Clinical Focus

Early recognition and intervention of sepsis in adults

Qin Yanjun, Dong Shimin

2018, 33(7): 553-557. doi:10.3969/j.issn.1004-583X.2018.07.001

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脓毒症往往被临床医生忽视，且容易被误诊为其他疾病。早期发现、早期干预可提高脓毒症患者生存率。本文就脓毒症相关的概念、病理生理、分子标志物及治疗等方面进行简要综述，为临床医生提供帮助。

Management of hypovolemia in sepsis

Li Ruijie1, Chen Lei1, Guo Yanli1, Qi Shifeng1, Ma Xiaoli1, Liu Jiangyan2

2018, 33(7): 558-561. doi:10.3969/j.issn.1004-583X.2018.07.002

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Patients with sepsis often have hypovolemia which is associated with adverse clinical outcomes. At present, the evidence concerning hypovolemia in sepsis is of low quality which is not conducive to the management of patients. Therefore, this article reviews the latest development of and controversies over the treatment of hypoxemia in sepsis, including the timing and objectives of liquid treatment, the volume and type of liquid. Finally, the article summarizes questions that still have no clear answers in clinical practices.

Meta analysis of levosimendan in treatment of severe sepsis and septic shock

Tian Wenlong1， Cheng Hongying1， Dong Shimin2

2018, 33(7): 562-567. doi:10.3969/j.issn.1004-583X.2018.07.003

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Objective To analyze and evaluate the effect of levosimendan in the treatment of severe sepsis and septic shock through metaanalysis, and then to provide evidentbased evidence for its application in the treatment of sepsis. Methods The CNKI, VIP, Wanfang database, PubMed, EMBASE, Ovidand Cochrane library database were searched for the randomized controlled trials of levosimendan in the treatment of severe sepsis and septic shock from the database inception to October 2015. Metaanalysis was conducted on the mortality, the left ventricular ejection fraction (LVEF), the cardiac index (CI), troponin I (TnI), lactate (Lac) and the amount of norepinephrine by using RevMan5.3 software.Results A total of 13 articles involving 491 cases were included, of which 251 cases were in levosimendan group, while the other 240 cases were in the control group. Compared with the control group, the mortality of the patients in the levosimendan group decreased significantly (RR=0.78，95%CI=0.630.96，P=0.02). Cardiac index (WMD=0.79, 95%CI=0.561.03, P＜0.001), LVEF (WMD=9.03%，95%CI=6.74%11.31%, P＜0.00001) of the levosimendan group increased significantly. And the TnI (WMD=-1.22，95%CI=-1.52-0.77，P＜0.00001), lactate (WMD=-1.41，95%CI=-1.56-1.27，P＜0.00001) decreased significantly compared with control group. There was no significant difference in the amount of norepinephrine between the two groups (WMD=-0.01, 95%CI=-0.030.01，P=0.45).Conclusion The evidence of meta analysis supports the application of levosimendan in paitents with severe sepsis or septic shock.

Clinical value of serum procalcitonin, T lymphocyte subsets and neutrophil CD64 in evaluating the severity and prognosis of patients with sepsis

Song Zhonghai1a, Gao Hui1a, Lu Chun1b, Dong Shimin2

2018, 33(7): 568-574. doi:10.3969/j.issn.1004-583X.2018.07.004

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Objective To explore the diagnostic and prognostic value of serum procalcitonin (PCT), the level of neutrophil CD64, the percentage of T lymphocyte subsets, SOFA score and APACHE Ⅱ score in patients with sepsis.Methods A total of 72 patients with sepsis were divided into the sepsis group and the septic shock group. The level of serum PCT, neutrophil percentage of CD64 and T lymphocyte subsets were measured, and APACHE Ⅱ score and SOFA score (five indicators) were calculated at the first day and the seventh day after admission.Logistic regression analysis and the receiver operating characteristic curve were applied to the probing of the relationship between those indicators and outcomes.Results ①Total mortality rate was 31.9%.The mortality rates of the two group were significantly different, with that of the sepsis group being 19.57% and septic shock group 53.85% (P=0.019). ②Compared with the sepsis group, the four indicators (namely, PCT，CD65（%）, APACHE Ⅱ and SOFA) of the septic shock group were all higher within the first 24 hour, but its ratio of T lymphocyte CD4+/CD8+ were lower than that of the sepsis group (P<0.05). ③Compared with the survival group, the abovementioned four indicators of the nonsurvival group within the first 24 hour were higher, but its ratio of T lymphocyte CD4+/CD8+ was relatively lower (P<0.05). ④Serum PCT and APACHE score were positively correlated at different time（r=0.702， 0.637，P＜0.01） , so were the percentge of CD64 and APACHE Ⅱ (r=0.676， 0.622，P<0.01), as well as SOFA and APACHE Ⅱ（r=0.676， 0.622，P＜0.01）, while the ratio of T lymphocyte CD4+/CD8+ and APACHE score were negatively related(P<0.01).⑤The five indicators above were all independent factors（P＜0.05） affecting the prognosis of sepsis patients and the more indicators combined, the higher sensitivity and specificity.Conclusion The serum PCT, the ratio of T lymphocyte CD4+/CD8+, neutrophil CD64(%), APACHE Ⅱ score and SOFA score can be used to assess the condition and risk of patients with sepsis. Combined together, these factors can have higher sensitivity and specificity in terms of the prognosis of patients with sepsis.

Effect of Xuebijing injection combined with ulinastatin on sepsis induced ARDS patients

Zhang Yanwei, Zhao Mailiang, Zhang Sheng, Zhou Kuilong, Gao Hui, Wang Junhui, Zhao Xing, Li Chao

2018, 33(7): 575-578. doi:10.3969/j.issn.1004-583X.2018.07.005

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Objective To explore the efficacy of Xuebijing injection combined with ulinastatin in the treatment of acute respiratory distress syndrome (ARDS) induced by sepsis. Methods A total of 60 patients with ARDS induced by sepsis from May 2014 to July 2016 were randomly divided into observation group (n=30) and control group(n=30). The patients in control group were treated with ulinastatin, and those in observation group were treated with Xuebijing on the basis of control group. The SOFA score and the APACHE Ⅱ score were used to analyze and compare the test indexes and clinical efficacy of the two groups. Results The PCT, BNP and CRP in observation group were significantly lower than those in control group(P<0.05). The time of invasive ventilation and EICU in observation group were significantly shorter than that in control group. The 28day mortality rate in observation group were significantly lower than that of control group(3.3% vs 10.0%, P>0.05). There was no significant difference in hospitalization time in general ward between two groups of patients (P>0.05).Conclusion Xuebijing combined with ulinastatin is effective in the treatment of patients with ARDS induced by sepsis. It reduces the incidence of complications and improves the cure rate of patients, worth popularizing in clinical practice.

Expression and clinical significance of peripheral blood immune factors in patients with severe sepsis

Xu Ruishana， Zhang Xiaolib

2018, 33(7): 579-582,586. doi:10.3969/j.issn.1004-583X.2018.07.006

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Objective To explore the expression of peripheral blood immune factors in patients with severe sepsis and its value in predicting the prognosis of patients. Methods The immune factors of 90 patients with severe sepsis who were diagnosed and treated in our hospital from June 2015 to December 2017 were divided into survival group (65 cases) and death group (25 cases) according to the prognosis. The clinical data, APACHEⅡ, SOFA, procalcitonin(PCT) serological indexes and the expression of peripheral blood immune factors (such as interleukin6, interleukin10, interleukin18, tumor necrosis factorα and transforming growth factorβ1) were compared between the two groups. And the receiver operating characteristic curve was applied to the effectiveness evaluation of the above three factors in predicting the prognosis of the patients.Results The APACHE Ⅱ score, SOFA score, PCT and IL18 of death group were significantly higher than those of the survival group (P<0.05). Pearson correlation analysis showed that IL6 and IL18 were significantly correlated with APACHE Ⅱ score (r=0.679, 0.651), SOFA score (r=0.643, 0.630) and PCT (r=0.711, 0.678). The ROC curve showed that the area under the curve(AUC) for predicting prognosis of the patients using IL6 and IL18 (AUC=0.841, 0.802) were higher, followed by PCT and APACHEⅡ scores (AUC=0.710 and 0.685), and the SOFA score was relatively lower (AUC=0.648). The combined diagnosis of IL6 and IL18 significantly improved the diagnostic efficiency (AUC=0.909). The sensitivity and negative predictive value of IL6 and IL18 in prognosis of patients with severe sepsis were significantly higher than those of SOFA, APACHEⅡ score and PCT (P<0.05). Conclusion There is obvious anomaly in the expression of peripheral blood immune factors in the patients. The IL6 and IL18 have high diagnostic efficacy in predicting the death of patients with severe sepsis.

Distribution of glycosylated hemoglobin and glycosylated serum protein in Yunnan Dai population

Zhao Yang, Feng Lei

2018, 33(7): 583-586. doi:10.3969/j.issn.1004-583X.2018.07.007

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Objective To investigate the distribution of HbA1c and GSP in the Dai people of Yunnan of different genders and ages. Methods The levels of glycosylated hemoglobin (HbA1c), hemoglobin (hemoglobin, Hb), FPGcose (fasting blood glucose, FPG), glycosylated serum protein (GSP) and albumin (albumin, ALB) were detected, analysed and compared in 860 cases of Dai people for the difference and the change trend of each index groups of different genders and ages (4150 years, 5160 years, 6170 years, >70 years old ). Results There was no statistical significance in levels of HbA1c, GSP and ALB between male and female (P>0.05), but the difference in Hb and FPG between two genders was significant(P<0.05). All the indexes in male decreased with aging, while those of the female kept increasing until 60 years old, then the indexes began to fall. The pearson correlation test showed that there was correlation in male and female between HbA1c and FPG, also ALB and GSP, and there was correlation in female between Hb and HbA1c. Conclusion On the premise of standardized determination, there is no gender difference in HbA1c and GSP levels among Dai people. However, their levels may vary in gender, and age, those of males decreased with age, but females increased until they reached the turning point60 years old.

Survey of thyroid nodules and iodine nutritional status of residents in Chengguan District of Lanzhou

Cao Chong1, Fu Songbo1, Tang Xulei1, Liu Jingfang1, Ma Lihua1, Sun Weiming1,

2018, 33(7): 587-590. doi:10.3969/j.issn.1004-583X.2018.07.008

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Objective To understand the iodine nutritional status in Chengguan District of Lanzhou, and the epidemiological characteristics and influencing factors of thyroid nodules. Methods Stratified cluster sampling was used to conduct a crosssectional survey on six communities. Thyroid ultrasound, thyroid function and urine iodine were tested. Results The prevalence rate of thyroid nodules was 21.0% as a whole, with that of the men being, 17.2% and that of women being. Obviously, the prevalence rate of. women was higher than men (P<0.05).The majority of patients under 60 years had single nodules less than 1.0 cm. Patients over 60 years had multiple thyroid nodules with the diameter greater than or equal to 1.0 cm. Thyroid function in patients with thyroid nodules was normal (81.6%), and there was no association between thyroid nodules and thyroid function(P＞0.05). The median urinary iodine level in Lanzhou area was 205.4 μg/L, higher than that in other areas of China, and significantly higher in women than men (P<0.05). The urine iodine level decreased with age (P<0.05). Age is an important factor affecting the occurrence and development of thyroid nodules. Conclusion The level of urine iodine is high in Lanzhou area. Both age and sex are related to the occurrence and development of thyroid nodules.

Application of red blood cell distribution width in the prognosis of acuteonchronic liver failure

Zhang Mengchen, Cai Junjun, Xie Xiaoli, Jiang Huiqing

2018, 33(7): 591-594. doi:10.3969/j.issn.1004-583X.2018.07.009

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Objective To investigate the clinical value of red blood cell distribution width (RDW) in the prognosis of acuteonchronic liver failure. Methods Totally 78 patients with hepatitis Brelated acuteonchronic liver failure (ACLF) were enrolled and divided into survival and death groups according to their prognosis to detect RDW level and other related clinical indicators in this study. Results The RDW level in ACLF was significantly increased in nonsurvivors than in survivors (t=-3.568, P=0.004). The level of RDW was correlated with WBC, NLR, TBIL, MELD scores (P<0.05). The area under the ROC curve (AUC) of RDW predicted mortality in ACLF was 0.64(0.520.77) at a cutoff value of 17.15%, and the sensitivity and specificity were 54.2% and 67.9%, respectively. Multivariate regression analysis showed that RDW, NLR and INR were independent risk factors for shortterm mortality of patients with ACLF. High RDW level showed a significantly lower survival rate (P<0.05).Conclusion RDW is a simple and effective indicator that can predict the shortterm prognosis of ACLF.

Changes in pathological spectrum of primary glomerulonephritis——a single center data

Dong Hu, Zhang Beiru, Li Luting, He Ping, Wang Yanqiu, Sun Guangping

2018, 33(7): 595-598,602. doi:10.3969/j.issn.1004-583X.2018.07.010

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Objective To evaluate the epidemiological characteristics of PGN by analyzing the pathological types and clinical manifestations of patients receiving renal biopsy in recent years. Methods The renal pathological data and clinical manifestation of patients receiving renal biopsy from August 2009 to April 2016 were collected. Patients were grouped according to the time of renal biopsy, gender and age in order to analyze the epidemiological characteristics of PGN. At the same time, the clinical manifestations of different pathological types were observed and the correlation between them were analyzed. Results A total of 1 642 cases diagnosed as PGN by renal biopsy were enrolled in this study. Among them, MN was the most common pathological type, which had 556 cases and accounted for 33.86%. The majority of the patients was the middleaged and the elderly, and the incidence of the disease was increasing year by year. IgAN was the second pathological type and had 511 cases (31.12%). Although it was still the main pathological type in the youth group, in middleaged and elderly patients, its incidence was inferior to MN, presenting a downward trend yearly. The clinical manifestations of patients with different pathological types were different. MN was mainly manifested as NS, while the main manifestation of IgAN was Pro and Hem. Conclusion The disease spectrum of PGN has changed in recent years, and the acquisition of epidemiological data will help to analyze the causes and further clarify the possible pathogenic factors of glomerulonephritis.

Relationship between obstructive sleep apnea and blood lipid level in maintenance hemodialysis patients

Pu Liumei1, Huang Guolan2, Lu Liwen1

2018, 33(7): 599-602. doi:10.3969/j.issn.1004-583X.2018.07.011

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Objective To investigate the relationship between obstructive sleep apnea hypopnea syndrome(OSAHS) and blood lipid level in maintenance hemodialysis patients.Methods A total of 74 patients with maintenance dialysis in our hospital from July 2015 to July2016 were selected as the research objects, and were divided into OSAHS group (32 cases) and nonOSAHS group (42 cases)in accordance with the monitoring results of the multi sleep monitor.Triglyceride (TG), total cholesterol (TC), high density lipoprotein (HDLC), low density lipoprotein (LDLC), apolipoprotein A (ApoA I) and apolipoprotein B (ApoB) were detected and compared between two groups.Logistic regression was used to analyze the influencing factors of OSAHS in maintenance hemodialysis patients.Results The duration of dialysis in OSAHS group was longer than that in nonOSAHS group, However, there was no significant difference in BMI between two groups (P>0.05); Two groups of patients with blood lipid levels were compared, TC, TG, LDLC, ApoB of OSAHS group were significantly higher than in those of nonOSAHS group (P<0.05); Pearson correlation analysis showed that AHI was positive correlated with TC and ApoB(P＜0.05); Logistic regression analysis showed that ApoB and TC were risk factors for maintenance hemodialysis patients with OSAHS(P<0.05).Conclusion The longer the duration of dialysis, the more risk of OSAHS, and the synergistic effect of OSAHS presented with dyslipidemia.

Prognosis of pneumonectomy in patients with nonsmall cell lung cancer by pleural lavage cytology：a metaanalysis

Wu Qinxun1,2, Liu Hua2, Li Yujing1,Ma Jilong1

2018, 33(7): 603-608. doi:10.3969/j.issn.1004-583X.2018.07.012

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Objective To systematically evaluate the effectiveness of intraoperative pleural lavage cytology(PLC) positive and negative on mortality,recurrence and relapse rate in five years after pneumonectomy in patients with nonsmall cell lung cancer(NSCLC). Methods We searched PubMed,EMBASE, Cochrane, library, CNKI, VIP, and Wanfang Data databases to collect cohort study of the prognosis of pneumonectomy in patients with NSCLC from construction of database to November 2017. RevMan 5.3 software was used to process the data, and to figure out the risk ratio (RR) and 95% of the confidence intervals （confidence interval，CI）. Results A total of 11 retrospective controlled studies were conducted, including 11 856 patients with NSCLC,among which, 533 were positive PLC patients and 11 323 were PLC negative patients. The Meta analysis results showed that,compared to PLC negtive patients were not only associated with poor survival rate, but also with recurrence and metastasis, especially pleural metastasis. The total mortality rate (RR=1.99, 95%CI=1.842.14,P<0.01) and the mortality rate of stage Ⅰ(clinical staging of nonsmall cell lung cancer,RR=2.10, 95%CI=1.852.39, P<0.01） five years after the pulmonary resection , the total relapse rate (RR=2.54, 95%CI=2.212.92, P<0.01) pleural metastasis (RR=8.17, 95%CI=6.0211.10, P<0.01), and the distant recurrence of the two groups were all of statistical significance(RR=2.65,95%CI=2.123.31,P<0.01). Conclusion The prognosis of patients with positive PLC is worse than that of patients with negative PLC, and PLC can serve as an independent prognostic factor in NSCLC patients. Given that the quantity and quality of the inclued studies are limited, the above conclusion still needs to be verified by higher quality studies.

Diagnosis of 18FFDG PET/CT in benign and malignant adrenal tumors: a systematic review and metaanalysis

Yang Yang1,2, Huang Shiming1, Gang Bo2, Chen Qinhua2, Lin Zhichun1

2018, 33(7): 609-614. doi:10.3969/j.issn.1004-583X.2018.07.013

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目的采用Meta分析系统评价18氟代脱氧葡萄糖正电子发射计算机断层显像（18FFDG PET/CT）对肾上腺肿瘤良恶性的诊断价值。方法计算机检索PubMed、EMbase、The Cochrane Library、中国知网（CNKI）、万方、中文科技期刊等数据库，查找有关18FFDG PET/CT对肾上腺肿瘤良恶性诊断性试验研究文献。由2名研究员按同一标准分别进行文献筛选、提取资料和评价文献质量，采用Meta DiSc1.4软件进行Meta分析。结果最终纳入20篇文献，肾上腺肿瘤患者1 481例，肾上腺病变共计1 663个。Meta分析结果示，PET/CT对肾上腺肿瘤良恶性的诊断灵敏度为0.92，特异度为0.92，阳性似然比为9.54，阴性似然比为0.09，合并效应量为139.60，受试者曲线下面积为0.9708。18FFDG在肿瘤摄取值/肝脏摄取值＞1时代谢参数SUVmax比值的诊断效能最高（灵敏度为0.95、特异度为0.93、受试者曲线下面积为0.9789）。结论 18FFDG PET/CT代谢参数中SUVmax比值(tumor/liver＞1)对肾上腺肿瘤的良恶性诊断效能最高。

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