (P=0.000).Conclusions In targeted therapy era,there is some change in the prognostic factors for mRCC and target drug play an important role in the prognosis of mRCC.Sunitinib 1M-RDI ≥50％ is the independent predictive factor for the prognosis of renal carcinoma.

Objective To evaluate the efficacy of dexmedetomidine (DEX) mixed with ropivacaine for transversus abdominis plane block (TAPB) combined with general anesthesia in the patients undergoing laparoscopic colorectal surgery.Methods 58 patients scheduled for laparoscopic colorectal surgery under general anesthesia were randomly divided into 3 groups using a random number table:general anesthesia group (group A n =19),ropivacaine for TAPB group (group B n =20),and Dex mixed ropivacaine for TAPB group(group C n =19).After the end of anesthesia induction,ultrasound-guided bilateral TAPB was performed in B and C groups.20 ml of 0.25％ ropivacaine and 0.5 μg/kg DEX mixed with 0.25％ ropivacaine were injected into each side in groups B and C respectively.Patient controlled intravenous analgesia (PCIA) with sufentanil 100 μg and tropisetron 5 mg in 100 ml of normal saline was provided to all patients after surgery.When the visual analogue scale (VAS) score ≥ 4,tramadol 50-100 mg was intravenously injected as remedial analgesic.VAS scores were measured respectively after extubation and 6,12,24 h after surgery.The consumption of remifentanil during the operation and sufentanil during PCIA,and the number of successfully delivered doses and patients requiring rescue analgesic were recorded within 24 hrs after surgery.The occurrence of TAPB-related adverse events were also recorded.Results Compared with group A,the consumption of reminfentanil during the operation and sufentanil during PCIA,and the amount of successfully delivered doses and patients requiring rescue analgsia within 24hrs after surgery,were decreased in B and C groups (P ＜ 0.05).Furthermore,those numbers in group C are more less than group B in 12-24 hrs after the surgery.There were no significant difference among the three groups in the incidence of adverse reactions (P ＞0.05).TAPB-related complication were not found in B and C groups.Conclusions 0.5 μg/kg DEX mixed with 0.25％ ropivacaine for TAPB combined with general anesthesia can play a better analgesic effect in the patiens urdergoing laparoscopic colorectal surgery.

Objective To analyze the antithrombotic effects of cilostazol combined with aspirin and clopi-dogrel in elderly patients with cerebrovascular disease after PCI .Methods 100 elderly patients with cerebrovascular diseases who treated with coronary artery interventional therapy ( PCI) were randomly divided into the control group and the observation group according to the digital table ,50casess in each group.The two groups were given control of blood pressure ,blood lipids ,blood sugar ,improve circulation and other conventional treatment .The control group was treated with aspirin combined with clopidogrel ,the observation group was treated with cilostazol based on the treatment of control group.Before and after treatment for 1,4 and 8 weeks,the platelet aggregation degree was detected by PL-11 automatic platelet analyzer .During 2 months of follow-up,the degree of platelet aggregation ,the volume of platelets,the efficacy of treatment and the incidence of adverse reactions were compared .Results The platelet aggre-gation rate between the two groups had no statistically significant difference before treatment (t0 =2.782,P>0.05). After treatment,the platelet aggregation rate of the two groups decreased significantly ,but after treatment for 1,4 and 8 weeks,the platelet aggregation rates of the observation group were significantly lower than those of the control group [(51.87 ±9.65)％,(40.85 ±10.24)％,(38.52 ±9.64)％;(69.25 ±8.41)％,(62.43 ±9.22)％,(58.46 ± 10.18)％],the differences were statistically significant (t1 =5.693,t4 =4.846,t8 =6.719,all P<0.05).Before treatment,the mean platelet volume between the two groups had statistically significant difference ( t0 =2.146,P>0.05).After treatment,the platelet volume of the two groups decreased significantly ( t1 =1.656,t4 =1.438,t8 =2.189,all P<0.05).There were no statistically significant differences between the observation group and the control group (t1 =3.716,t4 =1.271,t8 =2.523,all P>0.05).The effective rate of the observation group was 94.00％(47/50),which was significantly higher than that of the control group [82.00％(41/50)],the difference was statis-tically significant (χ2 =4.683,P<0.05).The incidence rates of adverse reactions in the observation group and the control group were 10.00％(5/50) and 8.00％(4/50),respectively,there was no statistically significant difference between the two groups (χ2 =1.947,P=0.136).Conclusion Cilostazol combined with clopidogrel and aspirin in the treatment of elderly patients with cerebrovascular disease after PCI can significantly reduce platelet aggregation rate,improve clinical curative effect ,and has certain clinical value .

Objective To discuss the clinical characteristics of adrenal metastases,and summarize the experience of diagnosis and treatment.Methods From January 2008 to June 2018,the clinical data of 55 patients with adrenal metastases treated in our hospital were analyzed retrospectively.This study included 34 male patients and 21 female patients and the median age was 60 years old (ranged 55 to 84 years old).The median value of maximum diameter of adrenal metastases was 3 cm (ranged 1.9 to 10.3 cm);with 35 cases on the left side,13 cases right and 7 cases bilateral.The primary sites of malignant tumors were pancreas (18 cases,32.7％),lung (12 cases,21.8％),liver (6 cases,10.9％) and colorectum (6 cases,10.9％),respectively.Thirty-four cases were confirmed by pathology after adrenalectomy and 21 cases were confirmed by needle biopsy.Thirty cases were diagnosed synchronously with the primary tumor and 25 cases were metachronous.The median time from diagnosis of primary tumors was 13.3 months (ranged 2.0 to 97.4 months).42 cases of these 55 cases were diagnosed within one year.Treatment options for adrenal metastatic lesions included single adrenalectomy in 18 cases,adrenalectomy combined with radiotherapy 16 cases,single intravenous chemotherapy 10 cases,intravenous chemotherapy combined with non-operative treatment 10 cases and single radiotherapy 1 case.Results The main pathological types were adenocarcinoma (19 cases,34.5％),ductal adenocarcinoma (10 cases,18.2％),hepatocellular carcinoma (6 cases,10.9％) and clear cell carcinoma (4 cases,7.3％).Two cases were lost follow-up and the follow-up rate was 96％,the median follow-up time was 8 months (ranged 1 to 135 months).The median overall survival (OS) time of 55 patients was 5.3 months (ranged 1 to 134 months).The one-year survival rate was 23.6％ (13/55),the two-year survival rate was 12.7％ (7/55),the three-year survival rate was 9.1％ (5/55) and the five-year survival rate was 1.8％ (1/55).Conclusions Pancreatic cancer was the most common type of malignant tumor for adrenal metastases in our hospital.Most primary tumors and adrenal metastases were diagnosed synchronously or within one year.Comprehensive treatment with retroperitoneal adrenalectomy may improve the OS,however the overall prognosis is poor.

OBJECTIVE： To investigate the situation and problems of clinical microecological preparations in pediatrics department of China， and to provide reference for rational application of microecological preparations in children. METHODS： Outpatient/emergency prescriptions of microecological preparations during Jan.-Mar. 2019 were retrieved from information system of 5 “Third Grade Class A” children hospitals， and were investigated and analyzed in respects of the type of microecological agents， age distribution， clinical diagnosis， drug combination， off-label medication， etc. RESULTS： A total of 74 210 outpatient/emergency prescriptions were collected， involving 18 kinds of microecological preparations. Among them， Clostridium butyricum combined viable powder ranked first （31 146， accounting for 41.97％）， followed by Brucella yeast powder （14 289， accounting for 19.25％） and Compound Lactobacillus acidophilus tablets （10 281， 13.85％）. The age of children was less than 18 years old， and the proportion of children aged 1-＜3 years old was the highest （33 753， 45.48％）. The most common clinical diagnosis     was digestive tract diseases （54 009， 72.78％）， followed    by respiratory infectious diseases （11 744， 15.83％）. In combination with microecological agents， there were Chinese patent medicine for invigorating the spleen and stomach     （18 546， 24.99％）， antibacterial medicine （10 595， 14.28％） and oral rehydration salt Ⅲ （8 238， 11.10％）. Off-label drug use was found in 19 532 prescriptions （26.32％）， mainly manifesting as super-indications （15 590， 21.01％）， super-usage and dosage （8 098， 14.52％）， super crowd medication （48， 3.91％） was found in a few prescriptions. CONCLUSIONS： There is a high incidence of off-label use of microecological agents in children. Medical staff should standardize prescription behavior and promote rational use of drugs. At the same time， the improvement of the information of children’s medication in drug instructions to ensure the safety and effectiveness of children’s medication should be encouraged.