The silent lung that occurs during the perioperative period is characterized by rapid onset,rapid progression,and high mortality.This article reports a case of a 62-year-old patient with a left lower lung nodule who underwent lower lung segmentectomy under thoracoscopy and was assisted with tracheal intubation using rocuronium.21 minutes after the first administration,the patient presented with increased airway pressure,difficult ventilation,a"steel lung"feel,and symptoms similar to silent lung.Subsequently,80 mg of methylprednisolone and 50 μg of epinephrine(in divided doses)were injected intravenously,but no relief was observed,and the blood oxygen saturation decreased to 38％.In this case,after giving another 1 mg of epinephrine,the airway pressure gradually decreased to 33 cmH2O,and the blood oxygen saturation gradually increased.Considering that airway spasm might be caused by multiple intubation stimulations,additional rocuronium bromide was added to allow for reintubation.However,the patient again experienced increased airway pressure and difficulty in ventilation prior to intubation.The clinical pharmacist conducted a correlation evaluation of this adverse event and considered the result as possible.The mechanism,rescue and prevention of silent lung induced by rocuronium was also discussed in the case report.A thorough anesthesia assessment should be conducted prior to surgery,and an appropriate anesthesia induction plan should be formulated.Once an adverse event occurs,it should be promptly identified and treated.

Circadian Clocks/genetics* ; Reactive Oxygen Species ; Methionine ; Gastrointestinal Microbiome ; Gastrointestinal Tract ; Racemethionine ; Gene Expression

Objective:To explore the value of detecting plasma donor-derived free DNA (dd-cfDNA) fraction in distinguishing antibody mediated-rejection (ABMR) and T cell-mediated rejection (TCMR) of renal allografts.Methods:Patients with acute rejection confirmed by allograft biopsy in the First Affiliated Hospital of Medical College of Zhejiang University from December 1, 2017 to July 18, 2019 were retrospectively included. Based on pathological classification of Banff renal allograft rejection in 2017, the patients were divided into ABMR group and TCMR group, and the latter was subdivided into TCMR Ⅰ subgroup and TCMR Ⅱ subgroup. The second generation sequencing and target region capture were used to detect candidates' peripheral blood dd-cfDNA. The demographic and clinicopathological data of the two groups were compared. The receiver operating characteristic curve (ROC) was used to evaluate the differential value of plasma dd-cfDNA and serum creatinine levels in two kinds of acute renal allograft rejection.Results:A total of 60 patients with acute rejection of renal transplantation were enrolled in this study, including 42 patients in TCMR group and 18 patients in ABMR group. The plasma dd-cfDNA percentage (%) in the ABMR group was significantly higher than that in the TCMR group [2.33(1.19, 4.30)% vs 0.98(0.50, 1.82)%, P=0.001]. The absolute value of dd-cfDNA in ABMR group was obviously higher than that in TCMR group [0.94(0.60, 2.27) ng/ml vs 0.43(0.20, 0.96) ng/ml, P=0.003]. ROC analysis to discriminate TCMR from ABMR showed that, the area under the curve ( AUC) of dd-cfDNA% was 0.76(95% CI 0.64-0.88), when the threshold was 1.11%, the sensitivity and specificity were 88.89% and 59.52%, respectively; the AUC of absolute value of dd-cfDNA was 0.74(95% CI 0.61-0.86), when the threshold was 0.53 ng/ml, the sensitivity was 88.89% and the specificity was 54.76%. TCMR subgroups were further analyzed, there was no significant difference between TCMR subgroups on the absolute value and percentage of dd-cfDNA (both P>0.05); dd-cfDNA% in ABMR group was apparently higher than that in TCMRⅠ subgroups ( P=0.008) and TCMRⅡsubgroup ( P=0.030). The absolute value of dd-cfDNA in ABMR group was significantly higher than that in TCMRⅠsubgroups ( P=0.003). Conclusion:Plasma dd-cfDNA level may help to distinguish between ABMR and TCMR rejection.

Objective:To analyze the weight score and clinical application of 2019 European League Against Rheumatism/American College of Rheumatology (EULAR/ACR) systemic lupus erythematosus (SLE) classification criteria in lupus nephritis patients.Methods:Lupus nephritis patients with renal biopsy results who were admitted in the First Affiliated Hospital of Zhejiang University College of Medicine between January 2014 and December 2018 were enrolled retrospectively. According to whether these patients were treated with glucocorticoids and/or immunosuppressants at the time of renal biopsy, they were divided into untreated group and post-treatment group. The weight scores were compared between the two groups, and the relationship between each weight score and remission after treatment was analyzed. Taking no remission as the end event, Cox regression analysis was used to analyze the influence of each weighted integral on the end event.Results:A total of 153 patients were enrolled, including 131 (85.6%) females. These were 70 (45.8%) patients in the untreated group and 83 (54.2%) patients in the post-treatment group. The patients in the untreated group had higher scores of fever (>38.3℃), blood system involvement, low complement and positive specific antibodies than those in post-treated group (all P<0.05). In a median follow-up of 34 (6-50) months, 99 patients (64.7%) achieved complete remission, 38 patients (24.8%) achieved partial remission and 16 patients (10.5%) had no remission. With no remission as the endpoint event, univariate Cox regression analysis showed that proliferative lupus nephritis (renal score of 10 points vs 8 points) and neuropsychiatric involvement were the risk factors (both P<0.05), while multivariate Cox regression analysis showed that neuropsychiatric involvement ( HR=4.758, 95% CI 1.324-17.101, P=0.017) was an independent risk factor. Conclusion:The weight scores of 2019 EULAR/ACR SLE classification diagnostic criteria have certain predictive value for remission of patients with lupus nephritis.

BK polyomavirus-associated nephropathy (BKPyVAN) is a common cause of allograft failure. However, differentiation between BKPyVAN and type I T cell-mediated rejection (TCMR) is challenging when simian virus 40 (SV40) staining is negative, because of the similarities in histopathology. This study investigated whether donor-derived cell-free DNA (ddcfDNA) can be used to differentiate BKPyVAN. Target region capture sequencing was applied to detect the ddcfDNAs of 12 recipients with stable graft function, 22 with type I TCMR, 21 with proven BKPyVAN, and 5 with possible PyVAN. We found that urinary ddcfDNA levels were upregulated in recipients with graft injury, whereas plasma ddcfDNA levels were comparable for all groups. The median urinary concentrations and fractions of ddcfDNA in proven BKPyVAN recipients were significantly higher than those in type I TCMR recipients (10.4 vs. 6.1 ng/mL,

Objective To compare the clinical outcomes of low-dose rabbit antithymocyte globulin (rATG ) vs basiliximab as induction therapy in recipients of ABO-incompatible kidney transplantation (ABOi-KT) .Methods Retrospective analysis was conducted for e the clinical data of 40 ABOi-KT recipients between March 2017 and March 2019 .17 recipients of them received induction therapy with basiliximab (basiliximab group) while another 23 recipients received low-dose rATG (rATG group ,rATG 25 mg/d × 3 d) .During a median follow-up period of 282 days , the data of serum creatinine and eGFR at 1 week and 1 month ,graft survival rate and complication rate of two groups were compared .Results No significant difference existed in age ,gender ,dialytic modality/ duration , blood groups of recipients , HLA mis-match , blood group antibody titers , dose of rituximab ,blood groups of donors or donor age ( P > 0 .05 ) . The times of double filtration plasmapheresis in Basiliximab group were more (P< 0 .05) .No significant difference existed in serum creatinine and eGFR at 1 week or 1 month ( P > 0 .05 ) . No significant difference existed in graft survival rate . No significant difference existed in rate of acute rejection ,parvovirus B19 infection , urinary tract infection or hematoma .Conclusions Low-dose of rATG is as effective as basiliximab for ABOi-KT recipients .And rATG does not increase the rate of infection .

A multi-style collective lesson preparation model was designed and implemented after analyzing the current status of teaching faculty in the teaching and research section of clinical pharmacology,which includes hierarchical collective lesson preparation and exploration of WeChat collective lesson preparation; enrichment of the lesson-preparation content, bringing teaching skills, teaching strategies, courseware design and motivation of students' interest into collective lesson preparation. After carrying out this model, the construction of teaching faculty has been strengthened and the improvement of young teachers has been accelerated. At the same time, the procedures of collective lesson preparation should be made clearer and teachers' performance evaluation should include the assessment result of implementing this model so as to standardize the multi-style collective lesson preparation model.

Objective To explore the effect of total parathyroidectomy (PTX) with forearm autograft on the anemia and cardiac function in uremic patients with secondary hyperparathyroidism (SHPT).Methods The clinical data of 130 uremic patients who received PTX with forearm autograft in the First Affiliated Hospital of Zhejiang University from October 2010 to December 2015 were retrospectively analyzed.The changes of anemia and echocardiogram before and after operation were compared.According to the presence of left ventricular hypertrophy (LVH) before operation,the patients were divided into LVH group and non-LVH group.Echocardiographic indexes before and one year after operation of the two groups were compared.Results (1) Three months and one year after operation,hemoglobin and hematocrit increased while erythropoietin average usage decreased significantly (P＜0.01).(2) Compared with preoperative period,the dry weight was significantly increased one year after operation,and the cardiac function indexes including left ventricular end diastolic diameter (LVDd),interventricular septum end diastolic thickness (IVSd),left ventricular posterior wall end diastolic thickness (LVPWd),interventricular septum systolic thickness (IVSs),left ventricular systolic diameter (LVDs),left ventricular myocardial mass (LVM),and left ventricular myocardial mass index (LVMI) decreased significantly (P ＜ 0.05).(3) In the non-LVH group,only IVSs decreased one year after operation (P ＜ 0.05).In the LVH group,LVDs,LVDd,LVPWd,LVM,LVMI and IVSs were decreased significantly one year after operation than those in preoperative period (P ＜ 0.05).Conclusions PTX with forearm autograft is an effective treatment for uremic patients with SHPT significantly improving anemia and left ventricular structure and function,especially for patients with ventricular hypertrophy in preoperative.

OBJECTIVE:To provide reference for exploring the way to improve the ability of pharmaceutical care in primary pharmaceutical staff. METHODS:Questionnaire survey was conducted among pharmaceutical staff(including head of pharmacy department),director/vice-director of hospital in charge of pharmacy,medical staff and patients from primary medical institutions in 9 provinces(regions,cities). The results of investigation were analyzed statistically. RESULTS:A total of 77 primary medical institutions involved in the survey. Totally of 2 273 questionnaires were sent out,and 2 248 effective questionnaires were collected with effective recovery rate of 98.9%. Among effective questionnaires,278 questionnaires were filled out by pharmaceutical staff (68 by head of pharmacy department),48 by director/vice-director of hospital in charge of pharmacy,771 by medical staff and 1 151 by patients. Results of survey showed that only 140 pharmaceutical staff had obtained pharmacy practice qualification,accounting for 50.4%. The surveyed primary medical institutions provided limited pharmaceutical care projects,and the projects with high proportion were medication explanation(85.7%)and medication consultation(84.4%). The establishment of Health Service Record Card in elderly patients(19.5%),the development of chronic disease management(23.4%)and the development of chronic disease related pharmaceutical knowledge publicity at the primary level(37.7%)took up low proportion relatively. Overall satisfaction of surveyed medical staff to pharmaceutical care of pharmaceutical staff was general(77.2%). Surveyed patients greatly satisfied with the attitude of pharmaceutical staff(85.5%)but overall satisfaction of them to professional knowledge of pharmaceutical staff(78.2%)was general. Surveyed pharmaceutical staff training needs in descending order were medication explanation(74.5%),medication counseling(71.9%)and providing pharmaceutical information(64.0%). However,the projects which had low proportion of training needs included chronic disease management(22.3%)and lifestyle guidance (27.0%),etc. The more favorite training forms in descending order were further study in medical institution at higher level(65.4%),expert lectures(60.1%)and training in the training base (57.9%). CONCLUSIONS:The primary medical institutions provided limited pharmaceutical care. It is necessary to further explore and standardize pharmaceutical care criteria. The overall satisfaction of medical staff and patients on pharmaceutical care of pharmaceutical staff is not high in primary institutions,and it needs to be further improved. The related pharmacy training for primary pharmaceutical staff still needs to be strengthened,and can be conducted according to the favorite form of training so as to improve the ability of pharmaceutical care.