objective:To investigate the tolerability of early enteral nutrition (EN), and to further explore the association of early EN with clinical outcome in critically ill patients with hemodynamic instability.Methods:The adult patients from Zhejiang Provincial People’s Hospital with an expected admission to ICU for at least 24 h were consecutively recruited from May 2014 to May 2016, and all clinical, laboratory, and survival data were prospectively collected. The AGI grade was daily assessed on the first week of ICU admission. Enteral nutrition (EN) started after 6 h of hemodynamic stability (MAP ≥ 65 mmHg) when the patients took vasoactive medication. The patients were divided into three groups based on the timing of EN initiation: early EN group (EN initiation within 48 h of ICU admission), late EN group (EN initiation at more than 48 h of ICU admission), and no initiation of enteral feeding within 7 days of ICU admission.Results:Of 201 patients enrolled, the mean age was 65.3 ± 16.4 years, APACHE II score was 22.4 ± 6.85, and 191 patients (95.0%) took mechanical ventilation. There were no differences in high gastric residual volume, diarrhea, and gastrointestinal (GI) bleeding between the early EN group and late EN group ( P>0.05). Whereas, patients in the no initiation of EN within 7 days of ICU admission had a lower prevalence of gastric residual volume (16.7% vs. 33.3%, P=0.05), but higher prevalence of GI bleeding (47.2% vs. 26.1%, P=0.02). Compared with those in the late EN group and in no initiation of EN within 7 days of ICU admission, patients in the early EN group had lower 28- (30.4% vs. 47.9% vs. 55.6%, P=0.01) and 60-day mortality rates (38.0% vs. 53.4% vs. 63.9%, P=0.017). Multivariate Cox regression analysis showed that the timing of EN initiation on the admission to ICU (early EN vs. late EN, χ 2≥5.83, P<0.05; early EN vs. no initiation of EN, χ 2≥7.90, P<0.01), serum creatinine ( χ 2=5.06, P<0.05), plasma albumin ( χ 2≥6.41, P<0.01), AGI grade ( χ 2≥8.15, P<0.01), and APACHE II score ( χ 2≥9.62, P<0.01) were independent predictors for 28- and 60-day mortality. Conclusions:Early EN on admission to ICU could be tolerated, and is significantly associated with lower risk of 28- and 60-day mortality in critically ill patients with vasoactive medication to maintain hemodynamic stability.

Objective To investigate the prevalence of feeding intolerance (FI),and to explore the FI within 7 days of ICU admission in association with clinical outcome in critically ill patients.Methods The adult patients from 14 general ICUs in Zhejiang Province with an expected admission to ICU for at least 24h were recruited from March 2014 to August 2014,and all clinical,laboratory,and survival data were prospectively collected.The AGI (acute gastrointestinal injury) grade was daily assessed based on gastrointestinal (GI) symptoms,feeding details and organ dysfunction within the first week of ICU stay.The intra-abdominal pressures (IAP) was measured using AbViser device.Results Of 550 patients enrolled,418 were assessed in GI symptoms and feeding details within 7 days of ICU stay.The mean age and SOFA score were (65.1 ± 18.3) years and (8.96 ±4.10),respectively.Of them,355 patients (84.9％) were under mechanical ventilation support,and 37 (8.85％) received renal replacement therapy.The mean length of time for enteral feeding was (30.8 ±26.2) h,and the prevalence of FI on the 3rd and 7th day of ICU stay accounted for 39.2％ and 25.4％,respectively.Compared to those with FI within 7 days of ICU stay,the patients without FI had higher rate of successively weaning from mechanical ventilation (21.3％ vs.5.7％,P =0.003) and higher rate of withdrawal of vasoactive medication (45.5％ vs.20.0％,P =0.037),as well as lower mortality rate of 28-day (24.4％ vs.38.7％,P =0.004) and 60-day (29.6％ vs.44.3％,P =0.005).In multivariate Cox regression model with adjustment for age,sex,participant center,serum creatinine and lactate,AGI grade on the first day of ICU stay,and comorbidities,the FI within 7 days of ICU stay (x2 ≥ 7.24,P ＜ 0.01) remained to be independent predictors for 60-day mortality.After further adjusted for SOFA score,the FI within 7 days of ICU stay (HR =1.71,95％ CI:1.18-2.49;P =0.006) and AGI grade on the first day of ICU stay (HR =1.33,95 ％ CI:1.07-1.65;P =0.009) could provide independent prognostic values of 60-day mortality.Conclusions There is high rate of FI occurred within 7 days of ICU stay,and is significantly associated with worse outcome.In addition,this study also provides evidence to further support that measurement of gastrointestinal dysfunction could increase value of SOFA score in outcome prediction for the risk of 60-day mortality.

Objective To explore the curative effect of colonoscopy combined with laparoscope in the treatment of colonic polyps.Methods The clinical data of 48 cases with colonic polyps were retrospectively analyzed.According to the operation pattern,the patients were divided into observation group(23 cases)and control group(25 cases).The observation group received colonoscopy combined with laparoscopy for radical surgery of colon polyps,the control group used the traditional open surgery to remove polyps.The operation time,bleeding volume, exhaust and defecation time,hospital days and cost as well as postoperative complications were observed.Results The two groups were successfully completed surgery.The operative time,bleeding volume of the observation group were (78.3 ±8.2)min and (1 3.1 ±4.5)mL respectively,which of the control group were (1 1 5.5 ±1 0.1 )min, (63.6 ±1 8.1 )mL,the differences between the two groups were statistically significant(t =1 3.93,1 3.01 ,all P <0.05).The anal exhaust time and defecation time of the observation group were (25.1 ±6.5)h and (42.5 ±7.6)h, which were significantly shorter than those of the control group[(36.6 ±8.1 )h,(82.3 ±1 1 .5)h],the differences were statistically significant(t =5.39,1 4.01 ,all P <0.05).The hospitalization time,hospital costs of the observation group were (5.5 ±0.6)d,(1 3 842.5 ±875.5)yuan,which of the control group were (8.2 ±1 .5)d,(1 8 992.5 ± 1 001 .5)yuan,the differences between the two groups were statistically significant(t =8.05,1 8.89,all P <0.05). Pulmonary infection in 1 case,anastomotic fistula in 2 cases,1 case of intestinal obstruction in the observation group, and in the control group,pulmonary infection occurred in 2 cases,2 cases of intestinal obstruction,the postoperative complications between the two groups had no statistically significant difference(P >0.05).Conclusion For simple colonoscopy treatment difficulties of colon polyps,colonoscopy,laparoscopy combined treatment is minimally invasive and can improve the safety,strictly control surgical indications,can give full play to the double mirror combined advantage.

OBJECTIVE:To prepare Ferulic acid/K/β-CD/metal organic framework (FA/K/β-CD/MOF) inclusion,and to opti-mize its preparation technology. METHODS:K/β-CD/MOF was synthesized by solvothermal method as inclusion material. Using FA as main component,FA/K/β-CD/MOF was prepared by grinding method. The preparation technology was optimized by orthogo-nal test using mole ratio of main component-inclusion material,grinding time,dropping time and inclusion temperature as factors, inclusion rate as index. Prepared FA/K/β-CD/MOF was indentified by IR spectrum and DSC,and inclusion rate and dissolution rate were determined. RESULTS:Optimized preparation technology was as follows as mole ratio of main main component to inclusion material 3∶1,dropping time 60 min,inclusion temperature 40 ℃,inclusion time 60 min. Prepared FA/K/β-CD-MOF had already formed a new kind of phase,and its average inclusion rate was(18.0±1.6)%(RSD=0.9%,n=6);its solubility was 15 times as much as FA(9.582 mg/ml vs. 0.647 mg/ml). CONCLUSIONS:FA/K/β-CD/MOF is prepared successfully;and the preparation tech-nology is reasonable and feasible.

Purpose To investigate the difference of imaging features of tree-in-bud (TIB) sign at CT between stage Ⅰ central lung cancer and bronchial disseminated pulmonary tuberculosis in order to reduce the misdiagnosis rate of central lung cancer.Materials and Methods 32 patients of stage Ⅰ central type lung cancer confirmed pathologically or clinically (lung cancer group) and 47 patients of bronchial disseminated pulmonary tuberculosis confirmed pathologically or clinically (tuberculosis group) underwent chest CT scanning and were found with TIB sign.The imaging data of all the cases were analyzed retrospectively in terms of distribution range,accompanying CT findings of TIB sign,and abnormalities of segmental and (or) larger bronchus proximal to it.Results TIB sign was mainly focal (unilobar) in lung cancer group (96.88％),while it was mainly diffuse (more than one pulmonary lobe) in tuberculosis group (80.85％).The difference was significant (P＜0.01).Accompanying CT findings:① Obstructive bronchial mucoid impaction distal to the TIB was more common in lung cancer group than in tuberculosis group (100％ vs 6.38％,P＜0.01).② Consolidation and/or ground-glass opacities were found both in lung cancer group (34.38％) and in tuberculosis group (48.94％).The difference was not significant (P＞0.05).③ Cavity was less common in lung cancer group than in tuberculosis group (0 vs 38.30％,P＜0.01).④ Nodules with diameter larger than 5 mm were much fewer in lung cancer group than in tuberculosis group (0 vs 76.60％,P＜0.01).TIB sign was found in 33 lobes in lung cancer group,and the abnormity was found in all these lobes (100％);while in tuberculosis group,TIB sign was found in 144 lobes and the abnormity was found in 56 lobes (38.89％).Conclusion TIB sign shows differences between stage Ⅰ central lung cancer and bronchial disseminated pulmonary tuberculosis.The TIB signs such as focal distribution,accompanied by bronchial mucoid impaction and abnormality of segmental or (and) larger bronchus may predict the high possibility of central lung cancer.

Objective To discuss the technical points and the clinical application of single wire-guided inverted Y-shaped tracheal stent implantation under general anesthesia in treating complex tracheal diseases. Methods During the period from January 2014 to October 2014 at authors’ hospital, a total of 6 patients with complex tracheal diseases received inverted Y-shaped tracheal stent implantation. The diseases included trachea-pleural fistula(n=1), trachea-esophageal fistula(n=2) and complex tracheal stenosis(n=3). Under general anesthesia and guided by DSA, inverted Y-shaped tracheal stent implantation was carried out in all the 6 patients. The results were analyzed. Results A total of 6 Y-shaped tracheal stents were used in the 6 patients, and single wire-guided implantation technique was employed in all procedures. In one case , the right branch of the Y-shaped tracheal stent was placed in the right upper lobe bronchus by mistake , and in the remaining 5 cases the stent implantation was successfully accomplished with single manipulation. Conclusion Under general anesthesia, Y-shaped tracheal stent implantation can effectively obstruct the trachea-pleural fistula and left main bronchus-esophageal fistula, and it can also quickly and significantly relieve the complex airway stenosis located at the tracheal carina region. This treatment is safe and reliable with satisfactory short-term effect. Moreover, single wire-guided manipulation is technically simpler, easier and faster than dual wire-guided manipulation. Therefore, this technique should be recommended in the clinical practice.

Objective To discuss the classification and treatment of the degloving hand.Methods All 68 degloving hand treated between January, 2005 and December, 2014 in our department were reviewed.The cases were divided into three types according to the extent of the injury.Type Ⅰ the degloving tissue had enough blood supply which was debrided and stitched.Type Ⅱ the degloving tissue had less or no blood supply which was revascularized with replantation or vein anastomosis, some degloving palm or dorsum resurfaced the wound by the degloving skin graft.Type Ⅲ the degloving tissue had no blood supply or severely damaged,the tissue defect should be resurfaced with other tissue reconstruction.Type Ⅱ and Ⅲ were further divided into subtype A, B and C depending on the degloving scope and location, each subtype has its own surgical procedure.Results The total survival rate was 83.8％.The survival rate decreased with the increasing extent of the injury and the increasing degloving scope.Conclusion Classification of the hand degloving injuries depending on the extent of the injury, the degloving scope and location is useful for the assessment of injury and the selection of proper operation procedures.

Bronchopulmonary Sequestration ; diagnosis ; Coronary Vessels ; pathology ; Humans ; Male ; Middle Aged

Objective To investigate the relationship between lymphadenectomy and the prognosis of endometrioid adenocarcinoma.Methods Eighty-six cases of endometrioid adenocarcinoma patients who got a clear diagnosis and accepted system surgical treatment and had complete follow-up data were collected in this study.Fifty-eight cases routined lymphadenectomy (lymphadectomy group),and 28 cases didn't routine lymphadenectomy (without lymphadectomy group).The relationship between related pathological features and lympha node dissection state were evaluated by univariate analysis,and through survival analysis to understand the relationship between lymphadenectomy and the prognosis of endometrioid adenocarcinoma.Results The 3-years disease-specific survival rate (DSS) in lymphadectomy group and without lymphadectomy group were 82.1％ and 61.8％,which reached statistical significance (P =0.006).The 3-year DSS of FIGO Ⅰ A stage in lymphadectomy group and without lymphadectomy group were 93.8％ and 95.7％ (P=0.704),the 3-year DSS of FIGO Ⅰ B-Ⅳ stage in lymphadectomy group and without lymphadectomy group were 49.1％ and 35.4％,which reached statistical significance (P =0.044).Correlation analysis results showed that FIGO stage late (≥ Ⅰ B stage),higher tumor grade (G2-3 grade) were independent poor prognosis factors of 3-year DSS,and lymphadenectomy was an independent good prognosis factor.Conclusion Lymphadectomy can improve the prognosis of endometrioid adenocarcinoma patients who are FIGO Ⅰ B-Ⅳ stage,has therapeutic significance.

Objective To evaluate the efficacy and safety of alemtuzumab in renal transplant recipients treated with induction therapy. Methods Eighty-nine cadaveric renal transplant recipients in our department were randomly divided into experimental group (n = 43) treated with alemtuzumab induction, 15 mg i. v. and control group (n = 46). Main immunosuppressive therapy regimen consisted of steroids, tacrolimus or cyclosporine and mycophenolate mofetil in all recipients. Post-transplant kidney function, acute rejection,infection, DGF, graft survival, lymphocyte counts were recorded within 1 year. ATP values in CD4+ T cells after transplantation was determined by using Cylex ImmuKnow assay. Results There was significant difference in the incidence of biopsy-proven acute rejection, but no significant difference was found in ImmuKnow ATP values during 6 months after transplantation and lymphocyte counts during 3 months, graft survival and the incidence of infections between the two groups. Conclusion Induction therapy with alemtuzumab appeared to be effective in the prevention of acute rejection.