The global coronavirus disease 2019 epidemic is still in a pandemic state. Aging population with underlying diseases is prone to become severe, and have a higher mortality. The treatment capacity of the critical care department directly determines the treatment success rate of critical illness. At present, there is still a certain gap between domestic and foreign countries in intensive care unit (ICU), which is not only in the allocation of medical staff, but also in the beds and settings. The current medical model cannot fully meet the needs of development. The experience and lessons of many major public health emergencies suggested that " dual track of peace and war" approach in discipline construction of critical care is the best medical model. Following the concept of "combination of peace and war", strengthening the discipline construction of critical care department in municipal and district designated hospitals, allocating reasonable standard ICU, step-down ICU and combat readiness ICU, establishing rapid response team, and strengthening regular training and scientific management may be the key measures to deal with the epidemic.

Humans ; COVID-19 ; Consensus ; SARS-CoV-2 ; China

To investigate the value of renal resistive index (RRI) in early predictor and discriminator of severe acute pancreatitis (SAP)-related acute kidney injury (AKI). Methods A retrospective observational study was conducted. SAP patients complicated with AKI (within 1 week of onset) and admitted to intensive care unit (ICU) of Ruijin Hospital Shanghai Jiaotong University School of Medicine from January 2016 to June 2019 were enrolled. The RRI within 24 hours admission was measured. Clinical data such as acute physiology and chronic health evaluation Ⅱ(APACHEⅡ), heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), intra-abdominal pressure (IAP), arterial blood lactate (Lac), oxygenation index (PaO2/FiO2), base excess (BE), serum creatinine (SCr), urine output, norepinephrine (NE) and RRI were collected. Within 24 hours and 7 days after ICU admission, patients were grouped according to AKI classification criteria of Kidney Disease: Improving Global Outcomes (KDIGO), and the differences of relevant parameters were statistically analyzed. Influence factors of AKI grading were screened by Logistic regression analysis. Pearson correlation analysis was used to analyze the correlation between RRI and other parameters. The predictive value of RRI for AKI classification was analyzed by receiver operating characteristic (ROC) curve. Results A total 57 patients were included, with an average age of (54.6±13.5) years old, and APACHEⅡscore of 21.8±5.6. Within 24 hours, the number of patients suffered from stage 1-3 AKI were 19 (33.3%), 18 (31.6%) and 20 (35.1%), respectively. On day 7, the number of patients suffered from stage 0-3 AKI were 21 (36.9%), 8 (14.0%), 9 (15.8%) and 19 (33.3%), respectively. The higher APACHEⅡ score, CVP, IAP, Lac, NE dosage and RRI were found in the group with higher AKI grades, especially in the group with stage 3 AKI on day 7. RRI of patients with stage 3 AKI was significantly higher than that of patients with stage 1 and 2 AKI within 24 hours (0.74±0.04 vs. 0.65±0.05, 0.68±0.05, both P < 0.05). Similarly, RRI of patients with stage 2 and 3 AKI were significantly higher than that of patients with stage 0 and 1 AKI on day 7 (0.70±0.04, 0.74±0.04 vs. 0.65±0.05, 0.66±0.05, all P < 0.05). Multivariate Logistic regression analysis showed that RRI was an independent factor of AKI classification [odds ratio (OR) = 3.15, 95% confidence interval (95%CI) = 1.09-9.04, P < 0.05], and IAP and CVP also had significant impacts on AKI grading [OR value was 2.11 (95%CI = 1.16-4.22), 3.78 (95%CI = 1.21-12.90), both P < 0.05]. ROC curve analysis showed that the area under curve (AUC) of RRI for predicting AKI ≥2 stage was 0.87 (P < 0.05); the cut-off ﹥ 0.71, sensitivity was 71% and specificity was 83%. The correlation analysis showed that RRI was positively correlated to a certain extent with IAP and lactic acid (r1 = 0.49, r2 = 0.39, both P < 0.05). Conclusion High RRI on ICU admission was a significant predictor for development of severe AKI during the first week, and RRI can help predict the tendency of AKI in SAP.

Objective To investigate the role and mechanism of ulinastatin on the hyper-permeability of vascular endothelial cell induced by matrix metalloproteinase-9 (MMP-9). Methods Human umbilical vein endothelial cells (HUVEC) were cultured in vitro to establish a complete monolayer vascular endothelial cell model. The monolayer vascular endothelial cells were randomly divided into three groups: blank control group [phosphate buffered saline (PBS) added], MMP-9 model group (1 mg/L MMP-9 added) and ulinastatin group (1 mg/L MMP-9 and 1 000 kU/L ulinastatin added). The permeability of monolayer vascular endothelial cells was measured by fluorescein isothiocyanate (FITC)-labeled dextran (FD40) leaking method; the soluble vascular endothelial cells calcium dependent adherin (VE-cadherin) concentration in culture solution was determined by enzyme linked immunosorbent assay (ELISA);the protein expression levels of zonular occlusion protein-1 or tight junction (ZO-1), VE-cadherin, claudin-5 were detected by Western Blot and immunofluorescence methods. Results Compared with the blank control group, the permeability of vascular endothelial cells in MMP-9 model group was significantly increased [(cm2/h, ×10-2):3.35±0.56 vs. 0.94±0.06, P < 0.05]; the concentrations of soluble VE-cadherin in the Transwell upper and lower chambers were increased significantly [upper chamber (μg/L): 5.02±0.40 vs. 3.83±0.42, lower chamber (μg/L):4.92±1.05 vs. 3.24±1.24, both P < 0.05]; the protein expression levels of ZO-1, VE-cadherin and claudin-5 were significantly decreased [ZO-1/β-actin: 0.152±0.067 vs. 0.262±0.090, VE-cadherin/β-actin: 0.137±0.048 vs. 0.246±0.094, claudin-5/β-actin: 0.148±0.062 vs. 0.336±0.119, all P < 0.05], and obvious rupture sites appeared in their fluorescent patterns, and fluorescent particles were significantly reduced; compared with MMP-9 model group, the permeability of vascular endothelial cells in ulinastatin group was significantly decreased [(cm2/h, ×10-2): 1.80±0.34 vs. 3.35±0.56, P < 0.05]; the soluble VE-cadherin concentrations were significantly reduced in upper and lower chambers than those in the MMP-9 model group [upper chamber (μg/L): 4.41±0.37 vs. 5.02±0.40, lower chamber (μg/L):3.85±1.04 vs. 4.92±1.05, both P < 0.05], the expressions of endothelial junction protein were significantly increased in ulinastatin group (ZO-1/β-actin: 0.229±0.097 vs. 0.152±0.067, VE-cadherin/β-actin: 0.236±0.089 vs. 0.137±0.048, claudin-5/β-actin: 0.262±0.101 vs. 0.148±0.062, all P < 0.05], and the continuity of their fluorescent patterns and fluorescent particles were both increased. Conclusion The in vitro experiment showed that the hyper-permeability of vascular endothelial cells induced by MMP-9 can be attenuated by ulinastatin through decreasing the destruction of VE-cadherin and maintaining the protein expression levels of ZO-1, VE-cadherin and claudin-5 in vascular endothelial cells.

Objective To investigate the CT features of renal oncocytoma(RO),and to analyze the causes of misdiagnosis.Methods CT and clinical data of 1 2 patients with RO confirmed by surgery and pathology were analyzed retrospectively,the CT features and the causes of misdiagnosis before operation were analyzed and summarized.Results According to CT features before operation,among the 1 2 cases of RO,9 were misdiagnosed as renal carcinoma,3 were considered as benign occupying lesions.There were 6 cases located in the left kidney and 6 in the right kidney.Seven cases showed round mass and 5 showed irregular mass.Plain CT showed homogeneous masses in 6 cases and heterogeneous masses in 6 cases.Enhanced CT showed masses with homogeneous enhancement in 2 cases and masses with progressive enhancement in 10 cases.The attenuation value of parenchymal enhancement ranged from 41 to 143 HU (mean 90.17 HU).Seven cases had central scar syndrome,of which 1 case had calcification in the scar.One case showed segmental enhancement inversion,8 showed conical interface and 5 had holding ball signs.Conclusion The CT features of RO is central scar syndrome, segmental enhancement inversion,conical interface and holding ball sign,etc,but the definitive diagnosis still rely on pathology.

Critical ultrasonography(CUS) is different from the traditional diagnostic ultrasound,the examiner and interpreter of the image are critical care medicine physicians.The core content of CUS is to evaluate the pathophysiological changes of organs and systems and etiology changes.With the idea of critical care medicine as the soul,it can integrate the above information and clinical information,bedside real-time diagnosis and titration treatment,and evaluate the therapeutic effect so as to improve the outcome.CUS is a traditional technique which is applied as a new application method.The consensus of experts on critical ultrasonography in China released in 2016 put forward consensus suggestions on the concept,implementation and application of CUS.It should be further emphasized that the accurate and objective assessment and implementation of CUS requires the standardization of ultrasound image acquisition and the need to establish a CUS procedure.At the same time,the standardized training for CUS accepted by critical care medicine physicians requires the application of technical specifications,and the establishment of technical specifications is the basis for the quality control and continuous improvement of CUS.Chinese Critical Ultrasound Study Group and Critical Hemodynamic Therapy Collabration Group,based on the rich experience of clinical practice in critical care and research,combined with the essence of CUS,to learn the traditional ultrasonic essence,established the clinical application technical specifications of CUS,including in five parts:basic view and relevant indicators to obtain in CUS;basic norms for viscera organ assessment and special assessment;standardized processes and systematic inspection programs;examples of CUS applications;CUS training and the application of qualification certification.The establishment of applied technology standard is helpful for standardized training and clinical correct implementation.It is helpful for clinical evaluation and correct guidance treatment,and is also helpful for quality control and continuous improvement of CUS application.

Objective To evaluate the value of 128-slice CT on locating the obstruction site of the upper airway in obstructive sleep apnea hypopnea syndrome (OSAHS)patients by three-dimensional reconstruction technology.Methods There were 52 patients with OSAHS diagnosed by the PSG and 32 cases of healthy volunteers in our hospital.All objects were performed 128-slice CT scan of the upper airway during awake state,and those patients’upper airways were scaned on Muller test.The airway volume of the ret-ropalatal region,retroglottal region and epiglottal region,and the total length of upper airway were measured,and statistical analysis of the each index was obtained.Results During awake state,compared with the control group,the length of upper airway in OSAHS patients increased significantly(P <0.001).Compared with the awake state,OSAHS patients’airway volume of the retropalatal region, retroglottal region and the total airway volume on the Muller test were reduced significantly(P <0.001).OSAHS patients’upper air-way length was correlated negatively to the average MSaO 2 (r=-0.33,P <0.05).Conclusion The three-dimensional reconstruc-tion of upper airway on 128-slice CT can evaluate the position and degree of the obstruction site in OSAHS patients’upper airway better,which has important significance to guide clinical treatment.

Objective To discuss the clinical diagnostic and guiding treatment value of changed positions of hyoid bonein the upper airway of patients with obstructive sleep apnea hypopnea syndrome. Methods 128-slice computed tomography was performed for 52 patients with severe OSAHS and 32normal healthy people to measure thehyoid bone in the upper airway in sober state and Muller maneuver. The correlationsbetweenthese indexes were analyzed under linear relation. Results (1)In comparison of the Muller maneuver with sober state , chinnodules and palatal plane to the hyoid in the OSAHS group were statistically higher than the healthy controlgroup (P < 0.001). (2)The distance of hyoid to chinnodules in the OSAHS group was significantlylonger and greater than that of the healthy control group (P < 0.001).(3)The distance of palatal plane to the hyoid was positively correlated with AHI , while thedistances of palatal plane andchinnodules to the hyoidwere both negatively correlated with MSaO2. Conclusion The changes ofhyoid positionare indicative for the clinical diagnosis and is helpful for the guidance of clinical treatment of OSAHS.

OBJECTIVE: To discuss the soft palate, hard palate and mandibule for the pathogenesis and clinical treatment of patients who have obstructive sleep apnea hypopnea syndrome. METHOD: There were 52 patients with OSAHS diagnosed by the PSG and 32 cases of normal healthy volunteers in our hospital. All objects were given 128 slice spiral CT scan of the upper airway. We measured the related indexes of the soft palate, hard palate and mandible, then analysed statistical differences between them and did Pearson correlation analysis with apnea hypoventilation index (AHI), average blood oxygen saturation (MSaO2) in PSG. RESULT: Compared with the control group, the soft palate length [(37.93 ± 5.20)mm VS (33.52 ± 4.25)mm] and the distance between mandible with cervical vertebra [(75.00 ± 7.10)mm VS (69.93 ± 5.58)mm] increased significantly, but the distance of trailing edge of hard palate to inferior margin of slope significantly reduced [(42.57 ± 4.52)mm VS (45.80 ± 2.94)mm, P < 0.01] in patients with OSAHS. Each measurement associated with AHI and MSaO2 had no significant correlation (P > 0.05). CONCLUSION The soft palate, hard palate and mandibular are some of the important risk factors of OSAHS, and they also have reference value for the choice of clinical treatment operation. Preoperative CT examination can offer help in the treatment of OSAHS.
Case-Control Studies ; Humans ; Mandible ; anatomy & histology ; Oximetry ; Palate, Hard ; anatomy & histology ; Palate, Soft ; anatomy & histology ; Sleep Apnea, Obstructive ; diagnosis ; Tomography, Spiral Computed

Objective To investigate the effects of rhubarb on the expression of glucocorticoids receptor (GR)and peripheral blood lymphocytes in burning-induced septic rats. Methods Sixty-six male healthy Sprague-Dawley(SD)rats were randomly divided into sham operated control group(n=18),sepsis model group(n=24) and rhubarb treatment group(n=24),each group was further randomly divided into 12,24 and 72 hours subgroups according to different time points. The model of scald sepsis was replicated by scald injury induced by boiling water at the rat back accounting for 30% total body surface area(Ⅲ grade of scald),and administration of endotoxin (5 mg/kg)into the peritoneal cavity 12 hours after scald injury. After the successful establishment of septic models, the rats in the rhubarb treatment group were immediately infused with 50 mg/kg rhubarb powder dissolved in 1 mL saline through a gastric tube,while the rats in sham operated control group and sepsis model group received saline by the same way as a substitute for rhubarb. The the binding capacity of GR of peripheral blood leucocyte and binding activity of GR of hepatocyte were analyzed by radiation ligands binding assay. The CD4+,CD8+as well as CD4+/CD8+ ratio in peripheral blood lymphocytes were detected by flow cytometer. Results The binding capacity of GR of peripheral blood leucocyte and binding activity of GR of hepatocyte were significantly decreased in a time-dependent manner in sepsis model group compared to those of the sham operated control group,while in the rhubarb treatment group they were increased in a time-dependent manner after interference of rhubarb, and they were higher than those in the model group at the same time points〔leukocyte GR binding capacity (locus/cell)at 12,24,72 hours :1 515.38±300.44,1 859.63±258.26,1 890.50±307.88 vs. 1 122.63±225.39, 1 008.88±150.41,724.38±91.19;hepatocyte GR binding capacity(fmol/mg):210.19±26.26,258.01±20.98, 283.38±38.21 vs. 153.11±30.07, 129.83±26.89, 94.08±14.30, all P<0.01〕. Compared with the sham operated control group,the CD4+ and CD8+ were decreased in various degrees at 12 hours and 24 hours in the septic group, at 24 hours the differences being statistically significant (P<0.01 and P<0.05). CD4+/CD8+ratios were decreased significantly at all time points,the differences were statistically significant at 24 hours and 72 hours(both P<0.01). The CD4+ T cell and CD4+/CD8+ ratio at all the time points were increased at various degrees in the rhubarb treatment group,and the differences from those in the sepsis model group at 24 hours and 72 hours were statistically significant (1.58±0.69, 1.56±0.49 vs. 1.02±0.41, 1.01±1.68, both P<0.01). Conclusion Rhubarb can modulate the binding capacity of GR of peripheral blood leucocyte and the binding activity of GR of hepatocyte,and via its influence on the number of peripheral leucocytes,the immune dysfunction in the sepsis processes is improved.