OBJECTIVE To provide a reference for the adjustment of antibacterial drug regimens， identification of adverse reactions， and personalized pharmaceutical care for patients with bullous pemphigoid and pulmonary aspergillosis combined with disseminated Nocardia farcinica infection. METHODS Clinical pharmacists participated in the entire treatment process of a patient with bullous pemphigoid and pulmonary aspergillosis combined with disseminated N. farcinica infection. Evidence-based medicine was used to assist in the selection of an initial combined drug regimen against nocardiosis， and timely communication with the microbiology laboratory to provide early antimicrobial susceptibility data. When the patient exhibited epilepsy， the suspected drugs were identified， and it was reminded that imipenem-cilastatin sodium could affect the efficacy of valproic acid. It was suggested to replace valproic acid with levetiracetam for anti-epileptic treatment and to discontinue imipenem-cilastatin sodium. During treatment， it was recommended to monitor the blood concentrations of voriconazole and linezolid， and assist in adjusting the dosage promptly based on the monitoring results. RESULTS The physicians accepted the recommendations of the clinical pharmacists. The patient’s condition improved， and they were discharged with medication. CONCLUSIONS Based on evidence-based medical evidence， antimicrobial susceptibility test results， and blood concentration monitoring data， clinical pharmacists assist clinicians in selecting a sensitive anti-infective regimen for the patient， identifying adverse reactions， adjusting the treatment regimen and providing full-course medication monitoring to ensure the safety and efficacy of clinical drug therapy.

Small cell lung cancer(SCLC),one of the histological subtypes of lung cancer,is characterized by high proliferation,early metastasis,susceptibility to drug resistance and recurrence.For several years,SCLC has always been regarded as a homogeneous disease,treated with a unified radiotherapy and chemotherapy strategy.Despite significant early therapeutic effects,drug resistance and recurrence occur quickly,and there is a lack of satisfactory treatment results,which may be due to insufficient understanding of the tumor heterogeneity of SCLC at present.Recently,the concept of SCLC molecular subtype based on the definition of relatively high expression of lineage transcription factors has been proposed in preclinical studies.This article mainly elaborates on the current status and latest findings of SCLC molecular subtype,emphasizing the potential problems that molecular typing may encounter in clinical practice,aiming to promote understanding of the research progress of molecular subtype in SCLC.

Objective:To investigate the efficacy and safety of plasma exchange(PE) in the treatment of autoimmune hemolytic anemia in children.Methods:The data from 8 hospitals in China during November 2014 to April 2017 were collected, and the clinical characteristics of PE in children with AHA were analyzed retrospectively.Results:A total of 21 children with AHA were included in the study, including 17 cases from PICU and 4 cases from pediatric kidney ward, with 11 boys and 10 girls, and the median age was 3.64(0.25, 11.10)years old, and median hospital stay was 12(4, 45)days.There were 15 cases(71.4%) with infection, 2 cases(9.5%)with autoimmune diseases, 4 cases(19.0%) with unknown.Consciousness disturbance occurred in 4 patients before replacement and recovered to normal after PE.The volume of blood decreased in two cases(9.5%) and completely relieved.There were 20 cases of anemia (95.2%), 15 cases were normal after PE, and 5 cases were improved.Jaundice occurred in 18 cases (85.7%), 12 cases were normal after PE, 6 cases were improved.Hepatosplenomegaly was found in 11 cases, 10 cases were normal after PE, 1 case was improved.After PE, the hemoglobin and red blood cell count increased, while the total bilirubin, indirect bilirubin, urea nitrogen and lactate dehydrogenase decreased, there were significant differences between pre-and post-replacement ( P<0.05). Only 1 case had allergic reaction, which was improved after symptomatic treatment, and PE was continued.After PE, 2 cases (9.5%) had complete remission, 16 cases (76.2%) had partial remission and 3 cases (14.3%) had been discharged. Conclusion:PE therapy can obviously improve the clinical symptoms and laboratory indexes of children with AHA who have failed to respond to conservative treatment.It can be used as a treatment measure for children with severe AHA and has a good safety.

Objective:An early diagnosis model of acute aortic dissection (AAD) was established based on chest pain center database.Methods:The clinical data of patients who attended Chest Pain Center of Department of Emergency in Affiliated Hospital of Jining Medical University of Shandong Province from January 2020 to December 2020 were retrospectively collected. Patients were divided into AAD and non-AAD groups according to whether or not AAD was diagnosed. The clinical related indicators of the two groups were compared. The research indicators with statistical differences between the two groups were included in multivariate Logistic regression analysis, and the early diagnosis of AAD nomogram model was established. The receiver operating characteristic (ROC) curve of the model was used to evaluate the prediction accuracy, and the Homser-Lemeshow statistics were used to test the goodness of fit for the model. A total of 630 patients with chest pain who visited the hospital from January 2021 to March 2021 were also collected for external validation of the model. The t-test of independent samples was used to compare the measurement data of normal distribution, nonparametric test was used to compare the measurement data of skewness distribution, and χ 2 test was used to compare the counting data between groups. Results:A total of 2 738 patients were included, of which 4.09% (112/2 738) were AAD patients. Univariate analysis showed that in AAD group, male morbidity (74.11%(83/112)), hypertension history (70.54%(79/112)), aortic disease history (10.71%(12/112)), family history of aortic disease (4.46%(5/112)), sudden onset of symptoms (76.79%(86/112)), percentage of patients with laceration pain (38.39%(43/112)), patients with back pain (66.07%(74/112)), patients with abdominal pain (16.96%(19/112)), systolic blood pressure ((159.44±30.94) mmHg), bilateral blood pressure/pulse asymmetry (23.21% (26/112)), incidence of complicated neurological signs (7.14%(8/112)) and D-dimer (3.57(2.10, 6.62) mg/L) were significantly higher than those in non-AAD group (59.56%(1 564/2 626), 46.23%(1 214/2 626), 0.23%(6/2 626), 0.08%(2/2 626), 35.99%(945/2 626), 0.08%(2/2 626), 3.08%(81/2 626), 3.81%(100/2 626), (142.46±27.90) mmHg, 0.15%(4/2 626), 0.27%(7/2 626), 0.31(0.20, 0.50) mg/L). Age ((57.95±14.35) years old) and CK-MB (1.50(0.90, 3.25) μg/L) were significantly lower than those in the non-AAD group ((61.94±15.77) years, 2.50(1.24, 4.81) μg/L). The differences were statistically significant (the statistical values were χ 2=9.47, χ 2=25.46, χ 2=180.80, χ 2=81.11, χ 2=76.17, χ 2=975.60, χ 2=798.00, χ 2=44.72, t=6.28, χ 2=527.20, χ 2=93.22, Z=14.09, t=2.61, and Z=3.51, respectively; P values were 0.002, <0.001, <0.001, <0.001, <0.001, <0.001, <0.001, <0.001, <0.001, <0.001, <0.001, <0.001, 0.009, and <0.001, respectively). Multivariate analysis showed that history of hypertension ( OR=3.088, 95% CI:1.294-7.374), history of aortic disease ( OR=20.771, 95% CI:2.132-202.361), family history of aortic disease ( OR=266.425, 95% CI:17.610-4 030.851), sudden onset of symptoms ( OR=3.538, 95% CI:1.643-7.619), laceration pain ( OR=1 771.971, 95% CI:204.048-15 387.935), back pain ( OR=61.550,95% CI:27.987-135.367), abdominal pain ( OR=12.325, 95% CI:4.201-36.161), systolic blood pressure ( OR=1.026, 95% CI:1.013-1.039), bilateral blood pressure/pulse asymmetry ( OR=338.357, 95% CI:60.704-1 885.949) and D-dimer ( OR=1.241, 95% CI:1.176-1.309) were independent factors for the diagnosis of AAD in patients with chest pain (P values were 0.011, 0.009, <0.001, 0.001, <0.001, <0.001, <0.001, <0.001, <0.001, and <0.001, respectively). Furthermore, the nomogram model was constructed. ROC curve analysis showed that the area under the curve was 0.976 ( P<0.01), the specificity was 94.52%, and the sensitivity was 91.96%. The statistics of Homser-lemeshow was used to test the goodness of fit, which shows that the model can be fitted well (χ 2=2.928, P=0.939). The prediction model was verified by external validation data, and the area under the ROC curve was 0.934 ( P<0.01), indicating that the model had good prediction performance. Conclusions:History of hypertension, history of aortic disease, family history of aortic disease, sudden onset of symptoms, laceration pain, back pain, abdominal pain, systolic blood pressure, bilateral blood pressure/pulse asymmetry and D-dimer were independent factors for the diagnosis of AAD in patients with acute chest pain. The AAD early diagnosis nomogram model based on the above factors has good predictive performance.

In order to improve the success rate of supraclavicular deep venous catheterization and reduce mechanical complications, we present an auxillary maneuver in regard to supraclavicular subclavian catheterization basing on the relatively fixed anatomy of subclavian vein and its adjacent surroundings, furthermore, we revised the standardized procedure of supraclavicular subclavian catheterization. The maneuver is summarized in the shape of verses (verses: thumb navigation is well designed according to anatomy. Needle penetrated into vein should be parallel to coronal plane. Fine needle in position should be immobilized. Is it difficult for parallel puncture? Pressure determination is required when needle is in place. It is critical to distinguish which vessel has been inserted. Guidewire is advanced smoothly. Check blood return after expansion of skin and catheterization.). For teaching convenience, verses are considered to be more concise and memorable, as well as applicable to clinical practice, in order to provide some help for clinical teaching.

Objective:To investigate the effect of early enteral nutrition in patients with severe traumatic brain injury requiring exploratory abdominal surgery.Methods:The clinical data of 104 patients with severe traumatic brain injury requiring exploratory abdominal surgery treated in the PLA Army 72th Group Military Hospital from January 2016 to December 2020 were retrospectively analyzed. Among them, 47 patients were given early enteral nutrition (24-48 hr) as the observation group, and 57 patients were given delayed enteral nutrition (>48 hr), as the control group. The levels of hemoglobin, albumin, prealbumin, total bilirubin, alanine transaminase, C-reactive protein, white blood cells, postoperative infectious complications and clinical outcomes were compared between the two groups on the 1st, 7th and 14th days after surgery.Results:On the 14th day after operation, the prealbumin level of the observation group was higher than that of the control group, and the leukocyte level of the observation group was lower than that of the control group, with statistical significance ( P=0.020, P=0.013). The hospital stay and hospitalization costs of the observation group were lower than those of the control group ( P=0.017, P=0.032). The incidence of pulmonary infection in the observation group was 10.6%, which was lower than 29.8% in the control group ( P=0.017). Conclusions:Early postoperative enteral nutrition in patients with severe traumatic brain injury requiring exploratory abdominal surgery can significantly improve the nutritional status of patients, reduce the incidence of pulmonary infection, the hospital stay and the hospitalization cost.

Objective:To investigate the clinical features and prognosis of duodenal lateral fistula (DLF), and to explore the high-risk factors affecting its prognosis, so as to improve its treatment outcome.Methods:The regression study was conducted based on the database of the Registration System of Chinese Gastrointestinal Fistula and Intra-Abdominal Infections. DLF patients who were hospitalized from January 1, 2018 to December 31, 2018 and had complete clinical data in the database were selected as the research object. The clinical data included patient gender, age, length of hospital stay, hospitalization costs, intensive care unit (ICU) admission, underlying diseases, primary diseases, direct causes of DLF, complications, treatment and outcomes.Results:A total of 142 patients with DLF were enrolled, including 97 males and 45 females, with a median age of 54 years. The top three primary diseases of DLF were gastrointestinal ulcers and perforations in 33 cases (23.2%), biliary tract disease in 27 cases (19.0%), and trauma in 24 cases (16.9%). There were 117 cases (82.4%) with single DLF, and 25 cases (17.6%) were combined with other fistula. Among the 142 patients, 127 were healed (49 by surgery and 78 self-healing) and 15 (10.6%) died. 14 cases (9.9%) underwent percutaneous catheter drainage, and 18 cases underwent laparotomy drainage. Univariate prognostic analysis showed that advanced age (≥60 years old) (χ 2=6.891, P=0.009), primary diseases as gastrointestinal ulcers/perforations (χ 2=8.515, P=0.004), combined with other fistula (χ 2=5.798, P=0.016), malnutrition (χ 2=5.595, P=0.018), pulmonary infection (χ 2=12.449, P<0.001), hemorrhage (χ 2=6.466, P=0.011), multiple organ dysfunction syndrome(MODS ) (χ 2=37.258, P<0.001), underwent laparotomy drainage (χ 2=6.466, P=0.011) were associated with mortality. Multivariate prognostic analysis confirmed that age ≥60 years old ( OR=44.375, 95% CI: 2.676-735.822, P=0.008), combined with other fistula ( OR=16.54, 95% CI: 1.744-156.913, P=0.015) and MODS ( OR=238.447, 95% CI: 9.496-5 987.78, P=0.001) were independent risk factors of the death for DLF patients. Conclusions:The mortality rate of DLF is still relatively high. Iatrogenic duodenal injury (surgical operation, endoscopic treatment) is the main direct cause of fistula. Advanced age, combined with other fistula and MODS significantly increases the risk of death of patients.

To investigate the clinical efficacy of extended thymectomy by subxiphoid approach video-assisted thoracoscopic surgery(VATS) for myasthenia gravis. Methods We retrospectively analyzed the clinical date of 64 cases of myasthenia gravis treated by subxiphoid approach VATS in the same surgical team from September 2015 to April 2018. The patients were equally divided into 4 groups(A, B, C and D) according to the date of operation. Comparisons were made among the four groups in operation time, blood loss during operation, rate of conversion to thoracotomy, postoperative complications, postoperative hospital stay, duration and amount of postoperative chest tube drainage, frequenlly of surgery. The operative effect of different stage was analyzed. Results There were no intraoperative deaths. 1 patient(group A) was converted to thoracotomy. 3 patients(2 cases of group A; 1 case of group D) had lung infection. 1 patient(group B) developed myasthenia crisis after surgery, and the rest patients showed obvious improvement in postoperative myasthenia symptoms. No significant differences were found in postoperative complications, rate of conversion to thoracotomy, postoperative hospital stay, duration and amount of postoperative chest tube drainage among the 4 groups(P >0. 05). The operation time was significantly longer in group A(186. 25 ± 25. 79) min than the other 3 groups [B(128. 75 ± 16. 28) min, C(135. 00 ± 21. 29) min, D(128. 75 ± 19. 62)min], P <0. 05. The blood loss in surgery was significsntly more in group A(110. 00 ±38. 82)ml than that in the other 3 groups[B(63. 75 ±28. 26)ml, C(58. 13 ±27. 86)ml, D(58. 75 ±25. 00)ml], P <0. 05, while no statistical difference was found among group B, C and D. The frequency of surgery was increased from 1. 6 cases in group A to 2. 3, 2. 7 and 2. 7 cases one month in B, C and D, respectively. Conclusion The results of the present study have shown that subxiphoid approach VATS thymectomy is safe and feasible for the treatment of MG patients. For thoracic surgeons with certain experience in thoracoscopic technique, a plateau of the surgical skill of the subxiphoid opproach can be reached after learning curve procedures.

Objective: To establish a method for simultaneous and rapid detecting of the polymorphisms in Cytochrome P450 2C9 (CYP2C9), CYP2C19, CYP4F2, Vitamin K epoxide reductase (VKORC1) and ATP-binding cassette subfamily B member1 (ABCB1) gene, which were associated with warfarin and clopidogrel, based on liquid phase chip technology. Methods: Method establishment. The eight gene sequences near targeted sites related to warfarin and clopidogrel were found in Genbank, and the specific primers and probes were designed. Through multiple PCR amplification, followed by allele specific primer extension (ASPE), and MagPlex-Tag microspheres hybridization, the suspension array Luminex 200 system step-by-step, the genotypes were determined by fluorescence signal. The reaction system was optimized and its methodological evaluation was performed. 260 patients with antithrombotic therapy from Dongguan houjie hospital were recruited in this study form June 2017 to December 2018. The eight genotypes of the 260 patients were detected by the established method, and the results were compared with the sequencing results. Results: The results of 260 samples showed that allelic median fluorescence intensity (MFI) ratios of homozygotes (mutant/wild-type) were all greater than 0.9 or less than 0.1, and all the allelic MFI ratios of heterozygotes were between 0.3 and 0.6. The within run and between run coefficients of variance for allelic MFI ratios were lower than 6.4% and 10.9%, respectively. The minimum DNA template requirements was 0.75ng. The genotypes of 260 patients determined by the established method were completely concordant with the sequencing results. Conclusion A method was established successfully for rapid detecting the genotypes which associated with warfarin and clopidogrel based on liquid phase chip technology.

Objective: To understand the consistency of ALK Ventana-D5F3 immunohistochemistry (IHC) interpretation in Chinese lung adenocarcinoma among histopathologists from different hospitals, and to recommend solution for the problems found during the interpretation of ALK IHC in real world, with the aim of the precise selection of patients who can benefit from ALK targeted therapy. Methods: This was a multicenter and retrospective study. A total of 109 lung adenocarcinoma cases with ALK Ventana-D5F3 IHC staining were collected from 31 lung cancer centers in RATICAL research group from January to June in 2018. All cases were scanned into digital imaging with Ventana iSCANcoreo Digital Slide Scanning System and scored by 31 histopathologists from different centers according to ALK binary (positive or negative) interpretation based on its manufacturer′s protocol. The cases with high inconsistency rate were further analyzed using FISH/RT-PCR/NGS. Results: There were 49 ALK positive cases and 60 ALK negative cases, confirmed by re-evaluation by the specialist panel. Two cases (No. 2302 and No.2701) scored as positive by local hospitals were rescored as negative, and were confirmed to be negative by RT-PCR/FISH/NGS. The false interpretation rate of these two cases was 58.1% (18/31) and 48.4% (15/31), respectively. Six out of 31 (19.4%) pathologists got 100% accuracy. The minimum consistency between every two pathologists was 75.8%.At least one pathologist gave negative judgement (false negative) or positive judgement (false positive) in the 49 positive or 60 negative cases, accounted for 26.5% (13/49), 41.7% (25/60), respectively, with at least one uncertainty interpretation accounted for 31.2% (34/109). Conclusion There are certain heterogeneities and misclassifications in the real world interpretation of ALK-D5F3 IHC test, which need to be guided by the oncoming expert consensus based on the real world data.