Objective To investigate the effects of the site for access to internal jugular vein (lateral versus anterior),lying position of patients (supine versus Trendelenburg),and head rotation (0°,20°,and maximum) during central venous catheterization on the location depth and cross-sectional area (CSA) of the right internal jugular vein (IJV).Methods Fifteen healthy volunteers were recruited in this prospective observational study from September 2008 to October 2008.Healthy volunteers were placed in flat supine position and 15°.Trendelenburg position separately.In each position,IJV were measured ultrasonographically from lateral site and anterior site with the head oriented at 0°,20°,and maximum rotation separately.Data of measured CSA and location depth of internal jugular vein in different positions were compared.Results The largest CSA (2.16 ±0.89) cm2 and location depth [(1.38 ± 0.43)cm] were occurred at the lateral approach in Trendelenburg position with head oriented at maximum rotation.The CSA in Trendelenburg position was larger than that in flat supine position.Only at the maximum head rotation,lateral approach got statistically larger CSA.The effects of head rotation varied with different degrees of rotation.Conclusions Site of approach,lying position and head rotation had noticeable effects on internal jugular vein cross-sectional area.Trendelenburg position increased the CSA of IJV.

Objective To evaluate the accuracy of five blood glucose measurements commonly used in ICU and to determine the potential factors interfering the accuracy. Method This prospective study carried out in consecutively enrolled 49 patients stayed more than 48 hours in the medical ICU of Peking Union Medical College Hospital from November 2007 to January 2008. A total of 130 blood samples were measured to determine blood glucose with five different methods, and the biochemistry analyzer in central laboratory was regarded as reference method for comparison with other four methods, ( 1 ) capillary blood/glucometer;(2) arterial blood/glucometer; (3) arterial blood/blood gas analyzer; and (4) arterial blood/biochemistry analyzer. The accuracy of a method tested was judged by the difference in level of blood glucose between it and reference method, correlation coefficient, bias correction factor and discrepancy. The independent factors for the discrepancies were identified by multivariate logistic regression. Results The values of differences in level of blood glucose between above four methods and the reference were ( 1.7 ± 1.4) mmol/L,( 1.6 ± 1.4 ) mmol/L, ( 1.1 ± 1.2) mmol/L, and (0.5 ± 1.2 ) mmol/L, respectively. The rates of discrepancy were 66.9%, 63.8%, 40.0% and 23.8%. The correlation coefficients were 0. 844, 0. 845, 0. 895and 0. 896. The bias correction factors were 0. 821,0.831,0.914 and 0. 979. Decrease in hematocrit was statistically associated with the discrepancy between glucometer analysis methods and the reference, with OR of 0.923 for capillary blood ( P = 0.03 ) and 0. 912 for arterial blood( P = 0.014), respectively. Conclusions Glucometer analysis poorly correlated with reference method and blood gas analysis in ICU patients. Decrease in hematocrit significantly increased the degree of discrepancy in glucose measurements between glucometer analysis and the reference.

[Summary] A 32 year-old woman in the third trimester of pregnancy was admitted for severe acute pancreatitis due to hypertriglyceridemia . During hospitalization she developed multiorgan dysfunction , infected pancreatic necrosis , abdominal compartment syndrome and intrauterine fetal death . She was successfully treated by multidisciplinary team including department of emergency medicine , ICU, gastroenterology, obstetrics, endocrinology, ultrasonography, radiology, infectious disease, nutrition and surgery.

A 56-year-old female was admitted to the Department of Rheumatology,Peking Union Medical College Hospital with complaint of recurrent fever and acute lumbar pain.Fever was complicated with malaise,cough and occasional blood-streaked sputum.Lab tests showed elevated white blood cell count,increased serum creatinine,erythrocyte sedimentation rate and C-reactive protein.Other lab findings included severe anemia,hematuria,and proteinuria.Immunological examinations were positive for antinuclear antibodies,antineutrophil cytoplasmic antibodies and antiglomerular basement membrane antibody.Ultrasonography and CT scan detected a huge spontaneous perirenal hematoma at right side.Angiography revealed multiple microaneurysms on bilateral renal arteries and branches.A diagnosis of systemic vasculitis was suggested.Under the combination therapy of corticosteroids and cyclophosphamide,the patient presented sustained remission for one year.This case indicates that prompt and sufficient treatment of primary disease is essential to a promising outcome.

Objective:To explore the anatomical and clinical effects of lateral-perineal approach in treating the fracture of inferior ramus of pubis-ischium ramus.Methods:The lateral approach of the perineum was simulated on 10 side of 5 intact wet adult cadavers to determine the surface symbols of incision design and to expose the operative field of the approach and to observe the anatomical characteristics of the perineal branch of the posterior femoral cutaneous nerve and the incision of the surgical approach. Five points were selected at the incision of the approach. The distance (L 1-L 5) between each point and the body surface projection of the perineal branch of the posterior femoral cutaneous nerve was measured. A total of 11 patients, including 5 males and 6 females with an average age of 41.55±14.32 years, ranging from 18 to 62 years, were treated by this approach in clinical practice. All patients had a reduction and fixation to the fracture of inferior ramus of pubis-ischium ramus. The operation duration, incision length, intraoperative blood loss and surgical complications were recorded. The quality of fracture reduction was evaluated according to Matta radiographic criteria. The strength of the adductor was measured. The pelvic function was evaluated according to Majeed Pelvic Score at the last follow-up. Results:Anatomical studies shown that the line between the two points. One point was 4 cm lateral to the level of the apex of the pubic arch. Another point was 4 cm from the ischial tubercle on the line from the ischial tuberosity to the point that 4 cm lateral to the level of the apex of the pubic arch was the axis of the approach lateral of the perineum. Anatomical studies showed that the lateral-perineal approach could expose the range from pubic symphysis to sciatic tuberculum. The distance between the points selected at the incision of the approach and the body surface projection of the perineal branch of the posterior femoral cutaneous nerve: L 1 was 19.40±1.17 mm, ranging from 18 to 21 mm; L 2 was 16.60±2.76 mm, ranging from 10 to 20 mm; L 3 was 18.30±1.89 mm, ranging from 16 to 21 mm; L 4 was 19.20±1.93 mm, ranging from 16 to 22 mm; L 5 was 14.70±1.83 mm, ranging from 13 to 18 mm. All patients were followed up for 17.91±4.09 months, ranging from 13 to 26 months. The incision length was 8.18±0.98 cm, ranging from 7 to 10 cm. The operation duration was 59.64±12.17 min, ranging from 43 to 85 min. The intraoperative blood loss was 100 ml, ranging from 50 to 130 ml. All incisions were healed in all patients. The fractures were healed in 13.36±2.06 weeks, ranging from 10 to 16 weeks. According to Matta radiographic criteria, the quality of fracture reduction was excellent in 6 cases, good in 4 cases and fair in 1 case. At the last follow-up, the adductor muscle strength reached grade 4 in 4 patients and grade 5 in 7 patients. Furthermore, according to the Majeed Pelvic Score, the score of every patient was 86.55±9.59, ranging from 66 to 100, and 8 cases were excellent, 3 cases were good at the last follow-up. The heterotopic ossification occurred in 2 patients, the pain during intercourse occurred in 2 patients. No patient had sensory disturbance or pain in the perineal area. Conclusion:A certain safe distance is between the lateral to the perineum and the perineal branch of the posterior femoral cutaneous nerve with limited risk of injuring posterior femoral cutaneous nerve via the lateral approach of the perineum. The advantages in treating the fracture of inferior ramus of pubis-ischium ramus by this approach have concealed incision, short operation duration and less bleeding with satisfied short-term clinical effects.

Objective:The principal components (PC) of venous-to-arterial carbon dioxide content diference [C(v-a)CO 2] were extraceted in septic shock patients, in orter to compare the contribution of the principal components to C(v-a)CO 2. Methods:Septic shock patients monitored by Swan Ganz floating catheter in the Medical Intensive Care Unit of Peking Union Medical College Hospital were included in the retrospective study. All pairs of arterial and mixed-venous blood gases within 1 h before and after a flood challenge were included in the analyses. The principal component method was used to extract the components of C(v-a)CO 2. Spearman correlation analysis was used to evaluate the correlation between the components and C(v-a)CO 2, and the correlation between the components and cardiac output. The differences of the components beween the 28-day survival group and 28-day death group were analyzed by univariate analysis. Results:A total of 504 pairs of blood gases in 104 septic shock patients were included in the analyses. The median age of patients was 62 years ( IQR, 48 to 71), and 59.6% (62/104) were men. Four principal components were extracted and the components account for 77.7% of variance. PC1 included PaO 2, PvO 2, SaO 2 and SvO 2. PC2 included pHa and pHv. PC3 included Hb and Hct. PC4 included PaCO 2 and PvCO 2. There was a significant difference in PC4 between the two group. PC4 could weakly predict the 28-day death (AUROC 0.634, 95% CI 0.527-0.741, P=0.015). Conclusions:In patients with infectious shock, arteriovenous [C(v-a)CO 2] consists of principal components of four dimensions: oxygenation, pH, Hb, and CO 2 partial pressure difference.Arterial CO 2 partial pressure difference [P(v-a)CO2] weakly predicts 28-d morbidity and mortality.

Objective To investigate clinicians'practice and opinions on sedation therapy in end-stage patients at Peking Union Medical College Hospital.Methods From August,2022 to April,2023,an online questionnaire survey was conducted among clinicians involved in end-stage patient management.Results A total of 205 questionnaires were distributed,with an effective response rate of 56.1% .Among the clinicians,55.7% of them had experience of applying sedation therapy in end-stage patients;85.2% of clinicians believed that se-dation could relieve the suffering of terminal patients from physical refractory symptoms;75.7% of clinicians considered that sedation therapy could be used to relieve agony from psycho-existential distress.Most clinicians had concerns about sedation therapy due to the lack of legal support(86.1% )and the lack of understanding of patients or families(59.1% ).The majority(90.4% )of clinicians were willing to receive training on palliative sedation.Conclusions A majority of clinicians agree that sedation therapy could relieve the physical distress and psycho-existential distress in end-stage patients.However,most clinicians have concerns about the application of sedation therapy due to the lack of legal support.It is necessary to enhance the training on palliative sedation.

Chronic refractory wound (CRW) is one of the most challengeable issues in clinic due to complex pathogenesis, long course of disease and poor prognosis. Experts need to conduct systematic summary for the diagnosis and treatment of CRW due to complex pathogenesis and poor prognosis, and standard guidelines for the diagnosis and treatment of CRW should be created. The Guideline forthe diagnosis and treatment of chronic refractory wounds in orthopedic trauma patients ( version 2023) was created by the expert group organized by the Chinese Association of Orthopedic Surgeons, Chinese Orthopedic Association, Chinese Society of Traumatology, and Trauma Orthopedics and Multiple Traumatology Group of Emergency Resuscitation Committee of Chinese Medical Doctor Association after the clinical problems were chosen based on demand-driven principles and principles of evidence-based medicine. The guideline systematically elaborated CRW from aspects of the epidemiology, diagnosis, treatment, postoperative management, complication prevention and comorbidity management, and rehabilitation and health education, and 9 recommendations were finally proposed to provide a reliable clinical reference for the diagnosis and treatment of CRW.