Objective To develop an effective method for delivering VEGF and CD47 double-modified exosomes to treat renal damage induced by heat stroke so as to reduce and repair renal damage. Methods A plasmid fusion-expressing VEGF and CD47 targeting renal injury was constructed, transfected into rat bone marrow derived mesenchymal stem cells (BMMSCs), and then fusion-exosomes were isolated and extracted. Transmission electron microscopy, nanoparticle tracking analysis, and Western blotting were used to identify the obtained exosomes. Rats were intravenously injected with 200 μg of DiD-labeled unmodified exosomes, VEGF-modified exosomes and VEGF-CD47 double-modified exosomes, respectively, through the tail vein, and the effects of exosomes on the kidneys were detected and analyzed using a small animal in vivo imaging instrument. A total of 60 SD rats were randomly divided into 6 groups, with 10 rats in each group, that is, blank control group (group A), heat stroke-induced renal injury model receiving PBS in 12, 24 and 36 h after modelling (group B), empty plasmid group (group C), Exos group (group D), ExosVEGF group (group E) and ExosVEGF-CD47. Kidney tissue and blood samples were collected in 72 h after 3 times of treatment. Pathological changes in kidney tissue were observed at the tissue level and the damage were scored. Changes in serum blood urea nitrogen (BUN) and serum creatinine (Scr) levels were detected to evaluate the therapeutic effect. Western blotting and qRT-PCR were used to analyze the expression of the pro-inflammatory factors TNF-α and NF-κB, the proliferation regulatory signaling molecules Ki67, FGF2, pAMPK and pERK, and the fibrosis regulatory molecule FGF23, in order to comprehensively analyze the effects on proliferation and inhibition of fibrosis. Results BMMSCs and ExosVEGF-CD47 were successfully isolated and characterized, and a rat model of acute kidney injury was effectively constructed. Higher fluorescence intensity was found in the kidney tissue of the ExosVEGF-CD47 group than the Exos-Ctrl group and ExosVEGF group (P<0.05). In 72 h after treatment, the ExosVEGF-CD47 group had significantly lower serum BUN and Scr levels (P<0.0001), and notably lower Tubular casts score (P<0.0001), decreased levels of pro-inflammatory factors TNF-α and NF-κB (P<0.0001), up-regulated Ki67 and FGF2 expression (P<0.05), and down-regulated FGF23 expression (P<0.0001) when compared with the AKI+Exos group and AKI+ExosVEGF group. Conclusion VEGF and CD47 show promise in targeting acute kidney injury induced by heat stroke, effectively mitigate damage and facilitate repair, which may be due to exosome-mediated inhibition of renal tissue inflammation, promotion of proliferation, and inhibition of fibrosis.

A potential inflammatory biomarker, soluble urokinase‐type plasminogen activator receptor (suPAR) has been utilized to assist the prognostic assessment of coronary artery disease (CAD) patients; however, outcomes have been inconsistent. The prognostic relevance of suPAR as a predictor of CAD patient adverse outcomes was therefore examined.

目的 探讨急性闭合性颅脑损伤进展性出血预测系统的初步建立与评价.方法 回顾性分析2012年6月～2020年6月陆军军医大学第一附属医院急救部收治的282例急性闭合性颅脑损伤患者的临床资料,按是否发生进展性出血性损伤分为进展组(n=62)和非进展组(n=220),采用卡方检验或t检验比较两组患者的年龄、性别、受伤部位、受伤机制、损伤类型(单一/多发颅脑损伤)、对光反射、GCS评分、多项生理指标和CT分级等资料,采用ROC曲线和多变量Logistic回归分析确定急性闭合性颅脑损伤后进展性出血的危险因素,根据回归系数β赋值后建立急性闭合性颅脑损伤进展性出血预测系统.结果 年龄(≥56.5岁)、合并多种颅脑损伤、对光反射(迟钝)、GCS评分(9～12分)、白细胞(WBC,≥14.76×109/L)、凝血酶原时间(PT,≥11.25 s)、D-2聚体(D-dimer,≥10.51 mg/L)、活化部分凝血活酶时间(APTT,≥27.4 s)等8个指标为进展性出血损伤的独立危险因素(P＜0.05),赋分后形成急性闭合性颅脑损伤进展性出血预测系统,并划分了低危、中危、高危和极高危四个危险分层,四个危险分层患者进展性出血发生率分别为2.4％、17.5％、46.4％、91.4％.结论 建立急性闭合性颅脑损伤进展性出血的预测系统可以早期、方便、准确地进行伤情评估.

Objective To explore the related risk factors of death in patients with severe trauma, and to establish a preliminary early warning scoring system for the prognosis of severe trauma (hereinafter referred to as the prediction model), so as to provide convenience for clinicians to judge the prognosis of patients early, timely and accurately. Methods The clinical data of 307 patients with severe trauma treated in the Emergency Department of the First Affiliated Hospital of Army Medical University from January 2019 to June 2021 were collected and retrospectively analyzed. They were divided into survival group (n=262) and death group (n=45) according to the outcomes. The age, sex, comorbidity, injury mechanism, number of injury sites, vital signs at admission, results of blood routine test, blood biochemistry test and blood coagulation test, blood gas analysis, endotracheal intubation at admission, emergency operation, use of vasoactive drugs and Glasgow coma score (GCS), injury severity score (ISS), and new injury severity score (NISS) were compared between the 2 groups with univariate analysis. The statistically significant indexes in univariate analysis were included in multivariate logistic regression analysis, and the risk factors affecting the prognosis of the patients were screened, and the prediction model was established according to the assignment of regression coefficient β, and receiver operating characteristic (ROC) curve was drawn to evaluate the predictive value of the prediction model for the prognosis of patients with severe trauma. Results There were differences in injury mechanism, number of injury sites, comorbidity, endotracheal intubation on admission and use of vasoactive drugs between the 2 groups. The age, serum sodium, serum creatinine (Scr), lactic acid, blood glucose, fibrin degradation products and D-dimer were higher, while the body temperature, blood potassium, activated partial thrombin time, oxygenation index and GCS were lower in the death group than the survival group. The results of multivariate logistic regression analysis showed that age (≥62.5 years), Scr (≥77.37 mmol/L), GCS (≤12.5), oxygenation index (≤253.5 mmHg) and body temperature (≤36.25 ℃) were independent risk factors for death in the patients with severe trauma (P < 0.05). The above 5 variables were scored to form the prediction model, which divided severe trauma patients into low-risk, medium-risk and high-risk, and the incidence of death was 2.2%, 28.2% and 74.4%, respectively. When the cut-off value of the prediction model was 15.5, the sensitivity was 86.7%, the specificity was 89.4%, and the Yoden index was 0.764. Conclusion The prediction model is composed of age, Scr, GCS, oxygenation index and body temperature. Its predictive effect is better than those of the 5 indicators alone, and has more advantages than ISS, NISS, acute physiology and chronic health evaluation Ⅱ, sequential organ failure assessment and modified early warning score. It is more helpful to evaluate the prognosis of patients with severe trauma quickly and accurately.

Objective To explore the predictive value of soluble urokinase-type plasminogen activator receptor (suPAR) for severe acute pancreatitis (SAP). Methods A prospective cohort study was designed to enroll 103 patients with acute pancreatitis who were admitted to our department from March 1 to June 1, 2021, including 23 SAP and 80 non-severe acute pancreatitis (NSAP). Another 30 healthy subjects were recruited concurrently as control group. The plasma samples of all subjects were collected on the first day of admission to detect the level of suPAR using ELISA. General clinical data and the levels of procalcitonin (PCT), interleukin-6 (IL-6), C-reactive protein (CRP), D-dimer and serum calcium (Ca2+), as well as the results of blood routine and biochemical examinations of patients were all collected. Acute Physiology and Chronic Health Evaluation (APACHEⅡ) score and Ranson's score were subsequently calculated. For the control subjects, only their demographic characteristics (age and gender) were collected. Statistical analysis was adopted on the above data. Results The plasma suPAR level was significantly higher in the patients with NSAP and SAP than the control group (P < 0.05), and also notably higher in those of the SAP group than those out of the NSAP patients (P < 0.05). Pearson correlation analysis showed that plasma suPAR level was positively correlated with both APACHE Ⅱ score and Ranson's score (R=0.554, R=0.485, P < 0.05). Multivariate Logistic regression analysis indicated that suPAR, D-dimer and Ca2+ levels were independent predictors of SAP. ROC curve demonstrated that serum suPAR had a good predictive value for SAP (AUC=0.869). Conclusion The plasma level of suPAR is closely correlated with the severity of acute pancreatitis, and plays an important role in prediction of SAP.

目的:探讨血浆可溶性尿激酶型纤溶酶原激活物受体(suPAR)和损伤严重度评分(ISS)、新损伤严重度评分(NISS)、改良早期预警评分(MEWS)对急诊严重创伤患者病情危重程度的评估价值.方法:纳入2019年12月-2020年10月期间我院急救部抢救室接诊并收住院的严重创伤患者,入院后检测血浆suPAR并完善上述评分,根据入院24 h内的急性生理学和慢性健康状况评分(APACHE)Ⅱ及序贯器官衰竭评分(SOFA)将患者分为危重组和一般组,比较两组患者的一般情况、ISS、NISS、suPAR和MEWS,采用多因素Logistic回归分析患者病情危重的独立预测因子,绘制受试者工作特征(ROC)曲线明确各指标的评估价值.结果:共纳入101例严重创伤患者,其中危重组34例(33.7％),一般组67例(66.3％),危重组患者的血浆suPAR水平、ISS、NISS和MEWS 均显著高于一般组[(6.9±2.7)ng/mL vs.(5.0±2.0)ng/mL,P=0.000;29(26,34)分vs.25(20,29)分,P=0.004;34(34,41)分vs.33(27,34)分,P=0.001;4(3,5)分vs.2(1,3)分,P=0.000],一般情况的组间差异无统计学意义(P＞0.05);多因素Logistic回归分析显示入院时高MEWS、高血浆suPAR水平和高NISS是严重创伤患者病情危重的独立预测因子(OR=2.286,95％CI:1.501～3.482,P=0.000;OR=1.361,95％CI:1.062～1.744,P=0.015;OR=1.102,95％CI:1.014～1.198,P=0.022),ROC 曲线下面积(AUC)分别为0.829(95％CI:0.741～0.896,P＜0.001)、0.721(95％CI:0.623～0.806,P＜0.001)、0.700(95％CI:0.601～0.788,P＜0.001),取截断值＞3分、＞5.02 ng/mL、＞33分时对应的敏感度和特异度分别为70.59％和83.58％、76.47％和61.19％、82.35％和53.73％;suPAR联合MEWS时AUC 为0.857(95％CI:0.774～0.919,P＜0.001),敏感度为73.53％,特异度为86.57％;suPAR联合NISS时AUC 为0.819(95％CI:0.730～0.888,P＜0.001),敏感度为91.18％,特异度为65.67％.结论:单独应用MEWS、血浆suPAR和NISS均能进一步评估严重创伤患者的病情危重程度,suPAR联合MEWS后评估效能最佳,更适用于急诊.

Objective To investigate the predictive value of plasma soluble urokinase-type plasminogen activator receptor (suPAR) for post-severe traumatic multiple organ dysfunction syndrome (MODS). Methods A total of 108 patients suffering from severe trauma admitted to the Trauma Center of our hospital from December 2019 to December 2020 were enrolled. Venous blood samples were collected at admission and plasma suPAR concentration was measured by ELISA, and their demographic and clinical data were collected. The patients were divided into MODS group and non-MODS group according to the sequential organ failure assessment(SOFA) within 14 d after admission. The general data and variables such as suPAR, white blood cell (WBC) count, and injury severity score (ISS) were compared between the 2 groups. Logistic regression analysis was used to screen the independent predictors for post-traumatic MODS, and receiver operating characteristic (ROC) curve was adopted to evaluate the predictive value of the variables. Results Age, rate of comorbidity, ISS, suPAR at admission, rate of shock, rate of infection and rate of surgery were significantly higher in the MODS group than the non-MODS group [52.6±14.1 vs 46.1±14.1 years old, 29.4% vs 9.5%, 29 (25, 33) vs 26 (21, 30) points, 6.7±2.7 vs 5.0±2.1 ng/mL, 41.2% vs 17.6%, 61.8% vs 24.3%, 52.9% vs 32.4%, P < 0.05]. There were no significant differences in sex, injury cause, injury site, WBC count, and rate of blood purification between the 2 groups. Multivariate Logistic regression analysis showed that comorbidity, ISS, suPAR, and infection were independent predictors for post-traumatic MODS (P < 0.05). ROC curve analysis indicated that the area under the curve (AUC) of suPAR for predicting post-traumatic MODS was 0.704 (P < 0.05). When the cutoff value was 5.04 ng/mL, the sensitivity was 73.5% and the specificity was 62.2%. The AUC of ISS was 0.632 (P < 0.05), and the sensitivity was 73.5% and the specificity was 58.1% when the cutoff value was 26. Conclusion The plasma suPAR level at admission can predict the occurrence of post-traumatic MODS in patients with severe trauma. Early monitoring of suPAR has a certain value in evaluation of inflammation and immune activation in the body and in guidance of clinical evaluation and treatment.

This study was assigned to assess the influence of different blood collection methods and sites on the results of thromboelastography (TEG) in patients underwent thoracic surgery. Forty patients, who underwent lobectomy or esophagectomy in our hospital from May 2014 to March 2015, were randomly divided into two groups (group A and group B; n = 20 in each group). In group A, blood was collected from femoral vein and internal jugular vein by direct venipuncture. In group B, femoral vein blood was sampled by direct venipuncture, and then blood from internal jugular vein was drawn via a deep venous catheter. Kaolin-activated TEG analyses were performed, and clotting time (R), clot kinetics (K), a angle and maximal amplitude (MA) were compared using paired t-test. All tested parameters were within the normal range. In group A, no significant differences in R, K, alpha angle and MA values were found between samples obtained by direct venipuncture from femoral and jugular vein (P > 0.05). In group B, however, the R value of blood sample collected by femoral vein puncture was significantly lower than that of sample captured via an indwelling internal jugular vein catheter (P < 0.05), while differences in K, a angle and MA values did not reach statistical significant (P > 0.05). In summary, all of these sampling routes were acceptable for thromboelastographic analysis. Howbeit, to avoid bias, the sampling method and site should be the same when conducting clinical dynamic observation.

Background Cholinesterase are widely expressed in human tissues and organs, especially in blood plasma and liver. Serum cholinesterase is used as an index of hepatic synthesis function. So far, serum cholinesterase has been found to play a critical role in the evaluation of patients' functional state of organism. Due to its participation in the drug metabolism, serum cholinesterase level can be used as an index for making drug selection by clinical doctors. Objective Here, we review studies on molecular structure, genetic background and physiological function of serum cholinesterase. This review provides reference for the perioperative evaluation and management of patients in clinical anesthesia. Content Different types of cholinesterase and their physiological functions are discussed. We focus on the change of serum cholinesterase and its value in the pre-anesthesia evaluation and drug selection. Trend With deeper studies on serum cholinesterase, its value in clinical care may be broaden.

Background Carbachol solution (0.01％) is an agonist of M cholinoceptor and skeletal muscle N cholinoceptor,and it is used to play miotic effect and open peripheral iridectomic hole during the surgery of implantable collamer lens (ICL) implantation in order to lower intraocular pressure (IOP).However,the anterior chamber injection of 0.01％ carbachol solution often causes relevant complications,while whether lower dose of carbachol solution is effective and safe is unclear.Objective This study was to compare the effectiveness and safety between 0.01％ carbachol solution and 0.005％ carbachol solution after anterior chamber injection during the ICL implantation.Methods One hundred and fifty-two eyes of 76 cataract patients were included in Daping Hospital of Third Military Medical University from September 2014 to September 2015.ICL implantation and periphery iridectomy were carried out on both eyes of the patients and the 0.01％ carbachol solution was injected into the anterior chamber during the surgery of the right eyes and 0.01％ carbachol solution was used in the left eyes.The operation duration and IOP at postoperative 2 hours and systemic choline-like reaction were compared between 0.01％ carbachol solution group and 0.005％ carbachol solution group.Results The mean operation duration was (11.86± 2.39) minutes and (11.22 ± 1.85) minutes in the 0.01％ carbachol group and 0.005％ carbachol group,without significant difference between two groups (t =1.851,P =0.066).IOP was (15.76 ± 2.18) mmHg and (13.58 ±2.24)mmHg in the 0.01％ carbachol group before and after surgery,and those in the 0.005％ carbachol group was (15.70±2.35)mmHg and (13.12±2.17)mmHg,there was no significant difference in the IOP between the two concentrations of carbachol (Fsroup =0.986,P=O.322).The IOP at postoperative 2 hours was lower than that before operation,the difference was statistically significant(Ftime =97.339,P =0.000).There was no interaction between drug concentration and time (Fcorrelation =0.772,P =0.381).The incidences of complications,such as dizziness,nausea and vomiting,were lower in the 0.005％ carbachol group than those in the 0.01％ carbachol group (x2 =13.01,5.16,4.03,all at P＜0.05).Conclusions Carbachol solution (0.005％) can play intraoperative miosis effect and maintain effective operation duration in ICL implantation.In addition,the application of 0.005％ carbachol solution is quite safe in both intraoperation and postoperation.

PNEUMONECTOMY COMMONLY is used to treat patients with end-stage lung cancer, lung cancer associated with hilar lymphadenopathy and pulmonary vascular and bronchial adhesions, or to treat loss of lung ventilatory function from any cause. Pneumonectomy carries a high risk of complications, one of which is cardiac herniation,1,2 which involves protrusion and/or rotation of some part(s) of the heart through a pericardial defect. The condition is well described in standard anesthesia textbooks. This rare clinical entity was first described by Bettman and Tannenbaum in 1948.

We aim to assess efficacy and safety of remifentanil or sulfentanyl combined with propofol during painless gastroscopic examination in patients. In this study, 270 patients were randomly divided into 3 groups: propofol was given only in group P; propofol and remifentanil in group PR; propofol and sulfentanyl in group PS during the gastroscopic examination. Efficiency of group P was significantly lower than that of group PR and PS (P < 0.01). Efficiency of group PR was lower than that of group PS (P < 0.05). Incidence of chest wall rigidity and oxygen desaturation in group PR were higher than group P and PS (P < 0.05), whereas there was no difference between groups P and PS (P > 0.05). Propofol combined with remifentanil could provide satisfying anesthesia and more respiratory depression, whereas sulfentanyl at equivalent dose combined with propofol could also provide with satisfying anesthesia and less respiratory depression. Combined sufentanyl with propofol would be an effective anesthesia technique in the daytime procedure.

<正>女性,60岁,身高150cm,体重65kg,因"活动后气促伴干咳15d"入院,诊断为"左上肺结节、左胸腔积液",拟在全麻下行"胸腔镜下左胸腔探查"术。患者既往体健,无慢性咳嗽、咯痰、活动后气促、心慌、夜间憋醒等症状,其余各系统检查无异常。入院后各项实验室检查指标正常,心电图及心脏彩超无异常,胸部CT提示左胸腔积液,左上肺结节伴左肺压缩70%。入院后在局麻下分别行4次左胸腔穿刺放液,每次放液约500～600ml,患者无特殊不适。

<正>近几十年来,机械通气(mechanical ventilation,MV)作为维护生命的呼吸支持技术在临床治疗中运用日趋广泛。但MV所致的肺损伤(ventilator-induced lung injury,VILI)也受到了国内外专家学者们的关注。研究VILI及其发病机制以用于临床中如何防止和减轻其在治疗过程中带来的危害已成为当前的热点之一。

Thoracoscopic esophagectomy is a feasible technique that has been shown to be safe for the treatment of esophageal cancer. There continues to be controversy about the optimal position during thoracoscopic esophagectomy. In this study, we compared the intraoperative hemodynamic parameters, clinical pathological characteristics, as well as postoperative complications in patients who underwent thoracoscopic esophagectomy in the prone position (PP) or left-lateral decubitus position (LDP).

Objective To evaluate the clinical effects of propofol respectively combined with fentanyl,remifentanil or sufentanil in anesthesia for painless gastroscopy. Methods 360 patients undergoing gastroscopy were randomly divided into four groups:F (fentanyl+propofol),R (remifentanil+propofol),S (sufentanil+propofol),C (propofol).Opioids in four groups were used in equivalent dose and the dosage of propofol in each group was 1.5 mg/kg.Anesthesia effects,onset time and duration of anesthesia with different combinations and the incidence of opioid-related side effects in each group were recorded.The subjects and observers were double-blind to this trial.Results The percentage of satisfactory anesthesia cases in the group C (only 25.6％) waslower than that in the groups F (75.6％),R (94.4％) and S (73.3％) significantly.Comparing the anesthesia onset time of each opiate,it was shorter in group R(3.90±0.39) s than in the group F(9.05±0.63 ) s and the group S (6.45:±0.27) s(P＜0.05 ).There was no significant difference on anesthesia action time in these three groups.No severe cardiac vascular inhibition occurred in all four groups.There were no abdomen rigidity,respiratory depression and other opioid-related side effects happened in the group C.There were higher incidence of abdomen rigidity and significant desaturation(＜90％) in the group R( 17.78％,1.11％) when compared with the group F (4.44％,1.11％ ) and the group S (6.67％,1.11％ )(P＜0.05 ),but lower incidence of bucking and body movement in the group R.Conclusions In anesthesia for painless gastroscopy,more rapid onset of action,better anesthesia effect,but more opioid-related side effects were achieved by using the combination of remifentanil,but not fentanyl and sufentanil,and propofol.

病人,男性,37岁,体重78 Kg,诊断为胆囊结石伴慢性胆囊炎.血常规、凝血功能指标、电解质均在正常范围;胸部影像学检查结果未见异常.无外伤史和手术史,无食物过敏史,药物过敏史不详.气道评估咽部结构Mallampati分级为Ⅱ级。