Objective To investigate the significance of monitoring P(c-a)CO2 (the gradients between transcutaneous PCO2 and arterial PCO2) in patients with septic shock.Method 31 patients with early septic shock were enrolled as the study group and 20 patients with stable hemodynamics as the control group from Fab.2013 to Sept.2014 in our Intensive Care Unit (ICU).The patients with septic shock were treated guided by early goal directed therapy (EGDT) within 6 hours since hospitalization.The differences of baseline P(c-a) CO2 levels and other index as arterial lactate (LAC) concentration between two groups and the variations of these indexes after EGDT in the study group were compared respectively.Results The baseline levels of P(c-a)CO2 and LAC in patients with septic shock were significantly higher than in patients of control group: (21.2 ± 10.1) mmHg vs.(7.5 ±4.6), P =0.000, and (4.0±2.4) mmol/ Lvs.(1.6 ± 0.5), P =0.000.The areas under receiver operator characteristic (ROC) curve (AUC) for baselineP(c-a)CO2 and LAC were 0.918 (95％ CI: 0.843-0.992) and 0.840 (95％ CI: 0.719-0.962) respectively.A threshold of 14.0 mmHg for P(c-a)CO2 and 2.1 mmol/L for LAC discriminated patients with septic shock from without shock with the same sensibility of 83.9％ and the same specificity of 90.0％, respectively.With regard to prognosis (Day 28), AUC for baseline P(c-a)CO2 and LAC were 0.739 (95％ CI: 0.562-0.917) and0.702 (95％ CI: 0.514-0.889) respectively.A threshold of 21.5 mmHg for P(c-a) CO2 and 3.9 mmol/L for LAC discriminated survivors from nonsurvivors with the same sensibility of 71.4％ and the same specificity of 70.6％ respectively.31 patients in the study group completed EGDT within 6 hours after the admission, 16 (51.6％) passed EGDT and 13 (81.3％) survived, 15 (48.4％) failed EGDT and 4 (26.7％) survived, and survival rates were significantly different, F =9.314, P =0.004.After EGDT, P(c-a) CO2 (18.8 ± 9.4) mmHg and LAC (3.3 ± 2.4) mmol/Lreduced significantly compared with the baselines, all P =0.000.AUC then for P(c-a) CO2 and LAC were 0.742 (95％ CI: 0.562-0.921) and 0.769 (95％ CI: 0.593-0.945), respectively.A threshold of 18.3 mmHg for P(c-a)CO2 and 3.1 mmol/L for LAC discriminated survivors from nonsurvivors with the same sensibility of 71.4％ and the specificity of 71.4％ and of 76.5％ respectively.P(c-a) CO2 and LAC of patients passed EGDT reduced significantly compared with those failed EGDT: (14.8 ± 7.5) mmHgvs.(23.6±9.6) mmHg (P=0.012)、 (2.5±1.5) mmol/L vs.(4.3±2.9) mmol/L (P=0.038), and so did with their baseline : (14.8±7.5) mmHgvs.(18.0±8.1) mmHg, (P=0.042)、 (2.5±1.5) mmol/Lvs.(3.2±1.8) mmol/L, P=0.043.In patients failed EGDT, P(c-a)CO2 and LAC changed little after EGDT, from (24.6 ± 9.2) to (23.6 ± 9.6) mmHg (P =0.238) and from (4.8 ± 2.5) mmol/L to (4.3 ± 2.9) mmol/L (P =0.629).When baseline levels were compared between patients passed EGDT with those failed EGDT, P(c-a) CO2 was (18.0 ±8.1) mmHg vs.(24.6 ± 9.2) mmHg (P =0.042), LAC was (3.2 ± 1.8) mmol/L vs.(4.8 ± 2.5) mmol/L (P =0.050).Conclusions P(c-a) CO2 ＞ 14.0 mmHg could play a role in recognizing early septic shock.EGDT was an effective therapy for the disease and P(c-a)CO2 level could reflect the efficacy of EGDT.P(c-a)CO2 ＞ 21.5mmHg before EGDT and P(c-a) CO2 ＞ 19.3 mmHg after EGDT both could predict the prognosis of patients with septic shock.All above correlated well with LAC and represented a new efficient technique to assess tissue microperfusion.

Objective To investigate the expression of gastric and intestinal phenotypic markers in Siewert typeⅡand Ⅲ early gastroesophageal junction(GEJ) cancer, and to explore its correlation with clinic-pathological features.Methods From April 2010 to July 2015, 53 cases diagnosed as early GEJ cancer were enrolled.The gastric and intestinal phenotypic markers such as mucin5AC(MUC5AC),mucin6(MUC6),mucin2(MUC2),caudal related homeodomain transcription 2(CDX2) and cluster of differentiation 10(CD10) were detected, and then the patients were divided into gastric type, gastrointestinal type, intestinal type and non-classified type according to the results of immunohistochemical staining.Combined with Siewert classification the clinicopathological features were analyzed.Chi square test or Fisher′s exact test was performed for statistical analysis.Results In the cancer tissues of 47 patients with Siewert type Ⅱand Ⅲ early GEJ cancer, the case numbers of positive expression of MUC5AC,MUC6,MUC2, CDX2 and CD10 were 21(44.7%),19(40.4%),31(66.0%),27(57.4%) and 17(36.2%),respectively;the case numbers of gastric type, gastrointestinal type, intestinal type and non-classified type were 11(23.4%),14(29.8%),21(44.7%) and one(2.1%), respectively.The positive expression rates of MUC5AC and MUC6 in Siewert typeⅡwere 55.9%(19/34) and 50.0%(17/34),which were higher than those of Siewert typeⅢ(2/13), and the positive expression rate of MUC2 was 55.9%(19/34), which was lower than that of Siewert typeⅢ(12/13), and the differences were statistically significant (x2=6.240,4.679 and 4.053;all P<0.05).In Siewert typeⅡ, the proportion of intestinal type was 32.4%(11/34), which was lower than that of Siewert typeⅢ(10/13), and the differences were statistically significant (x2=7.142,P=0.010).In patients with Siewert typeⅡand Ⅲ early cancer, males predominated in intestinal type which were mostly well differentiated type with less submucosal carcinoma.The maximum diameter of tumor was less than those of gastric type and gastrointestinal type.In paracancerous mucosal tissues, the incidences of intestinal metaplasia in gastrointestinal type and intestinal type were 11/14 and 81.0%(17/21), which were higher than that of gastric type (3/11);the incidences of atrophy in gastrointestinal type and intestinal type were 12/14 and 85.7%(18/21),which were higher than that of gastric type (4/11),and the differences were statistically significant (Fisher′s exact test,all P<0.05).Conclusions Siewert typeⅡand Ⅲ early GEJ cancer can directly originated not only from gastric mucosa, but also from gastrointestinal and intestinal mucosa.Atrophy and intestinal metaplasia could exist before cancer genesis.

Objective To determine the effects and dosage of N?acetylcysteine( NAC) in the im?provement of the visibility in esophagogastroduodenoscopy( EGD) . Methods A prospective randomized con?trolled study was performed on 193 patients scheduled for EGD from November 2014 to July 2015 were ran?domized into five groups using digital table. In group A, 100 mg dimethicone and 2 g NaHCO3 were given. In group B,100 mg dimethicone, 2 g NaHCO3 and 20 000 U pronase were given. Group C received 100 mg dimethicone, 2 g NaHCO3 and 200 mg NAC. Group D received 100 mg dimethicone, 2 g NaHCO3 and 400 mg NAC and group E 100 mg dimethicone, 2 g NaHCO3 and 600 mg NAC.The agents were dissolved in 100 ml water for each patient.Endoscopy was completed by one endoscopist and the score of image visibility assessment was completed by 2 other endoscopists. The 3 endoscopists were unaware of grouping. The total scores, the time of washing, the time of examination and complications were compared and analysed. The total image scores of group A, B, C,D and E were 30?83±3?78, 35?69±2?88, 33?16±3?90, 34?95±3?46 and 36?76±2?91, respectively. Group A was the lowest(P<0?05),followed by group C(P<0?05). There were no differences among group B,D, and E(P>0?05).Images that were scored 3 were the most in group E.The washing times of each group were 38?00±19?10, 17?03±11?44, 15?92±10?81, 15?78 ±10?24 and 15?55±9?69, and the examination times of each group were 13?49±2?49, 9?41±1?86, 9?08± 1?80, 8?73±1?91 and 8?78±1?79 minutes.Group A was the longest in these two indices(P<0?05). There were no significant differences among group B, C, D and E ( P<0?05) . There were no significant differences in adverse effects among groups after EGD( P>0?05) . Conclusion The preoperative NAC can improve the visibility in EGD. The best dose is 600 mg, whose effects and safety were similar to those of 20 000 U, but yield to less washing time and the examination time in EGD.

Objective To explore 64 row volumetric CT 3D reconstruction in the clinical application of severe craniocerebral injury.Methods 60 patients with craniocerebral injury in our hospital were retrospectively analyzed who accept craniocerebral 64 row volumetric CT 6 to 24 hours after injury. Results All cases got timely diagnosis and treatment, especially for the special parts of brain lesions, ventricle base of skull fractures and pool, and various angles show. Conclusion 64 row volumetric CT reconstruction for the diagnosis of craniocerebral injury shows important significance and may estimate the prognosis in diagnosis, guiding treatment and surgery, reducing misdiagnosis.

Malaysia is a multi-ethnic and multi-cultural constitutional monarchy and federal system located in Southeast Asia. The top three diseases that cause deaths are ischemic heart disease, lower respiratory tract infections and stroke. Lower respiratory tract infections, colorectal cancer and Alzheimer’s disease have been the fastest growing diseases in recent years. The health insurance system complements public and private health care system. Traditional medicine in Malaysia includes Malaysian Medicine, Traditional Chinese Medicine (TCM), Indian Medicine, Islamic Medicine and homeopathy. Although TCM, such as acupuncture, has not been covered by health insurance, it is widely used under the impetus of the local Chinese people. At present, in Malaysia, the TCM public acceptance and education need promotion, and scientific researches need to be improved. It is hoped that in the future, the development of TCM in Malaysia will be better developed and disseminated by promoting TCM relevant legislation, increasing public awareness, focusing on education and training, and carrying out international scientific research cooperation.

Objective:To investigate the relationship between serum albumin(SA)levels and left atrial thrombosis(LAT)in elderly patients with nonvalvular atrial fibrillation(NVAF), and to evaluate the clinical value of SA in predicting LAT in elderly NVAF patients.Methods:Clinical data of 180 elderly patients with NVAF undergone transesophageal echocardiography(TEE)in our hospital were retrospectively analyzed.According to whether there was thrombosis in the left atrium, patients were divided into the thrombus group(n=42)and the non-thrombus group(n=138). Logistic regression was used to analyze factors related to left atrial appendage thrombosis in NVAF patients.The receiver operating characteristic(ROC)curve was used to evaluate the value of serum albumin levels in predicting LAT formation in elderly NVAF patients.Results:The duration of AF was longer in the thrombus group than in the non-thrombus group(all P<0.05). C-reactive protein(CRP)levels and platelet(PLT)counts were higher, and SA levels and the international normalization ratio(INR)were lower in the thrombus group than in the non-thrombus group(all P<0.05). The left atrial diameter(LAD)was larger in the thrombus group than in the non-thrombus group( P<0.05). Multiple Logistic regression analysis showed that the duration of AF and CRP levels were independent risk factors for LAT( P<0.05), and SA levels and INR were independent protective factors for LAT( P<0.05). ROC curve results showed that the area under the curve(AUC)of SA in predicting LAT was 0.778(95% CI: 0.711-0.837, P<0.001). Conclusions:Low serum albumin levels are closely related to LAT in NVAF patients and can be regarded as a predictor of LAT.Serum albumin levels should be monitored in clinical practice to reduce the incidence of stroke events in patients with AF.

In this paper, the domestic and international demand and development trend of clinical diagnostic radionuclides are analyzed, and the medium and high-energy cyclotrons, adequate and systematic facilities, and preparation techniques required for the production of medical radionuclides based on solid targets are introduced. This paper focuses on the research and development carried out by some important medical institutions and scientific research institutes in China over the years in the aspects of medium and high-energy cyclotrons, beam transmission lines, high-power irradiation target stations and new medical isotope production processes etc. It also looks forward to some new directions for the development of medical radionuclides in China during the 14th Five-Year Plan period.

Objective:To investigate the safety of minimally invasive liver resection for resectable hepatocellular carcinoma (HCC) complicated with portal hypertension.Methods:The propensity score matching and retrospective cohort study was conducted. The clinicopathological data of 807 patients with resectable HCC who underwent minimally invasive liver resection in 8 medical centers, including Sir Run Run Shaw Hospital, Affiliated with the Zhejiang University School of Medicine et al, from June 2011 to November 2022 were collected. There were 670 males and 137 females, aged 58(50,66)years. Of the 807 patients, 173 cases with portal hypertension were divided into the portal hypertension group, and 634 cases without portal hypertension were divided into the non-portal hypertension group. Observation indicators: (1) propensity score matching and comparison of general data of patients between the two groups after matching; (2) intraoperative and post-operative situations; (3) subgroup analysis. Propensity score matching was done by the 1:1 nearest neighbor matching method, with the caliper setting as 0.001. Measurement data with skewed distribution were represented as M( Q1, Q3), and comparison between groups was conducted using the rank sum test. Count data were described as absolute numbers, and comparison between groups was conducted using the chi-square test or Fisher exact probability. Comparison of ordinal data was constructed using the non-parameter rank sun test. Results:(1) Propensity score matching and comparison of general data of patients between the two groups after matching. Of the 807 patients, 268 cases were successfully matched, including 134 cases in the portal hypertension group and 134 cases in the non-portal hypertension group. The elimination of the tumor diameter and robot-assisted surgery confounding bias ensured comparability between the two groups after propensity score matching. (2) Intraoperative and postoperative situations. The occlusion time of porta hepatis, cases with intraoperative blood transfusion, cases with postoperative complication, cases with complication >Ⅱ grade of Clavien-Dindo classification, cases of Clavien-Dindo classification as Ⅰ grade, Ⅱ grade, Ⅲ grade, Ⅳ grade, cases with liver related complication were 27.0(15.0,43.0)minutes, 33, 55, 15, 13, 29, 14, 1, 37 in the portal hypertension group, versus 35.0(22.0,60.0)minutes, 17, 25, 5, 14, 9, 4, 1, 13 in the non-portal hypertension group, showing significant differences in the above indicators between the two groups ( Z=-2.15, χ2=6.30, 16.39, 4.38, 20.72, 14.16, P<0.05). (3) Subgroup analysis. Results of subgroups analysis showed that in cases with major live resection, the operation time, volume of intraoperative blood loss, duration of postoperative hospital stay were 243.5(174.6,296.3)minutes, 200.0(150.0,600.0)mL, 7.5(6.0,13.0)days in the portal hypertension group, versus 270.0(180.0,314.5)minutes, 200.0 (75.0,450.0)mL, 7.0(5.5,10.0)days in the non-portal hypertension group, showing no significant difference in the above indicators between the two groups ( Z=-0.54, -1.73, -0.92, P>0.05). In cases with non-major live resection, the operation time, volume of intraoperative blood loss, duration of postoperative hospital stay were 170.0(120.0,227.5)minutes, 100.0(50.0,200.0)mL, 8.0(5.0,10.0)days in the portal hypertension group, versus 170.0(120.0,227.5)minutes, 100.0(50.0,200.0)mL, 7.0(5.5,9.0)days in the non-portal hypertension group, showing no significant difference in the above indicators between the two groups ( Z=-1.39, -0.10, 1.05, P>0.05). In cases with anatomical liver resection, the operation time, volume of intraoperative blood loss, duration of postoperative hospital stay were 210.0(150.0,285.0)minutes, 150.0(50.0,200.0)mL, 8.0(6.0,9.3)days in the portal hypertension group, versus 225.5(146.3,306.8)minutes, 100.0(50.0,250.0)mL, 7.0(6.0,9.0)days in the non-portal hypertension group, showing no significant difference in the above indica-tors between the two groups ( Z=-0.75, -0.26, -0.91, P>0.05). In cases with non-anatomical liver resection, the operation time, volume of intraoperative blood loss, duration of postoperative hospital stay were 173.5(120.0,231.5)minutes, 175.0(50.0,300.0)mL, 7.0(5.0,11.0)days in the portal hyper-tension group, versus 186.0(123.0,262.5)minutes, 100.0(50.0,200.0)mL, 7.0(5.0,9.5)days in the non-portal hypertension group, showing no significant difference in the above indicators between the two groups ( Z=-0.97, -1.12, -0.98, P>0.05). Conclusion:Minimally invasive liver resection or even major liver resection is safe and feasible for screened HCC patients complicated with portal hyper-tension, but attention should be paid to the prevention and treatment of postoperative complications.

Few studies have described the key features and prognostic roles of lung microbiota in patients with severe community-acquired pneumonia (SCAP). We prospectively enrolled consecutive SCAP patients admitted to ICU. Bronchoscopy was performed at bedside within 48 h of ICU admission, and 16S rRNA gene sequencing was applied to the collected bronchoalveolar lavage fluid. The primary outcome was clinical improvements defined as a decrease of 2 categories and above on a 7-category ordinal scale within 14 days following bronchoscopy. Sixty-seven patients were included. Multivariable permutational multivariate analysis of variance found that positive bacteria lab test results had the strongest independent association with lung microbiota (R² = 0.033; P = 0.018), followed by acute kidney injury (AKI; R² = 0.032; P = 0.011) and plasma MIP-1β level (R² = 0.027; P = 0.044). Random forest identified that the families Prevotellaceae, Moraxellaceae, and Staphylococcaceae were the biomarkers related to the positive bacteria lab test results. Multivariable Cox regression showed that the increase in α-diversity and the abundance of the families Prevotellaceae and Actinomycetaceae were associated with clinical improvements. The positive bacteria lab test results, AKI, and plasma MIP-1β level were associated with patients' lung microbiota composition on ICU admission. The families Prevotellaceae and Actinomycetaceae on admission predicted clinical improvements.
Acute Kidney Injury/complications* ; Bacteria/classification* ; Chemokine CCL4/blood* ; Community-Acquired Infections/microbiology* ; Humans ; Lung ; Microbiota/genetics* ; Pneumonia, Bacterial/diagnosis* ; Prognosis ; RNA, Ribosomal, 16S/genetics*