Terminology of persistent inflammation immunosuppression and catabolism syndrome (PICS) is developed based on the concept of multiple organ failure (MOF), which reflect that the preponderance is gradually reversed from pro-inflammation to anti-inflammation, and eventually the state of simultaneously persistent inflammation and severe immunosuppression appeared. Although the improvement of rescue technology and management increase the early survival rates of patient with critical illnesses, the long-term outcomes of most patients are not optimistic. The patients with PICS are difficult to treat or prevent, and are likely to indolent death and have a rising incidence, which is an important challenge to the intensive care unit (ICU). The paper review the understanding of PICS, summarize the specific changes of immune system in PICS, and explore the immunological markers for early recognition of PICS and judgment of immune state in order to provide new thinking for prevention and control of PICS.

ObjectiveThis study evaluates the feasibility of intensity-modulated radiation therapy (IMRT) to treat patients with 1 -5 brain metastases from non-small cell lung cancer (NSCLC).Methods 30 IMRT patients with brain metastases for NSCLC studied retrospectively.Whole brain radiotherapy plus three-dimensional conformal radiotherapy (WBRT + 3DCRT) and WBRT plus stereotactic radiotherapy ( WBRT + SRT) plans were generated.Planning target volume ( PTV ) and organs at risk dose were measured and compared by dose volume histogram.Differences were analyzed in the three techniques by Wilcoxon Z -test.Results D99％ of the shoulder ( D99％-D90％ ) from IMRT were higher than from WBRT +3DCRT and WBRT+SRT in all cases.From D15％ of slope (D90％-D10％) to D5％ of tail (D10％ -D1％ ),IMRT were lower than WBRT + 3DCRT and WBRT + SRT ( Z =- 4.72,P =0.000 and Z =- 4.72,P =0.000).D10％ and D5％ of IMRT were (35.1 ±1.42) Gy and (37.7 ±2.91) Gy,WBRT +3DCRT were (36.5±2.86) Gy and ( 39.1 ± 3.56) Gy ;WBRT + SRT were (36.2 ± 2.57) Gy and ( 38.7 ± 3.67) Gy.IMRT vs WBRT+ 3DCRT and WBRT + SRT were significant ( Z=-3.18,-3.18,P=0.001,0.001 and Z=- 4.11,- 3.02,P =0.000,0.002) in 13 patients with 3 - 5 brain metastases.The total mean monitor units were 14756.3,9614.8 and 9043.2 for IMRT,WBRT +3DCRT and WBRT + SRT plans,respectively,with a 38.7％ reduction from IMRT to WBRT + SRT (Z =-4.78,-4.78,P =0.000,0.000).The brain doses around metastases were similar in the three techniques with 1 -2 metastases,but IMRT was the best with 3 -5 metastases.ConclusionsIMRT can advance brain metastases dose and improve the planning target minimum dose and spare the dose around brain metastases.Only IMRT is the best choice for just sparing the dose around brain metastases among 3 -5 brain metastases.

Objective To investigate the effect of thymosin α1 on immunity,metabolism and prognosis in elderly patients with sepsis followed by persistent inflammation,immunosuppression,and catabolism syndrome (PICS).Methods In this retrospective study,68 patients diagnosed with sepsis followed by PICS in medical intensive care unit (MICU) from Jan.2014 to Dec.2016 were involved.Thirty-four patients treated with thymosin α1 for 2 weeks were allotted to the observational group;other 34 patients were to the control group.Patients' clinical information and data of laboratory test were collected in addition.We compared patients' general information,and the indexes before and after treatment,then the indexes between the two groups to analyze the effect of thymosin α 1 on immunity and metabolism;moreover,we conducted survival analysis and compared the mortality of different periods to analyze the effect of thymosin α1 on prognosis.Results The number of monocytes,the levels of CD4/CD8 and HLADR/CD14 before and after treatment in the observational group were significantly higher than those in the control group [(0.11 ± 0.31)× 109/L vs.(-0.16 ± 0.36)× 109/L,(0.20 ± 0.94) vs.(-0.22 ± 0.74) and (5.8 ±16.3)％ vs.(-3.3 ± 18.2)％ respectively],which suggested that the number of monocytes and the levels of CD4/CD8 and HLADR/CD14 were significantly increased by thymosin α1 intervention,and the difference were statistically significant(P ＜ 0.05).Kaplan-meier survival analysis showed prognosis between the two groups was not statistically significant (P ＞ 0.05).The further analysis of mortality in different periods indicated that the mortality within 28 days,90 days and 120 days and overall mortality between the two groups [8 (23.5％) vs.12 (35.3％),18(52.9％) vs.25 (73.5％),20 (58.8％) vs.27 (79.4％) and 24 (70.6％) vs.28 (82.4％) respectively],were not statistically significant(P ＞ 0.05).Conclusions Thymosin α1 can be used to regulate the immunity of elderly patients with sepsis followed by PICS,but its effect on regulating metabolism and improving prognosis needs further study.

Objective To analyze the low dose-volume associated with radiation-induced lung injury (RILI) in patients with advanced non-small cell lung cancer (NSCLC) treated by three-dimensional confor-real radiation therapy (3DCRT). Methods Data of 100 patients with histologically proved NSCLC treated with 3DCRT or IMRT between November 2006 and January 2009 were collected. Nine patients treated with radiotherapy alone and 91 with radiotherapy combined with chemotherapy. A median dose of 70 Gy (range,60-80 Gy) was delivered with late-course accelerated hyperfractionated radiotherapy (LAHRT). Twenty-four patients received dose of 61-69 Gy and 76 received more than 70 Gy. The V_5 ,V_(10) ,V_(20) ,V_(30)and mean lung dose (MLD) were calculated from the dose volume histogram system. The RILI was evaluated according to Common Toxicity Criteria 3.0(CTC 3.0). Results The range of V_5 ,V_(10) ,V_(20) ,V_(30) was 37%-98%,27%-78%, 17%-54% and 9%-31%, respectively, with a median value of 65%, 47.5%, 31% and 24%, respectively. The acute RILI of grade 1, 2, 3, 4 and 5 was observed in 34, 27, 8, 1 and 1 patients,respectively. The chronic RILI of grade 1, 2 and 3 was observed in 46, 14 and 2 patients, respectively. V_5 ,V_(10) ,V_(20) and MLD were significantly correlated with acute RILI of ≥ grade 1. V_5 ,V_(20) ,V_(30) and MLD were significantly correlated with acute RILI of ≥ grade 2. The acute RILI of ≥ grade 2 was significantly in-creased when V_5, V_(20) and V_(30) were more than 65%, 31% and 24%, respectively. The acute RILI of ≥ grade 3 was significantly increased when V_5 was more than 65%. The acute RILI of ≥ grade 1 was signifi-candy increased when V_(20)was more than 31%. The gross tumor volume and planning target volume were sig-nificantly correlated with the acute RILI of ≥ grade 1 and chronic RILI of ≥ grade 2. Conclusions The dose-volume V_5 and V_(10) are effective in predicting RILI.

Objective To analyze the clinical outcome of concurrent ehemo-radiotherapy in stage Ⅳ non-small cell lung cancer(NSCLC).Methods From Jan.1997 to Dec.2006,214 patients with patho logically or cytologically proven stage Ⅳ NSCLC were included in this analysis.Of those patients,98 re ceived radiotherapy concurrently with 3-week cycle chemotherapy(group A),18 received radiotherapy con currently with weekly chemotherapy(group B) ,44 received chemotherapy alone,37 received radiotherapy a lone and 13 received sequential chemo-radiotherapy.The primary tumor was treated by three-dimensional conformal radiotherapy(3DCRT) or conventional radiotherapy with conventional fraefionation or late-course accelerated hyperfraction (LA H RT).Group A received 21-28 days cycle cisplatin-based chemotherapy (cis platin combined with PTX,DTY,NVB or Vp-16) ,and group B received weekly DDP combined with PTX or topteeon for 4-6 weeks.Results The follow-up rate was 99%.The 1-and 2-year overall survival rates of group A,group B,chemotherapy alone,radiotherapy alone and sequential chemo-radiotherapy were 41% and 11% ,16% and 0,31% and 7% ,34% and 10% ,26% and 3% ,respectively(x2 = 11.18,P=0.025).The patients with concurrent 3DCRT,LAHRT and radiotherapy dose≥70 Gy had better survival in group A than those in chemotherapy alone group.Patients who received≥2 cycles chemotherapy with concurrent radio therapy had longer survival time than those who had ≥2 cycles chemotherapy alone. Conclusions Con current chemotherapy and 3DCRT,LAHRT with the dose ≥70 Gy can improve the overall survival of patients with stage Ⅳ non-small cell lung cancer.

Objective To investigate the clinical characteristics,risk factors and prognosis of patients with persistent inflammation,immune-suppression and catabolism syndrome(PICS)secondary to sepsis in medical intensive care unit(MICU)in initial stage,in order to increase the understanding of PICS and provide the reference experience for the early screening of high-risk patients.Methods A total of 298 elderly patients diagnosed as sepsis admitted into MICU from Aug.2013 to Dec.2016 were retrospectively studied.Of them,97 patients meeting inclusion criteria were ultimately enrolled and separated into the PICS group and the non-PICS group.General and clinical data and laboratory indexes at first day admitted into MICU were compared between the two groups.The indexes between the two groups were analyzed statistically by multivariate logistic regression analysis.The survival-time distributions were estimated by Kaplan-Meier model,and the difference in prognosis was compared between the two groups.Results Of 97 patients,36 patients (37.1％)met the diagnosis of PICS.The acute physiological function and chronic health evaluation Ⅱ (APACHE Ⅱ) score had a significant difference between the two groups(27.7±5.8 vs.22.9±6.0,P＜0.01).The grade of acute gastrointestinal injury(AGI)were significantly higher in the PICS group than in the non-PICS group(P ＜0.05).Platelet counts,helper T cell counts and CD4+/CD8+ ratios were significantly lower in the PICS group than in the non-PICS group[(164.39 ± 84.29) × 109/L vs.(235.16 ± 126.89) × 109/L,(238.97± 181.11)/μl vs.(385.93±308.22)/μl,(1.58 ± 1.13) vs.(2.12± 1.23),all P ＜0.05)].Multivariable logistic regression analysis revealed that APACHE Ⅱ score was an independent risk factor for PICS and its optimal cut-off value for predicting PICS was 26.5.Kaplan-Meier analysis showed that the overall survival was poorer in the PICS group than in non-PICS group in the whole observation phase.The further Kaplan-Meier analysis on survival time of subdivisions showed that the survival of patients at 90-day and 180-day after admission and in stage 1-3 during one year had significant differences between the two groups (P ＜ 0.05).While the survival of patients at 28-day after admission had no significant difference between the two groups(P＞0.05).Conclusions The elderly patients with persistent inflammation,immune-suppression,and catabolism syndrome(PICS) secondary to sepsis in medical intensive care unit(MICU)show the higher levels of APACHE Ⅱ score and AGI grade,and lower values of platelet counts,CD4+ T cell counts and CD4+/CD8+ ratio in initial stage.And APACHE Ⅱ score is an independent risk factor for PICS in elderly sepsis patients,and the optimal cut-off value of APACHE Ⅱ score for predicting PICS is 26.5.The prognosis for advanced stage and long term prognosis are poor.It is essential to use APACHE Ⅱ and so on,to timely identify and intervene PICS.

So far, there is still lack of effective treatment to control persistent inflammation immunosuppression catabolism syndrome (PICS) appeared generally in those chronic critical illnesses (CCI) patients, restricted by the development of medicine and scientific research nowadays. Because the uncontrolled PICS aggravates continuously, ICU stay of the CCI patients has been obviously prolonging and the late mortality elevates greatly. So exploring effective therapeutic strategies is obviously pressing. With the characteristics in PICS such as that elderly with sepsis or severe trauma tops the list of morbidity, progressing illness is difficult to intervent and various pathology changes occur simultaneously, the fundamental principle of treatment, "Focal screening, early control, joint intervention" must be followed. As for the specific intervention, lessoning from some diseases with immune and metabolic disorders to take "anabolic nutrition support", is a research focus presently as well as a considerably potential breakthrough at the treatment research in the future. This review retrospects a series of therapeutic strategies of PICS, such as immunity, metabolism regulation, nutrition support, glucose control and physiotherapy, in the purpose of laying the foundation of the development of joint intervention strategy for PICS.