Standardized pain assessment is a precondition of appropriate analgesia for mechanical ventilation patients. However, routine pain assessment rates remain very low in intensive care unit (ICU). Behavioral pain scale (BPS) and critical-care pain observation tool (CPOT) can be used to assess pain in mechanical ventilation patients who are unable to report pain by themselves. No matter what strategy we taken, analgesia-first sedation should be used in priority. Meanwhile, patient-centered and goal-directed sedation strategy should be adopted based on the individual condition.If condition permits, patients should be maintained in light states of sedation as long as possible, because this is associated with improved clinical outcomes. Humanistic care, multidisciplinary cooperation and comprehensive training are also important components of a perfect analgesia strategy.

Objective To compare the characteristics and risk factors of prognosis between elder and young patients with acute respiratory distress syndrome(ARDS)in intensive care unit(ICU). Methods The data of 150 patients meeting ARDS Berlin guideline who admitted to ICU of Affiliated First Hospital of Dalian Medical University from August 2011 to November 2013 were retrospectively analyzed. The patients over 65 years old were served as elderly group(n=78),and those younger than 65 years old were served as young group(n=72),and the patients were subdivided into survivors and non-survivors groups. The characteristics of patients at admission was recorded to investigate the characteristics of elder and young patients by univariate analysis. The univariate analysis was also conducted between different prognosis groups,and the risk factors of mortality were demonstrated by multivariate logistic analysis. Results Compared with the young group,the hospital length of stays〔days:27.0 (16.0,36.0)vs. 15.0(8.0,21.0),P=0.000〕,ICU length of days〔days:25.0(15.0,32.0)vs. 13.0(7.0,19.00), P=0.000〕,mechanical ventilation days〔days:19.0(11.0,27.0)vs. 8.0(5.0,15.0),P=0.000〕,the proportion of tracheotomy:〔39.74%(31/78)vs. 18.06%(13/17),P=0.003〕,the number of organ dysfunction(3.78±0.49 vs. 1.97±1.03,P=0.043)and creatinine(μmol/L:153.85±16.89 vs. 108.26±9.14,P=0.017)of elderly group were significantly increased. The mortality〔67.95%(53/78)vs. 59.72%(43/72),P=0.190〕and acute physiology and chronic health evaluationⅡ(APACHEⅡ)score(17.94±6.04 vs. 15.99±6.93,P=0.068)in the elderly group were higher than those in the young group but without the significant differences. The causes of death in elderly patients were mainly with respiratory failure;the mainly causes in young and middle-aged patients were complex with multiple organ dysfunction syndrome,circulatory failure and other reasons. APACHEⅡscore,the number of organ dysfunction,and maximum positive end-expiratory pressure(PEEP)in the non-survivors of the elderly group were significantly higher than those of the survivors〔APACHEⅡ score:19.45±6.00 vs. 14.72±4.83,the number of organ dysfunction:4.13±0.88 vs. 2.16±1.01,maximum PEEP(cmH2O,1 cmH2O=0.098 kPa):13.93±4.16 vs. 9.72±3.72, all P<0.01〕,and the proportion of tracheotomy and pH value were significantly lower than those of the survivors〔the proportion of tracheotomy:32.08%(17/53)vs. 56.00%(14/25),pH value:7.35±0.14 vs. 7.42±0.08,both P<0.05〕. Logistic analysis showed that APACHEⅡ score〔odds ratio(OR)=7.068,95% confidence interval (95%CI)=1.358-3.273,P=0.023〕,the number of organ dysfunction(OR=2.328,95%CI=1.193-4.520,P=0.029)were related with prognosis in elderly patients with ARDS. APACHEⅡscore,the number of organ dysfunction, blood lactate,maximum PEEP in non-survivors of the young group were significantly higher than those of the survivors〔APACHEⅡ score:18.12±6.88 vs. 12.83± 5.80,the number of organ dysfunction:3.16±1.23 vs. 2.55±1.29, blood lactate(mmol/L):4.84± 4.07 vs. 2.56±1.86,maximum PEEP(cmH2O):13.93±5.50 vs. 10.54±4.05, P<0.05 or P<0.01〕,and the pH value,hospital length of stays,ICU length of days were significantly lower than those of the survivors〔pH value:7.30±0.16 vs. 7.41±0.10,hospital length of stays(days):11.09±10.97 vs. 25.17±19.05,ICU length of days(days):8.0(5.0,13.0)vs. 20.0(12.0,31.0),all P<0.01〕. Multivariate logistic analysis showed that APACHEⅡ score was related with the prognosis in young patients with ARDS(OR=5.735, 95%CI=1.921-3.310,P=0.004). Conclusions Higher APACHEⅡscore and the number of organ dysfunction were independent predictors of worse outcome in elder ARDS patients. Higher APACHEⅡscore was the independent predictor of worse outcome in young ARDS patients.

Objective To explore the anatomical basis for the flexor pollicis brevis branch of median nerve transfer to the deep branch of ulnar nerve.Methods Eight fresh upper limb were dissected and observed.The specimen were dissected under the loup.Observed the number of the flexor pollicis brevis branch and measured the distances from pisiform bone to the flexor pollicis brevis branch.Then the transfer operation on the cadaver were imitated.After the anastomosis was completed,the stumps of the nerves were sectioned and stained with HE.The crossing-sectional area and the density of nerve fiber were obtained by Image-Pro Plus version 6.0,then the number of the nerve fiber were calculated.The data analyzed by SPSS 17.0.Results The flexor pollicis brevis branch constantly appear,there were two branches in 2 specimens,one branch in 6 specimens.The flexor pollicis brevis branch could transfer to the deep branch of ulnar nerve by end-to-end surture without tension.The regeneration distances was (37.3 ± 5.76) mm.The crossing-sectional area were (0.0575 ± 0.0086)mm2 and (0.2039 ± 0.0396)mm2,the number were (492.50± 62.62) and (1651.13± 79.01),the density were (8781.4246 ± 1676.2894)/mm2 and (8371.1592 ± 1677.6509)/mm2 in the flexor pollicis brevis branch and the deep branch of ulnar nerve,respectively.There were no significant differences in the density of the nerve fiber between the donor and recipient nerve (P ＜0.05).But there were differences in the crossing-sectional area and number of the nerve fiber(P ＜ 0.05).Conclusion The flexor pollicis brevis branch transfer to the deep branch of ulnar nerve can provide a short regenerating distance,but can supply a part of recipient nerve to reinnervate.

Objective To explore the correlation of pulse pressure(PP) and outcome in refractory septic shock patients.Methods A total of 68 patients with refractory septic shock consecutively admitted in our ICU from January 2012 to December 2012 were retrospectively studied.Hemodynamic data and arterial lactate concentration were collected at the time of admission and 24 hours after admission.The outcome of Day 28 post-diagnosis was also recorded.Results (1) Compared with the survivors,heart rate(HR) at 24hours after admission was higher in non-survivors,while 24 h lactate clearance rate (rLac) was lower in them (P ＜ 0.05).Other hemodynamic parameters showed no difference between the non-survivors and the survivors at 24 hours after admission,including central venous pressure (CVP),mean arterial pressure (MAP),systolic blood pressure(SBP),diastolic blood pressure(DBP),PP,pulse pressure/heart rate (PP/HR),pulse pressure/mean arterial pressure(PP/MAP),pulse pressure/systolic pressure(PP/SBP),pulse pressure/diastolic pressure (PP/DBP),the value of SBP above MAP (SMP) and the value of DBP below MAP(MDP).(2)The mortality rate was higher in the patients with HR≥100 b/min than those with HR ＜ 100 b/min,but without statistical significance (56.25％ vs 36.11％,P =0.096).Compared with the survivors,no matter with HR≥100 b/min or HR ＜ 100 b/min,lactate(Lac) at the 24 hours after admission was higher in all the non-survivors (P ＜ 0.05),while with lower rLac (P ＜ 0.05).In those with HR ≥100 b/min,the following hemodynamic parameters were higher in the non-survivors than in the survivors,including PP,PP/HR,PP/MAP,PP/SBP,PP/DBP,SMP and MDP (all P values ＜ 0.05),while no statistical difference was observed in those with HR ＜ 100 b/min.(3)The mortality rate showed no statistical difference in those with MAP≥85 mmHg(1 mmHg =0.133 kPa) and with MAP ＜ 85 mmHg(42.42％ vs 48.57％,P =0.611).No matter MAP≥85 mmHg or MAP ＜ 85 mmHg,compared with the survivors,all the non-survivors had higher Lac at the 24 hours after admission (P ＜ 0.05),while with lower rLac (P ＜ 0.05).In those with MAP≥85 mmHg,HR was higher in the non-survivors than the survivors (P ＜ 0.05).In those with MAP ＜ 85 mmHg,compared with the survivors,the non-survivors had higher PP,PP/MAP,PP/SBP,PP/DBP,SMP and MDP (P ＜0.05),while with lower DBP (P ＜0.05).Conclusion PP is correlated with the outcome in refractory septic shock patients.When the HR and MAP differ,PP has different effect on the outcome and contributes more to the tissue perfusion and outcome in those with higher HR and lower MAP.

Objective To study the foxml gene and its protective effect on the lung tissue of rats with acute lung injury (ALI) induced by lipopolysaccharide (LPS), and to observe the dexamethason' s (DEX) impacts on foxml gene and the prognosis of ALI. Method Seventy-two healthy mice were randomly(random number) divid-ed into three groups: control group (A group, n = 24), model group (B group, n = 24) and DEX treatment group (C group, n = 24). The observing intervals were respectively set in 24 h, 48 h and 72 hours. At each ob-serving interval, the foxml protein in lung tissue of mice was detected by using immunohistochemistry (IHC), and the expression of foxml gene in lung tissue was detected by using RT-PCR, as well as to observe the pathological changes in lung tissue. Results Comparisons were made between paired groups at 24 h,48 h and 72 h intervals in which the expression of foxml mRNA and the level of foxml protein in lung tissue of mice in C group were signifi-cantly higher than those in B group (P < 0.05), and those in B group were significantly higher than those in A group (P < 0.05). The expression of foxml mRNA and the level of foxml protein in lung tissue of mice in B group at 48 h interval were significantly higher than those both at intervals of 72 h and 24 h (P < 0.05), and the those at 72 interval were significantly higher than those at 24 h interval (P < 0.05). Compared with B group, the pathologi-cal changes in lung tissue of mice in C group were lessened. Conclusions In both model group and dexamethasone treatment group, the expression of foxml mRNA and the level of foxml protein in lung tissue of mice are increased significantly. Dexamethasone lessens the injury of both vascular endothelial cells and alveolar epithelial ceils of lung tissue, and it also significantly increases the expression of foxml mRNA and the level of foxml protein.

Objective:To investigate the expression of serum matrix metalloproteinase 3 (MMP-3) in patients with rheumatoid arthritis (RA) and analyze its correlation with bone erosion and disease activity.Methods:100 RA patients diagnosed in the First People's Hospital of Changde from July 2018 to December 2019 were selected as the RA group, and 35 healthy volunteers who came to the hospital for physical examination at the same time were selected as the control group. The clinical data of the patients were collected, and the serum MMP-3 levels of the patients and healthy volunteers were detected by enzyme-linked immunosorbent assay (ELISA). The serum MMP3 levels of RA patients with different disease activity, different imaging stages and different bone mineral density were compared, and the correlation with clinical indicators were analyzed.Results:⑴ RA patients were grouped according to the Disease Activity Score (DAS) 28. Serum MMP-3 levels in the highly active group (300.87±15.93)ng/ml and in the moderately active group (213.78±12.79)ng/ml were higher than those in the clinical remission group (82.87±8.19)ng/ml increased significantly. ⑵ The serum MMP3 level in the RA group (190.98±13.43)ng/ml was significantly higher than that in the healthy control group (69.97±10.63)ng/ml. ⑶ There were significant differences in serum MMP-3 levels among RA patients with different imaging stages ( P<0.05). The level of MMP-3 in stage Ⅲ (206.18±13.58)ng/ml and stage Ⅳ (301.72±13.43)ng/ml were significantly higher than those in stage Ⅰ (89.16±10.13)ng/ml. ⑷ RA patients were divided into normal group, osteopenia group, and osteoporosis group according to bone mineral density. The serum MMP-3 level in the osteopenia group (180.87±12.69)ng/ml and osteoporosis group (289.54±13.28)ng/ml were significantly higher than that in the normal group (121.05±8.45)ng/ml. ⑸ Serum MMP-3 levels were positively correlated with C-reaction (CRP), erythrocyte sedimentation rate (ESR), DSA 28, rheumatoid factor (RF), joint swelling index, joint tenderness index, and platelet count in the RA group ( P<0.05). Conclusions:The serum MMP-3 plays an important role in the progression of RA, and is closely related to RA disease activity and bone erosion. It is expected to become a serological indicator for predicting RA bone erosion and radiological progress.

Bacterial infection is the main cause of infectious diseases in children. Antibacterials play an important role in anti infection treatment of children. At present, the treatment of antimicrobial drugs in children is facing a severe situation of bacterial resistance. In January 2020, a children′s specialized hospital carried out the practice of precise management of antibiotics in combination with key performance indicators. Through the multi sectoral linkage of management and technology, eight key performance indicators and assessment methods were set up from three levels of antibiotic use, bacterial resistance and hospital infection, to standardize the clinical application of antibiotics and continue to promote the rational use of antibiotics. This practice had improved the performance indicators of antibacterial management. Among them, the use intensity of antibacterial drugs for inpatients decreased from 40.07 DDD in 2019 to 29.00 DDD in 2021, the use rate of antibacterial drugs for inpatients decreased from 81.32% to 64.40%, the percentage of antibacterial drug expenses in total drug expenses decreased from 35.41% to 26.82%, the use proportion of non restricted antibacterial drugs in antibacterial drugs increased from 71.30% to 82.21%, and the drug resistance rate of Salmonella to β-Lactam/enzyme inhibitors decreased from 4.84% to 0.03%, and the incidence of hospital infection decreased from 1.16% to 0.96%. The precise management of antibiotics in combination with key performance indicators improved the level of rational use of antibiotics, effectively curbed bacterial resistance, achieved phased results, so as to provide a reference for the scientific management of antibiotics in children′s hospitals.

Humans ; Norepinephrine ; Bacterial Infections/drug therapy* ; Immunity, Innate

To investigate the impact of goal directed analgesia on the outcome of patients with mechanical ventilation in intensive care unit. A total of 126 patients who needed mechanical ventilation were recruited. With a method of before and after paired comparison, they were divided into two group:( 1 ) analgesia with empirical administration or control group; ( 2 ) goal directed analgesia based on critical-care pain observation tool (CPOT). Compared with the control group, after goal directed analgesia was applied, the consumption of midazolam significantly dropped from ( 368. 47 ± 27. 41 ) mg to ( 151. 27 ± 29. 31 ) mg (P<0. 05), whereas the consumption of dexmedetomidine significantly increased from ( 623. 62 ± 20. 91) μg to (812. 34 ± 22. 57) μg(P<0. 05). The median score of Richmond agitation-sedation scale increased from -3 to -1. The incidence of delirium significantly reduced from 23. 81% to 17. 46%( P<0. 05). The mean ventilator duration was significantly shortened from (168. 49 ± 11. 41) h to (142. 38 ± 13. 24) h(P<0. 05). ICU length of stay was significantly shortened from (23. 64 ± 9. 26) d to (19. 63 ± 8. 46) d ( P < 0. 05 ) . Due to the mild sedation, patients receiving goal directed analgesia report less delirium, less ventilation time and shorter ICU length of stay, suggesting that the general outcome is improved.

Actinomycosis is a rare chronic granulomatous disease characterized by granuloma formation and tissue fibrosis with sinus tracts,often misdiagnosed due to its similarity to many infectious and non-infectious diseases.This report presents a case of a 60-year-old female with more than 10 years history of rheumatoid arthritis who developed actinomycosis infection after long-term treatment with immunosuppressants and biologics,including methotrexate,leflunomide,and infliximab,leading to recurrent joint pain,poorly controlled rheumatoid arthritis activity,and persistent elevation of white blood cell counts.Abdominal CT revealed a pelvic mass and right ureteral dilation.Pathological examination of cervical tissue showed significant neutrophil infiltration and sulfur granules,indicating actinomycosis.The patient received 18 months of doxycycline treatment for the infection and continued rheumatoid arthritis therapy with leflunomide,hydroxychloroquine sulfate,and tofacitinib,resulting in improved joint symptoms and normalized white blood cell counts.After 2 years of follow-up,the patient remained stable with no recurrence.This case highlights the importance of clinicians being vigilant for infections,particularly chronic,occult infections from rare pathogens,in rheumatoid arthritis patients on potent immunosuppressants and biologics,advocating for early screening and diagnosis.