Objective:To evaluate the application value of SimMan 3G simulator combined with CBL method in teaching of emergency tracheal intubation.Methods:A total of 48 resident physicians participating in standardized training in during 2021 were selected as the research objects, who were randomly divided into two groups, with 24 residents each. The general Annie simulator was used in the control group while SimMan 3G simulator was used in the experimental group. The training pattern of all participators was based on case-based learning(CBL)teaching. At the end of the training, a theory test and a clinical skill test were carried out for the standardized training of resident physicians.The differences were compared between the two groups.And the teaching feedback was conducted by a questionnaire survey.Results:The questionnaires survey showed that the teaching of interaction, learning of interest, clinical analysis ability and total teaching satisfaction rate in the experimental group were higher than that in the control group (P<0.05).Conclusions:The application of SimMan 3G simulator combined with CBL in teaching of emergency tracheal intubation can effectively improve the training effectiveness and enhance first-aid capabilities. It provides a new idea for standardized training of emergency resident physician.

Objective:To summarize the clinical manifestations, imaging features, the experience of diagnosis and treatment, and prognosis of diffuse alveolar hemorrhage (DAH) caused by anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV).Methods:The clinical data of the 2 patients with AAV complicated with DAH admitted to the emergency department of the Affiliated Drum Tower Hospital of Nanjing University Medical School were analyzed retrospectively." Vasculitis" , " ANCA-associated vasculitis" , " diffuse alveolar hemorrhage" and " alveolar hemorrhage" were used as keywords.The case reports published by Wanfang Medical database, CNKI, PubMed and Embase database from January 1980 to August 2021 were searched.Results:Both critically ill patients needed ECMO support.After combining with prone ventilation, their conditions were alleviated.Finally, they improved articles including 32 patients meeting the standard were retrieved.With 2 patients from our department, a total of 34 patients were included in the analysis.There were 16 males and 18 females, with the median age of them 45.5 (28.0 and 73.25) years, the age range from 8 to 81 years.The median duration of disease was 13 (8 and 20) days, the course of disease from 2 to 85 days, and the overall mortality is 20.59% (7/34).The clinical features of DAH include coughing, hemoptysis and dyspnea, even progressing acute respiratory distress syndrome and acute kidney injury.Chest imaging showed multiple patchy, diffuse pulmonary infiltration or consolidation.Bronchoscopy and alveolar lavage fluid showed bleeding and macrophages containing hemosiderin.Immunosuppressive therapy with high-dose hormone shock and cyclophosphamide was selected for treatment.ECMO is an essential salvage treatment (35.29%, 12/34), and none of them who received ECMO support therapy died.Conclusions:DAH is one of the rare serious complications and the strongest predictor of early mortality in the course of AAV.ECMO combined with prone position ventilation is a feasible and efficient treatment in the acute stage of DAH induced by AAV.It is conductive to secretion drainage and lung recruitment, which will also gain precious time for later primary etiology identification.

目的 探讨间歇经口至食管管饲(intermittent oro-esophageal tube feeding,IOE)在急性卒中合并吞咽障碍患者中的应用效果.方法 本研究为前瞻性随机对照研究,连续纳入2018年1月-2020年9月南京大学医学院附属鼓楼医院急诊科收治的急性卒中合并吞咽障碍患者,使用分层随机化方式将患者分为鼻饲组和IOE组.采用洼田饮水试验和标准吞咽功能评价量表(standardized swallowing assessment,SSA)分别在入院时及出院时对患者吞咽障碍进行评估,同时记录患者BMI、血红蛋白(hemoglobin,Hb)、血清白蛋白(albumin,ALB)及血清前白蛋白(prealbumin,PA)的变化,住院期间吸入性肺炎、消化性溃疡、便秘、腹泻、呕吐及口鼻黏膜破损的发生情况,以及住院天数等,比较两组上述指标的差异.结果 符合纳入标准并进行分析的患者共126例,鼻饲组62例,IOE组64例.出院时IOE组吞咽功能临床疗效评级1级和2级的患者比例高于鼻饲组,但差异无统计学意义;IOE组SSA评分改善优于鼻饲组(24.88±3.07分vs?28.87±3.04分,P<0.001).营养状况方面,出院时IOE组ALB(37.40±4.40?g/L?vs?35.31±3.32?g/L,P=0.003)、PA(0.28±0.04?g/L?vs?0.24±0.03?g/L,P<0.001)及Hb(127.60±6.93?g/L?vs?124.76±6.69?g/L,P=0.021)均显著优于鼻饲组;IOE组患者吸入性肺炎(4.69％?vs?22.58％,P=0.007)、呕吐(3.13％?vs?25.81％,P=0.001)及口鼻黏膜破损(0?vs?17.74％,P=0.001)的发生率及住院天数(中位数15?d?vs?17?d,P=0.029)也显著低于鼻饲组.结论 IOE可改善急性卒中合并吞咽障碍患者的吞咽功能,在提供良好营养支持的同时可降低吸入性肺炎、呕吐及口鼻黏膜破损的发生,值得临床推广.

背景 经鼻高流量氧疗(HFNC)是一种新型无创氧疗方式,能提供恒温、恒湿和高流量的气流,对Ⅰ型呼吸衰竭具有良好的治疗效果,但其在急性缺血性脑卒中(AIS)并Ⅰ型呼吸衰竭患者中的应用效果尚不明确.目的 比较HFNC与常规氧疗辅助治疗AIS并Ⅰ型呼吸衰竭患者的临床疗效.方法 选取2017年8月—2019年3月南京大学医学院附属鼓楼医院急诊病房和急诊重症监护室(EICU)收治的AIS并Ⅰ型呼吸衰竭患者98例,采用随机数字表法分为常规氧疗组(n=48)和HFNC组(n=50).常规氧疗组患者经普通氧气湿化装置行经鼻/面罩吸氧,HFNC组采用费雪派克呼吸湿化治疗仪行HFNC.比较两组患者氧疗前及氧疗后2、12、24 h呼吸频率(RR)、心率(HR)及血气分析指标〔包括pH值、动脉血氧分压(PaO2)、动脉血二氧化碳分压(PaCO2)、血乳酸(Lac)及氧合指数〕,氧疗前及氧疗24 h痰液黏稠分度,EICU住院时间、3 d内气管插管率及90 d内病死率.结果 时间与方法 在RR、pH值、Lac、氧合指数上无交互作用(P>0.05);时间与方法 在HR、PaO2、PaCO2上存在交互作用(P<0.05).时间在RR、HR、pH值、PaO2、PaCO2、Lac、氧合指数上主效应显著(P<0.05).方法 在RR、HR、PaO2、PaCO2上主效应显著(P<0.05);方法 在pH值、Lac、氧合指数上主效应不显著(P>0.05).氧疗2、12、24 h,HFNC组患者RR和HR低于常规氧疗组,PaO2和氧合指数高于常规氧疗组(P<0.05).氧疗24 h HFNC组患者痰液黏稠分度优于常规氧疗组(P<0.05).HFNC组患者EICU住院时间短于常规氧疗组,3 d内气管插管率低于常规氧疗组(P<0.05).结论 与常规氧疗相比,采用HFNC纠正AIS并Ⅰ型呼吸衰竭患者缺氧效果更优,可减轻患者气道干燥程度,缩短EICU住院时间,并降低3 d内气管插管率.

1997年,Hiroyuki Nishiyama等[1]发现了细胞核质中的一种新型蛋白,命名为冷诱导RNA结合蛋白(cold-inducible RNA-binding protein,CIRP),也称为A18 hnRNP,属于富含甘氨酸的RNA结合蛋白(GRP)家族的18kDa.结构上,CIRP由172个氨基酸残基组成.N端含有在不同物种中高度保守的RNA识别基序(RRM).C端含有精氨酸和甘氨酸(RGG)基序[2].功能上,CIRP涉及生殖发育、神经发育和调节、胚胎发育、肿瘤发生和动物冬眠等许多生理过程.近年来,其在肿瘤、神经系统保护、脓毒症等方面的研究也逐渐展开,本文就CIRP的临床应用研究的最新进展进行综述.

维持性血液透析是慢性肾脏病患者的重要替代治疗方法,脑出血是维持性血液透析患者的常见并发症,有较高的致死率和致残率,严重影响患者的生活质量.本文探讨维持性血液透析患者的血清磷水平与其并发脑出血的相关性,为临床诊疗提供帮助.

Objective To evaluate the role of gray-white-matter ratio (GWR) on neurological outcome in patients with coma after cardiopulmonary resuscitation (CPR) post-respiratory and cardiac arrest (CA).Methods Respiratory and CA patients with restoration of spontaneous circulation (ROSC) and coma after CPR admitted to Nanjing Drum Tower Hospital Clinical Medical College of Nanjing Medical University from February 2013 to June 2016 were enrolled. All patients were subjected to target temperature management (TTM) after CPR, and received cranial CT within 5 days after ROSC. Attenuation (hounsfield units) was measured at special sites (basal ganglia, centrum semiovale), and specific locus (caudate nucleus, put amen, corpus callosum, posterior limb of internal capsule, medial cortex, medial white matter). The GWR was calculated for basal ganglia and cerebrum. Neurological outcome was judged according to the Glasgow-Pittsburgh cerebral performance category (CPC) at 3 months after ICU discharge. CPC 1-3 were divided into good prognosis, CPC 4-5 were divided into poor prognosis. The receiver-operating characteristic (ROC) curve was drawn to evaluate the prognostic value of GWR in patients with respiratory and CA.Results Forty-three patients were enrolled, including 26 males and 17 females; age (63±15) years old; 14 good prognosis and 29 poor prognosis. Compared with the good prognosis group, the basal ganglia GWR (GWRbg) and the average GWR (GWRav) were significantly lowered in the poor prognosis group (1.064±0.103 vs. 1.163±0.818, 1.068±0.087 vs. 1.128±0.071, bothP < 0.05), the centrum semiovale GWR (GWRce) was similar to that in the good prognosis group (1.072±0.077 vs. 1.092±0.075,P >0.05). It was shown by ROC curve analysis that the GWRbg, GWRav could evaluate the neurological outcomes of patients, but GWRce could not. The area under the ROC curve (AUC) of GWRbg was 0.756 [95％ confidence interval (95％CI) =0.607-0.905,P = 0.007], the cut-off value was 1.13, the sensitivity was 71.4％, and specificity was 69.0％; the AUC of GWRav was 0.701 (95％CI = 0.532-0.869,P = 0.035), the cut-off value was 1.13, the sensitivity was 71.4％, andspecificity was 65.5％; the AUC of GWRce was 0.590 (95％CI = 0.405-0.775,P = 0.344).Conclusions Respiratory and CA patients receiving TTM with high GWR had favorable neurological outcome. GWR, especially GWRbg could provide help for clinical treatment and prognostic value of survival after CA.