Patients with SAP have a hypermetabolic and hypercatabolic state.Nutritional support for patients with SAP is needed.EN by the jejunal route does not stimulate pancreatic secretions and is safe.At present,the beneficeal effects of EN towards improving the nutritional condition,protecting gut barrier function,reducing translocation of bacteria and endotoxins,modulating the inflammatory response,and decreasing the cost have been observed.Therefore,the EN rather than PN should be used by the jejunal route to provide nutritional support for patients with SAP.

Toxic epidermal necrolysis (TEN) is an acute skin inflammation,which belongs to heavy drug eruption.With the extensive and widespread use of antibiotics,nonsteroidal antipyretic analgesics and other pharmacotherapies in the treatment of critically ill patients,the trend of morbidity of TEN is gradually increased,especially in intensive care unit.In consideration of the high mortality rate of TEN and its great influence on the overall prognosis of patients with critical illness,we summarized the diagnosis and treatment experiences in the management of TEN based on retrospective analysis of one patient with severe acute pancreatitis and TEN.

Objective To study the effect of mechanical ventilation guided by esophageal pressure on hemodynamics and oxygen metabolism of severe acute pancreatitis (SAP) swine model with intra-abdominal hypertension (IAH) Methods By self-controlled study,SAP model was made by infusing sodium taurocholate (5％) into the pancreatic duct in 6 domestic swine.Mechanical ventilator mode was volumeassist control with tidal volume 10 ml/kg ; FiO2 40％ and PEEP 5 cm H2O (routine ventilation) given to SAP model swine.After 3 h ventilation,pneumo-peritoneum was made with N2 gas to increase the intraabdominal pressure (IAP) to 25 mm Hg in SAP swine.Three more hours later,PEEP was adjusted as the measurement of esophageal pressure (Pes guided ventilation) to such a level that trans-pulmonary pressure stayed above 0 cm H2O during end-expiratory occlusion.During the investigation period,heart rate (HR),cardiac output index (CI),central venous pressure (CVP),mean arterial pressure (MAP) and pulmonary arterial wedge pressure (PAWP) were continuously recorded with the aid of Swan-Ganz catheter and ECG monitor,and oxygen partial pressure of artery (PaO2) and carbon dioxide partial pressure of artery (PaCO2) were measured by blood-gas analysis.In addition,systemic oxygen delivery (DO2) and systemic oxygen consumption (VO2) were calculated by using the data of blood-gas analysis of arterial and central venous blood.Results No swine model was subjected to barotrauma.After routine mechanical ventilation,there were significant differences in HR,CI,MAP,CVP,PAWP,Ppeak,Pplat,Pes,pulmonary compliance (Cstat),PaO2,and DO2 between SAP and IAH in swine (all P ＜ 0.05).Compared with routine ventilation,however,PaO2 and Cstat improved significantly with lower CI and increased Pplat after PEEP adjusted according to measurements of esophageal pressure (all P ＜ 0.05).The lactate decreased significantly after esophageal pressure guided ventilation (all P ＜ 0.05).There were no significant changes in PaCO2,HR,MAP,CVP and PAWP in IAH swine after mechanical ventilation with routine parameters (all P ＞ 0.05).Conclusions There were remarkable effects on oxygen metabolism in response to mechanical ventilation guided by esophageal pressure.In case of clinical application of mechanical ventilation,the results of this study are in favor of setting transpulmonary pressure according to measurements of esophageal pressure in SAP patients with IAH in an early stage.

Objective To investigate the early diagnostic value of traditional scoring systems in critical acute pancreatitis.Methods From Jan 2007 to Ju12013,consecutive 184 patients with AP who were admitted to the surgical intensive care unit of the Institute of General Surgery,Nanjing Generai Hospital of Najing Militery Region within 72 h from the onset of the disease were studied.Patients were assigned to four groups,including mild,moderate,severe and critical AP according to the determinant based classification and the receiver operating characteristics(ROC) curve was used to predict the presence of critical AP,and Z test and logistic regression was applied to determine the diagnostic value of traditional scoring systems.Results The area under ROC (AUC) of Sofa,BISAP and CTSI score for early diagnosis of critical AP was 0.896,0.877 and 0.862;the best cut off value was 4.5,9.5 and 2.5.Moreover,the AUC of APACHE Ⅱ and Ranson score was 0.807 and 0.707,and the best cut off value was 8.5 and 3.5,respectively.Z test showed early diagnosis rate of Sofa,BISAP,CTSI score was significantly higher than that in Ranson score,and the difference between the two groups was statistically significant (P ＜ 0.05);though they were higher than APACHE Ⅱ score,the difference between the two groups was not statistically significant (P ＞ O.05).Logistic regression showed that high APACHE Ⅱ,Sofa,BISAP and CTSI score were independent risk factors for the development of critical AP (P ＜ 0.05).Conclusions Sofa,CTSI and BISAP score may be clinically important for early diagnosis of critical AP.

Objective To explore the epidemic situation of nontuberculous Mycobacteria in both Yuexiu and Zhuhai districts. Methods Mycobacterium tuberculosis culture and strain identification were conducted in suspected smear-positive tuberculosis patients who had visited our clinics at Yuexiu and Haizhu districts in Guangzhou during the period of 2010 to 2012. Results 2 014 sputum samples were identified as NTM and MTC, 1 630 samples were MTC (80.9%), and 384 samples were NTM (19.1%). The isolated rate for NTM from 2010 to 2012 was 17.6%, 17.1% and 21.2%, respectively. 79 strains of 384 NTM were identified; the rapid-growing mycobacterium was 50.6%, and the slow-growing mycobacterium was 49.4%. Conclusions The sputum-isolated rate of NTM for the suspected tuberculosis patients was 19.1% in Yuexiu and Haizhu districts in Guangzhou. For the smear-positive pulmonary tuberculosis patients who respond to treatment poorly , we should pay attention to NTM lung disease.

Objective To observe the clinical effectiveness of percutaneous catheter drainage ( PCD ) and PCD + negative pressure irrigation ( PCD + NPI ) for treatment of severe acute pancreatitis ( SAP ) patients with infective pancreatic necrosis (IPN).Methods Data of 71 IPN patients admitted from January 2010 to December 2011 were included and retrospectively analyzed.They were divided into two groups by the different treatment choices:PCD group (52 patients) and PCD + NPI group (19 patients).In PCD group,percutaneous pig-tail drainage catheter was inserted for intermittent IPN drainage,and in PCD + NPI group,negative pressure irrigation catheter was inserted for continuous IPN drainage.The indication for laparotomy surgery was no improvement after PCD or PCD + NPI for 3 days,or septic shock,abdominal cavity bleeding,digestive tract fistula occurred,the area of IPN decreased less than 1/2.Results The surgery rate of PCD +NPI group was 15.8％,which were significantly lower than that in PCD group (48.1％,P ＜0.05).7(36.8％ ) patients in PCD + NPI group received endoscopic drainage,which were significantly higher than that in PCD (0,P ＜0.05).The time interval between initial tube placement and operation in the PCD + NPI group was (22 ± 11 ) d,which were significantly longer than that in PCD group [ ( 10 ± 6 ) d,P ＜ 0.05 ].The difference of mean session and number of tube placement,number of laparotomy surgery,complications of laparotomy surgery in the two groups was not statistically significant.The mortality rate in the PCD + NPI group was 15.8％,which was not significantly higher than that in PCD group ( 13.5％ ).The ICU days,length of hospital stay and hospital costs in PCD + NPI group were lower than those in the PCD group,but the difference between the two groups was not statistically significant.Conclusions PCD + NPI can effectively reduce operation rate for patients with infective pancreatic necrosis.

BACKGROUND: As a micro-injurying and reduplicative treatment of osteoarthritis,the arthroscopic debridement has got the affirmation of numerous scholars. But as one of the standard procedures in artnroscopic debridement,synovectomy is called in question recently.OBJECTIVE: To explore the applied value of synovectomy in the arthroscopic debridement of osteoarthritis.DESIGN: Retrospective controlled analysis.SETTING: Department of Orthopaedics, Fushun Central Hospital.PARTICIPANTS: Sixty-five patients received synovectomy in the arthroscopic debridement of knee joint osteoarthritis in the Department of Orthopaedics,Fushun Central Hospital from February 1997 to December 2000.Thirty-two among them,with complete data and over 1 year's followup,were taken for synovectomy group. Forty-eight patients received the arthroscopic debridement of knee joint osteoarthritis without synovectomy in the Department of Orthopaedics,Fushun Central Hospital from January 2001 to November 2003.Thirty among them,with complete data and over 1 year's follow-up,were taken for control group.METHODS: Synovectomy was taken as the factor of intervention in the operation to perform grouping. The analysis of curative effect was performed to control with joint douching,corpus liberum removal,osteophyma cleaning,meniscus fitting,cartilage gouging,synovectomy and without synovectomy or part synovectomy. Lysholm evaluation standard of knee joint osteoarthritis was used to the knee joint functional evaluation beween preoperation and postoperative 1 year in two groups. And operative time,postoperative draining quantity,postoperative 7-day visual analog score,postoperative 1-year Lysholm score of knee joint, were recorded.MAIN OUTCOME MEASURES: Preoperative and postoperative 1-year Lysholm score of knee joint,operative time,postoperative draining quantity,postoperative 7-day visual analog score.RESULTS: Sixty-two patients were included and all of them entered the result analysis.The preoperative patients in two groups were comparable with each other and the differences of Lysholm score were not significant (t=0.127,P=0.899).The operative time was longer in synovectomy group than in control group,the differences were significant (t=9.547,P ＜ 0.001)and the postoperative draining quantity was more in synovectomy group.The postoperative visual analog score was bigger in synovectomy group than in control group and the differences were significant [the scores of synovectomy and control groups were respectively (4.6±1.1),(2.8±1.4),t=6.206,P ＜ 0.001].The differences of knee joint score in 1-year follow-up were not significant [the scores of synovectomy and control groups were respectively (77.6±11.9),(79.0± 10.3),t=0.562,P=0.576].CONCLUSION: Synovectomy can not increase the curative effect in the near future in the arthroscopic debridement of osteoarthritis. On the contrary,the operative time was longer,the operative wound was larger and postoperative reaction was more serious. It should not be used in the debridement generally.

Objective To determine the feasibility of human routine blood tests as a surrogate for CD4+ T cell count through studying the correlation of CD4+ T cell count with total lymphocyte count(TLC),hemoglobin(Hb),blood platelet(PLT),and white cell count(WBC)in HIV/AIDS patients.Methods 1 038 person-time blood tests among 778 HIV/AIDS patients were performed and Spearman correlation analysis was used.Predictive power and the cut-off for potential predictors of CD4+ T cell count were assessed through receiver operating characteristic(ROC)curves.Combination test was used to assess the capability of multipie indexes to serve as surrogate markers for CD4+ T cell counL Results Significant correlations with CD4+ T cell count were observed for TLC,Hb,PLT and WBC.The Spearman correlation coefficients were r=0.64,P=0.000;r=0.36,P=0.000;r=0.24,P=0,000;r=0.09,P=0.000,respectively.No correlation between TLC and CD4+ T cell count was found when,TLC was more than 2 000 × 106/L(r=0.12,P=0.15).The areas under ROC curve of TLC and Hb for predicting CD4+ T cell count were between 0.82 to 0.84,and 0.66 to 0.70,respectively.When CD4+ T cell count were less than 50,200,350 cells/μl respectively,the optional cut-off value was TLC＜1 100 × 106/L,1 200 × 106/L and 1 400 × 106/L.When the study combined TLC＜1 200 × 106/L and Hb＜120 g/L for prediction of CD4+ T cell count＜200/μl,the sensitivity was 45.3% and specificity was 82.8%.Conclusion There is no significant application value for combination of TLC＜1 200×106/L and Hb＜120 g/L as a surrogate for prediction of CD4+ T cell count＜200/μl.

Infected pancreatic necrosis is a fatal complication of severe acute pancreatitis ( SAP),while traditional laparotomy has many disadvantages,such as great trauma and many complications,in recent years,minimally invasive treatment has got great progress in clearing the necrotic tissue of pancreas,but its drainage effect is not optimal.From January 2010 to December 2011,19 patients with infected pancreatic necrosis complicated by SAP who were admitted to the Nanjing General Hospital of Nanjing Military Area were implemented computed tomography or ultrasound-guided Seldinger puncture.Along the puncture needle,a guide wire was inserted into the necrotic tissue,and then the sinus was expanded,in which a tube was placed for negative pressure irrigation and drainage.By continuous postoperative negative pressure irrigation and drainage,the necrotic tissue gradually dropped off and disappeared in 12 patients,and the other 7 patients were performed endoscopic necrotic tissue removal and drainage along the sinus.Systemic symptons of infection obviously improved in all of the 19 patients,and no organ dysfunction or complications occurred.Finally,16 patients were cured and 3 patients died.Continuous percutaneous negative pressure irrigation and drainage combined with the endoscopic necrotic tissue removal could become an important choice to treat the infected pancreatic necrosis.

Objective To investigate the management of retroperitoneal infected necrotic tissues in pelvic cavity in patients with severe acute pancreatitis (SAP).Methods The clinical data of 5 patients with SAP complicated with retroperitoneal infected necrotic tissue in the pelvic carvity who were admitted to the General Hospital of Nanjing Military Area from December 2009 to February 2012 were retrospectively analyzed.Systemic comprehensive treatement combined with local management were applied to all the patients.Results Systemic comprehensive treatment:all the 5 patients were treated by enteral nutrition,3 by mechanical ventilation and 3 by continuous blood purification.All the retroperitoneal infected necrotic tissues in the pelvic carvity were treated by computed tomography (CT)-guided percutaneous catheter drainage,and then the patients were converted to open surgery for further drainage.Four patients had complication of infected pancreatic necrosis bleeding,and they were treated by arterial embolism and (or) sandwich therapy.Local management:5 patients with retroperitoneal infected necrotic tissues received CT-guided percutaneous catheter drainage via buttocks.The average time of puncturation after illness was 38.4 days,and the average CT density of infected necrotic tissue was 24.4 Hu (20-28 Hu).Catheterization was successfully done in the open surgery for all the 5 patients,and the average time of abdominal drainage was 21 days.The body temperature and white blood cell count were decreased after puncturation.The average duration of intensive care unite stay,the average time of hospital stay and the average cost of hospitalization were (47 ± 20 )days,(88 ±34 )days and (186 342 ± 15 467 )yuan.All the patients were followed up till May 2012,no recurrece of the retroperitoneal infected necrotic tissue was detected.Conclusion CT-guided percutaneous catheter drainage via buttocks is effective for the treatment of retroperitoneal infected necrotic tissue in the pelvic cavity in SAP patients.