Tetanus consists of neonatal tetanus and non-neonatal tetanus. Non-neonatal tetanus remains a serious public health problem, although neonatal tetanus has been eliminated in China since 2012. Non-neonatal tetanus is a potential fatal disease. In the absence of medical intervention, the mortality rate of severe cases is almost 100%. Even with vigorous treatment, the mortality rate remains 30%-50% globally. These specifications aim to regulate non-neonatal tetanus diagnosis and treatment in China, in order to improve medical quality and safety. These specifications introduce the etiology, epidemiology, pathogenesis, clinical manifestations and laboratory tests, diagnosis, differential diagnosis, grading and treatment of non-neonatal tetanus.

Objective To investigate the correlation between plasma 25-hydroxyvitamin D(25-OHVD)levels and the CD4+/CD8+ ratio in elderly men in different states of glucose metabolism.Methods Clinical data of 206 elderly male patients at the geriatrics department of our hospital from April 2011 to August 2017 were collected and retrospectively analyzed.There were 85 patients with type 2 diabetes mellitus(T2DM),39 patients with impaired glucose tolerance(IGT) and 82 patients with normal glucose tolerance(NGT).Locally weighted regression and multivariate generalized linear regression models were used to analyze the correlation between plasma 25-OHVD levels and the CD4+/CD8+ ratio.Results There were significant differences in two-hour postprandial blood glucose and homeostasis model assessment of insulin resistance(HOMA-IR) between the NGT,IGT and T2DM groups (6.5 mmol/L,9.2 mmol/L vs.11.0 mmol/L,11.92 ± 10.57,16.46 ± 10.89 vs.32.67±7.39,respectively,P ＜0.01).Fasting plasma glucose and 2-hour postprandial insulin levels were higher in the IGT and T2DM groups than in the NGT group(5.1 mmol/L,6.3 mmol/L vs.4.9 mmol/L,440.5 nmol/L,367.8 nmol/L vs.255.4 nmol/L,P＜0.05).The haemoglobin A1c(HbA1c)level was higher in the T2DM group than in the NGT and IGT groups(7.1％ vs.5.5％ and 5.8％,P＜0.05).The 25-OHVD and CD4+ levels in the T2DM group were lower than those in the NGT and IGTgroups[11.6 μg/L vs.18.3 μg/L and 17.4 μg/L,(34.0±11.8)％ vs.(40.7±10.5)％ and (40.7±10.2)％,P＜0.01],but were not significantly different between the NGT and IGT groups(P ＞0.05).The CD4+/CD8+ ratios in the T2DM and IGT groups were not significantly different from each other(1.4 vs.1.6,P＞0.05),but were lower than that in the NGT group(2.7,P＜0.01).After adjusting for the influence of related confounders,CD4+/CD8+ increased by 0.4 on average with each standard deviation(7.62 μg/L)increase of 25-OHVD.Compared with 25-OHVD patients in the first quartile,CD4+/CD8+ in the second,third and fourth quartile increased by 0.7,0.9 and 1.1 respectively on average,showing a significant positive correlation and a significant linear trend in the level of 25-OHVD and the CD4+/CD8+ ratio(P＜0.01).Conclusions With the aggravation of glucose tolerance,plasma 25-OHVD levels and the CD4+/CD8+ ratio decrease by varying degrees in elderly men.The deficiency of plasma 25-OHVD may be an independent risk factor for a low CD4+ /CD8+ ratio.

Objective To discuss the dosimetric differences in the planning methods between physical and biological optimization during thehypofractionated radiotherapy for lung cancer.MethodsTen cases of non-small cell lung cancer (NSCLC) receiving radiotherapy were selected in this retrospective study.The VMAT plans for all patients were re-designed by physical functions (DV group),biological combined with physical functions (DV+EUD group and EUD+DV group) and biological functions (EUD group).The constrained functions were different,whereas the constrained conditions and optimized parameters were identical among four groups.The dosimetric differences among four optimization methods during thehypofractionated radiotherapy for lung cancer were evaluated through calculating and analyzing each dosimetry parameter.Results For the target area,the equivalent uniform dose was approximate between the EUD and EUD+DV groups.The EUD in these two groups was approximately 2.8％-3.6％ and 3.2％-3.7％ higher than those in the DV and DV+EUD groups.The average tumor control probability (TCP) in the EUD and EUD +DV groupswas considerably higher than those in the other two groups (both P＜0.05).The homogeneity index (HI) significantly differed (all P＜0.05),whereas the conformity index (CI) did not differ (all P＞0.05).For the organ at risk (OAR) area,the differences of EUD,V5,V1o,V20,V30 of normal lung tissues and the difference of dosimetry parameters in heart and spinal cord were not statistically significant (all P＞0.05).The mean dose of all lungs in the EUD and EUD+DV groupswas slightly lower than those in the other two groups.ConclusionsBiological optimization method has certain advantages in increasing EUD and TCP in the target area and decreasing the irradiation dose of normal lung tissues,which provides references for selecting the optimization method with biological functions in clinical practice.

Objective To investigate the relationship between nutritional risk status and implementation of nutrition therapy in mechanical ventilated (MV) chronic obstructive pulmonary disease (COPD) patients, so as to provide evidence for individualized nutrition therapy. Methods A prospective multicenter observational study was conducted. MV COPD patients admitted to Department of Intensive Care Units (ICU) of 10 County Hospitals in Zhejiang Province from January 2015 to January 2016 were enrolled, and according to nutrition risk screening 2002 (NRS2002) score, they were divided into nutritional high risk group (NRS2002 3-5) and nutritional extremely high risk group (NRS2002 6-7). Nutrition therapy situation and hospital mortality were compared between the two groups; multivariate Cox regression analysis was used to analyze the risk factors affecting the prognosis of patients with COPD under mechanical ventilation. Kaplan-Meier curve was used to analyze the prognosis at 30 days; receiver operating characteristic (ROC) curve was used to test the robustness of multivariable regression analysis. Results ① One hundred and six COPD patients with MV were analyzed; among them, 90 patients were in the nutritional high risk group, and 16 were in the nutritional extremely high risk group. There were no significant differences in age, gender and body mass index (BMI) between the two groups (all P > 0.05); the acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) score, NRS2002 score in patients of nutrition risk extremely high group were obviously higher than that in patients with nutrition high risk group (APACHEⅡ: 24.9±6.1 vs. 20.3±5.8, NRS2002 score: 6.3±0.5 vs. 4.2±0.8, both P < 0.05). ② Patients in both groups received early enteral nutrition (EN) therapy, the proportion of patients in nutritional extremely high risk group received early EN was lower than that of patients in the nutritional high risk group [12.5% (2/16) vs. 17.7% (16/90)], along with the prolongation of hospital stay, the proportions of patients beginning to receive the EN were gradually increased in the nutrition extremely high risk group and high risk group, after 2 days the EN increased significantly, and reached the highest value on day 6 after entering ICU [100.0% (16/16), 98.9% (89/90), respectively]; within 3 days after admission into ICU, the proportion of EN in nutrition extremely high risk group was obviously lower than that in nutrition high risk group, and from day 4, there was no statistical significant difference in proportion of EN between the two groups (all P > 0.05). The time to start parenteral nutrition (PN) treatment was relatively early admission to the ICU on day 1 and the proportion of this therapy was high in the two groups [56.2% (9/16), 27.7% (25/90), respectively], the PN proportion did not decrease with the length of hospitalization and the increase of EN. The proportion of patients in the nutrition extremely high risk group who started PN treatment was higher, which reached 56.2% admission to the ICU on day 1.③ With extension of hospital stay, the calories of EN were gradually increased in the nutritional high risk group, the highest calories in nutritional high risk groups was 4 318 (3 912, 4 812) kJ/d at day 7; while the highest calories in nutritional extremely high risk groups was 3 602 (2 167, 4 615) kJ/d at day 6 and a slight decreased at day 7; the difference of calories within the first week between the two groups had no significance (all P > 0.05). The calorific value of PN therapy remained at a constant level during hospitalization within 7 days, and after admission into ICU for 4-5 days, the target range of calories was achieved. ④ Kaplan-Meier survival curve analysis showed that the mortality at 30 days in the extremely high risk group was significantly higher than that in the high risk group [62.5% (10/16) vs. 11.1% (10/90), χ2 = 15.4, P < 0.01]. ⑤ Multiple cox-regression analysis showed that NRS2002 scoring was the independent risk factor affecting the mortality of patients in hospital [odds ratio (OR) = 2.08, 95% confidence interval (95%CI) = 1.39-3.12, P = 0.005]. ⑥ ROC curve analysis: according to ROC curve analysis of the effectiveness of multi-factor regression model, area under ROC curve (AUC) was 0.79, sensitivity was 70.00%, specificity was 74.42%, positive likelihood ratio was 2.74, negative likelihood ratio was 0.40, 95% confidence interval (95%CI) was 0.702-0.864, P = 0.001, and it showed that the regression model had a good prediction effect. Conclusions MV COPD patients have significant nutritional risk and all receive early EN therapy. The proportion of beginning to use PN treatment in patients with nutritional extremely high risk is relatively high. Initial nutritional status is the independent risk factor of poor prognosis in MV patients with COPD.

Tetanus consists of neonatal tetanus and non-neonatal tetanus. Although neonatal tetanus in China has been eliminated since 2012, non-neonatal tetanus remains a serious public health problem. Non-neonatal tetanus is a potential fatal disease, and the mortality rate of severe cases is almost 100% in the absence of medical intervention. Even with vigorous treatment, the mortality rate is still 30~50% globally. In order to standardize the diagnosis and treatment of non-neonatal tetanus in China, this specification is hereby formulated. This standard includes etiology, epidemiology, pathogenesis, clinical manifestations, laboratory tests, diagnosis, differential diagnosis, classification, grading and treatment of non-neonatal tetanus.

Objective To analyze the difference between indirect calorimetry (IC) and predicted energy estimation in patients with chronic obstructive pulmonary disease (COPD), and its possible factors affecting the difference, to provide reasonable energy supply basis for COPD patients. Methods A prospective cohort study was conducted. Twenty-six patients with COPD undergoing mechanical ventilation (MV) admitted to intensive care unit (ICU) of Hangzhou City Fuyang District First People's Hospital in Zhejiang Province from January to December in 2016 were enrolled. The energy values of patients were calculated by IC and predicted energy estimation, respectively. According to the degree of IC values deviating from the predicted energy estimation, the patients were divided into energy approaching group (IC values deviating from the empirical energy estimation ≤15%) and energy deviation group (IC values deviating from the empirical energy estimation > 15%). Bland-Altman diagram was drawn, and the consistency of the energy target values assessing by two methods was analyzed. The factors influencing the energy value deviation of the two measuring methods were screened by the multivariate Logistic regression and linear regression analysis. Results Twenty-six patients were enrolled in the final analysis. The energy target value of IC was significantly higher than that of predicted energy estimation (kJ: 7 079.3±1 213.4 vs. 6 527.0±949.8), and the difference between two values was statistically significant (P < 0.01). Bland-Altman heterogeneity analysis showed that the overall consistency of the energy values between the predicted energy estimation and IC was quite good. There were 14 patients in energy approaching group, and 12 in energy deviation group. There was no significant difference in gender, age, body mass index (BMI), type of COPD, or acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) score between the two groups. In energy deviation group, the IC value of patients was significantly higher than predicted energy estimation (kJ: 7 711.1±1 125.5 vs. 6 556.3±907.9, P < 0.01). However, in energy approaching group, there was no significant difference between the energy values of IC and predicted energy estimation (kJ: 6 539.6±1 037.6 vs. 6 501.9±1 016.7, P > 0.05). Multivariate Logistic regression analysis showed that APACHEⅡ score was an independent risk factor inducing the deviation of energy evaluation between IC and predicted energy estimation [odds ratio (OR) = 1.403, 95% confidence interval (95%CI) =1.019-1.932, P = 0.038]. Multivariate linear regression analysis showed that the APACHEⅡ score increased by 1, and the energy deviation increased by 2.0 kJ (β = 0.476, 95%CI = 0.004-0.956, P = 0.047). Conclusions For patients with COPD, there was a good correlation between predicted energy estimation and the resting energy expenditure measured by IC. APACHE Ⅱ score was an independent risk factor inducing the deviation of energy evaluation between IC and predicted energy estimation. It is suggested that the target value of energy should be determined by IC for patients with high APACHE Ⅱ score.

Objective To investigate the situation about cognitive performance of critical care staffs in nutrition therapy for mechanical ventilated chronic obstructive pulmonary disease (COPD) patients in county hospitals.Methods A chart of questionnaire about nutrition therapy was formulated according to the current guidelines.Critical care staffs from 12 hospitals of county-level of Hang Zhou city were enrolled.The role of staffs in management of nutritional therapy for patients was observed to assess their cognitive performance and influence factors were analyzed according logistic analysis.Results A total of 137 staffs were enrolled.Almost all of the staffs thought that nutrition therapy for ventilated COPD patients was very important.About 90％ of the staffs never heard about the use of NRS2002 (nutritional risk screening 2002)to evaluation COPD patients but the rate of using it was higher among senior staffs (OR =1.08,95％ CI:1.01-1.16,P =0.04).Most of staffs assess the nutritional status of patients according to biomarkers and other methods.However,doctors might assess nutritional status more often according to their experience.The majority of staffs did choose enteral nutrition for patients especially seen in doctors and senior staffs (OR =3.10 and1.13,95％ CI:1.27-7.55 and 1.03-1.23,both P =0.01).For those without malnutrition,senior staffs did not choose parenteral nutrition (OR =0.14,95％ CI:0.04-0.57,P =0.01).Besides,senior staffs did not continue the enteral nutrition in patients with unstable haemodynamics (OR =1.10,95％ CI:1.03-1.16,P =0.002).Most of staffs considered that the head piece of bed was raised up to 30-45 degree and gastric residual volume monitoring was very important.However,compared with nurses,the cognitive performance of doctors was poorer (OR =0.39,95％ CI:0.18-0.83,P =0.01).Most of staffs thought that the nutrition therapy implementation checklist was necessary but it was used in only 20％ institutions.The understanding and demand for nutritional knowledge was more urgent among doctors than nurses (OR =3.13 and 5.33,95％ CI:1.45-6.75 and 1.13-25.02,P =0.004 and 0.03).Conclusions Nutrition therapy was important for ventilated COPD patients,but the staffs were not very familiar with nutritional knowledge.The cognitive performance of medical staffs was influenced by their profession and experience of practice.

Objective To investigate the influence of the purging fire and removing toxin method on chemokines and adhesion factors related to vascular endothelialitis injury induced by toxin of trimeresurus stejnegeri bite.Methods ① Animal experiment:50 healthy New Zealand white rabbits were chosen.According to random numbers generated by statistical software,they were divided into normal control group,model group,low,middle and high dose Sheshang capsule groups,10 in each group.Trimeresurus stejnegeri bite model was replicated by injecting 0.75 mL/kg snake venom into subcutaneous tissues of rabbits' right hind legs.And the same volume of normal saline was injected into the rabbit in the normal control group.After the model was established for 6 hours,the rabbits in low,middle and high dose Sheshang capsule groups received 174,348 and 522 mg· kg-1 · d-1 of Sheshang capsule solution respectively (the content of capsules was dissolved in normal saline to make liquid with 17.4,34.8 and 52.2 g/L Sheshang solution respectively,so the volume of gavage of each group was 10 mL· kg-1 · d-1);in the model and normal control groups,the same amount of normal saline was given by gavage,once daily for consecutive one week.24 hours after the last gavage,the blood of the rabbits was collected through an auricular border vein and the serum was separated by centrifuge ready for use.Meanwhile,the whole abdominal aorta segment of the rabbit was harvested and kept them in liquid nitrogen ready for use.② Cell experiment:human umbilical vascular endothelial cell (HUVEC) was cultured with MEM for 24 hours.The solution was replaced and according to the random number generated by statistical software,the cells were divided into blank control group,model group and low,middle,high dose Sheshang capsule medicinal serum groups,10 wells in each group.Trimeresurus stejnegeri toxin cell model was reproduced by addition of 5 mg/L snake venom into the cell culture medium.After 6-hour culture,the cells of model group and blank control group received 10％ normal rabbit serum,and the cells of low,middle and high dose Sheshang medicinal serum capsule groups received serum containing 5％,10％ and 15％ drug,respectively.After culture for 72 hours,the cells were collected and the total RNA was extracted.The real-time fluorescent quantitative polymerase chain reaction (qPCR) was used to detect the levels of mRNA of interleukin-8 (IL-8),monocyte chemoattractant protein-1 (MCP-1),intercellular adhesion molecule-1 (ICAM-1) and vascular endothelial cell adhesion molecule-1 (VCAM-1) in the vascular endothelial cells of rabbit aorta abdominalis and human umbilical vein,and the content of serum E-select element (CD62E) was measured by enzyme linked immunosorbent assay (ELISA).Results In model group,the expression levels of mRNA in IL-8,MCP-1,ICAM-1,VCAM-1 and the content of CD62E were all increased significantly in the endothelial cells of rabbit aorta abdominalis and HUVEC compared with those in control group [when the mRNA expression levels of IL-8,MCP-1,ICAM-1 and VCAM-1 in normal and blank control group were all being 1,the mRNA expression levels (2-△ △Ct) of the above mentioned inflammatory factors and adhesion molecule in animal model group were 3.96 ± 0.39,3.07 ± 0.27,3.71 ± 0.26,3.94 ± 0.26,and the mRNA expression levels (2-△ △Ct) of the above mentioned inflammatory factors and adhesion molecule in HUVEC model group were 3.53±0.70,2.24±0.48,3.13±0.44,2.80±0.13,respectively,all P ＜ 0.01].The content of CD62E in serum was increased significantly in model group compared with that in normal control group (μg/L:1.31 ± 0.22 vs.0.82 ± 0.13,P ＜ 0.01),the mRNA expression levels of IL-8,MCP-1,ICAM-1 and VCAM-1 were decreased significantly in low,middle,high dose Sheshang capsule groups compared with those in model group in endothelial cells of aorta abdominalis of rabbits and HUVEC [abdominal aorta:IL-8 mRNA (2-△ △Ct) were 1.13 ± 0.19,1.26 ± 0.16,1.27 ± 0.17 vs.3.96 ± 0.39,MCP-1 mRNA (2-△ △ Ct) were 1.79 ± 0.24,2.22 ± 0.38,1.76±0.19 vs.3.07±0.27,ICAM-1 mRNA (2 △△Ct) were 2.05±0.11,1.68±0.09,2.37±0.48 vs.3.71±0.26,VCAM-1 mRNA (2-△△Ct) were 1.59±0.08,1.40±0.11,1.84±0.11 vs.3.94±0.26;HUVEC:IL-8 mRNA (2-△△Ct) were 2.33±0.59,2.82±0.82,2.51±0.77 vs.3.53±0.70,MCP-1 mRNA (2-△△Ct) were 1.59±0.35,1.48±0.36,1.54±0.29 vs.2.24±0.48,ICAM-1 mRNA (2-△△Ct) were 1.46±0.38,1.77±0.65,1.73±0.50 vs.3.13±0.44,VCAM-1 mRNA (2-△△Ct) were 2.49±0.24,2.18±0.19,2.45±0.24 vs.2.80±0.13,all P ＜ 0.05].The contents of CD62E were decreased significantly in middle,high dose Sheshang capsule groups compared with the content in model group (μg/L:1.01 ±0.14,1.04±0.13 vs.1.31 ±0.22,all P ＜ 0.01),but there were no statistical significant differences among the three drug group (all P ＞ 0.05).Conclusion The therapy of purging fire and removing toxin can treat vascular endothelial injury by inhibiting the inflammatory response induced by Trimeresurus stejnegeri bites.

Objective The aim of this study was to find out the carrying rate and the type of mutation of children deafness gene and discuss the significance of combined screening of deafness gene and hearing screening.Methods From October 2015 to December 2016,a total of 505 children from primary screening institutions were done with AABR hearing re-screening and deafness gene through blood filter paper by heel for gene sequencing at the hearing screening clinic of Hefei Maternal and Child Health Hospital.The 9 mutation sites of deafness genes included GJB2 (235delC,299delAT,176del16,35delG),GJB3 (538C＞T),SLC26A4 (IVS7-2A＞G,2168A＞G) and mitochondrial 12SrRNA (1555A＞G,1494C＞T).Results There were 69 children with deafness susceptibility genes in 505 cases and its overall carrying rate was 13.7％.There were 56 cases (81.16％)with GJB2 gene mutations,10 cases (14.49％) with SLC26A4 gene mutations,and 3 patients (4.35％) with mitochondrial 12SrRNA gene mutations.GJB3 gene mutations wer not detected.There were 376 who failed AABR rescreening out of 505.The total failure rate for AABR rescreening was 74.46％.Thirty-seven cases were examined with ABR out of 69 cases with deafness gene abnormal.32 cases (86.49％) had different degrees of hearing impairment.Conclusion GJB2 gene mutation was the highest carrying rate of deafness genes in this region,followed by SLC26A4 gene,less mitochondrial 12SrRNA gene mutations while GJB3 gene mutations was not detected.Hereditary deafness gene screening was a valid supplement for physical screening,the combination of both methods was helpful for early detection and intervention of deaf children.

Objective To evaluate the efficacy of closed-loop coadministration of propofol and remifentanil guided by Narcotrend index (NI) in laparoscopic cholecystectomy.Methods Sixty American Society of Anesthesiologists physical status Ⅰ or Ⅱ patients of both sexes,aged 20-64 yr,with body mass index of 18-25 kg/m2,scheduled for elective laparoscopic cholecystectomy,were randomized into 2 groups (n =30 each):program regulation group (group P) and artificial regulation group (group A).After the initial target effect-site concentration of propofol was selected,the target effect-site concentration of remifentanil was determined according to the formula.In group A,the target effect-site concentrations of propofol (2-4 μg/ml) and remifentanil (3-4 ng/ml) were adjusted artificially according to anesthesiologists' experience every 5 min to maintain NI value at 26-46.Induction time,anesthesia induction and mean maintenance doses and the initial,highest and lowest target concentrations of propofol and remifentanil,mean NI value,percentage of time with NI between 26 and 46,emergence time,and development of fluctuation in heart rate or mean arterial pressure ＞ 20％ of the baseline value and intraoperative awareness were recorded.Results No intraoperative awareness was found in the two groups.Compared with group A,the induction time was significantly shortened,the induction dose and initial target concentration of remifentanil were increased,the mean maintenance dose and lowest target concentration of propofol and remifentanil were decreased,the percentage of time with NI between 26 and 46 was increased,and the emergence time was shortened (P＜0.05 or 0.01),and no significant change was found in the induction dose and initial target concentration of propofol,the highest target concentrations of propofol and remifentanil,mean NI value,or incidence of fluctuation in heart rate or mean arterial pressure ＞ 20％ of the baseline value in group P (P＞ 0.05).Conclusion For laparoscopic cholecystectomy,NI-guided closed-loop coadministration of propofol and remifentanil produces safe and effective anesthesia,and the efficacy of precise administration is superior to that of artificially regulated target-controlled infusion.