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Volume 7 ， Issue 4 ， 2020
- Abstract：Since December 2019, a novel type of coronavirus disease (COVID-19) in Wuhan led to an outbreak throughout China and the rest of the world. To date, there have been more than 1,260,000 COVID-19 patients, with a mortality rate of approximately 5.44%. Studies have shown that coagulation dysfunction is a major cause of death in patients with severe COVID-19. Therefore, the People's Liberation Army Professional Committee of Critical Care Medicine and Chinese Society on Thrombosis and Hemostasis grouped experts from the frontline of the Wuhan epidemic to come together and develop an expert consensus on diagnosis and treatment of coagulation dysfunction associated with a severe COVID-19 infection. This consensus includes an overview of COVID-19-related coagulation dysfunction, tests for coagulation, anticoagulation therapy, replacement therapy, supportive therapy and prevention. The consensus produced 18 recommendations which are being used to guide clinical work.Keywords：COVID-19;Severe;Coagulation dysfunction;diagnosis;Treatment5|0|0Updated：2023-06-05
POSITION ARTICLE AND GUIDELINES
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Abstract：Background:Gastric cancer is the 2nd most common cause of cancer-related deaths, and the morbidity rate after surgery is reported to be as high as 46%. The estimation of possible complications, morbidity, and mortality and the ability to specify patients at high risk have become substantial for an intimate follow-up and for proper management in the intensive care unit. This study aimed to determine the prognostic value of the preoperative platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) and their relations with clinical outcomes and complications after gastrectomy for gastric cancer.Methods:This single-center, retrospective cohort study evaluated the data of 292 patients who underwent gastrectomy with curative intent between January 2015 and June 2018 in a tertiary state hospital in Ankara, Turkey. A receiver operating characteristic curve was generated to evaluate the ability of laboratory values to predict clinically relevant postoperative complications. The area under the curve was computed to compare the predictive power of the NLR and PLR. Then, the cutoff points were selected as the stratifying values for the PLR and NLR.Results:The area under the curve values of the PLR (0.60, 95% CI 0.542–0.657) and NLR (0.556, 95% CI 0.497–0.614) were larger than those of the other preoperative laboratory values. For the PLR, the diagnostic sensitivity and specificity were 50.00% and 72.22%, respectively, whereas for the NLR, the diagnostic sensitivity and specificity were 37.50% and 80.16%, respectively. The PLR was related to morbidity, whereas the relation of the NLR with mortality was more prominent. This study demonstrated that the PLR and NLR may predict mortality and morbidity via the Clavien-Dindo classification in gastric cancer patients. The variable was grade ≥3 in the Clavien-Dindo classification, including complications requiring surgical or endoscopic interventions, life-threatening complications, and death. Both the PLR and NLR differed significantly according to Clavien-Dindo grade ≥3. In this analysis, the PLR was related to morbidity, while the NLR relation with mortality was more intense.Conclusion:Based on the results of the study, the PLR and NLR could be used as independent predictive factors for mortality and morbidity in patients with gastric cancer.Keywords：Preoperative;Platelet-to-lymphocyte ratio;Neutrophil-to-lymphocyte ratio;Morbidity;Gastrectomy;Stomach cancer4|1|0Updated：2023-06-05 -
Abstract：Background:Attrition rate in new army recruits is higher than in incumbent troops. In the current study, we identified the risk factors for attrition due to injuries and physical fitness failure in recruit training. A variety of predictive models were attempted.Methods:This retrospective cohort included 19, 769 Army soldiers of the Australian Defence Force receiving recruit training during a period from 2006 to 2011. Among them, 7692 reserve soldiers received a 28-day training course, and the remaining 12,077 full-time soldiers received an 80-day training course. Retrieved data included anthropometric measures, course-specific variables, injury, and physical fitness failure. Multivariate regression was used to develop a variety of models to predict the rate of attrition due to injuries and physical fitness failure. The area under the receiver operating characteristic curve was used to compare the performance of the models.Results:In the overall analysis that included both the 28-day and 80-day courses, the incidence of injury of any type was 27.8%. The 80-day course had a higher rate of injury if calculated per course (34.3% vs. 17.6% in the 28-day course), but lower number of injuries per person-year (1.56 vs. 2.29). Fitness test failure rate was significantly higher in the 28-day course (30.0% vs. 12.1%). The overall attrition rate was 5.2% and 5.0% in the 28-day and 80-day courses, respectively. Stress fracture was common in the 80-day course (n=44) and rare in the 28-day course (n=1). The areas under the receiver operating characteristic curves for the course-specific predictive models were relatively low (ranging from 0.51 to 0.69), consistent with "failed" to "poor" predictive accuracy. The course-combined models performed somewhat better than the course-specific models, with two models having AUC of 0.70 and 0.78, which are considered "fair" predictive accuracy.Conclusion:Attrition rate was similar between 28-day and 80-day courses. In comparison to the 80-day full course, the 28-day course had a lower rate of injury but a higher number of injuries per person-year and of fitness test failure. These findings suggest fitness level at the commencement of training is a critically important factor to consider when designing the course curriculum, particularly short courses.Keywords：Military training;Predictive modelling;Risk management;Soldier4|0|0Updated：2023-06-05 -
Abstract：Background:Incidence and risk factors of parachute injuries has been studied in developed countries, but not in trainees of the airborne forces in the Royal Thailand Army.Methods:A prospective cohort study was conducted among 992 military personnel who attended the basic airborne training program from February to July 2018. Information sheets were used to collect data about (a) personal demographics; (b) environmental conditions surrounding the parachute practice; and (c) parachute-related injuries. The incidence rate of injury was then calculated. Risk factors were examined using multilevel Poisson regression analysis and presented as incidence rate ratio (IRR) and 95% confidence interval (95% CI).Results:A total of 166 parachute-related injuries occurred in 4677 jumps. The incidence rate of injury was 35.50 per 1000 jumps (95% CI 30.04–41.21). Factors significantly related to parachute injury included: jumping with equipment versus without equipment [adjusted IRR (95% CI): 1.28(0.88–1.87)], higher wind speed [1.54(1.27–1.87) per knot], airplane versus helicopter exit [1.75(0.68–4.55)], side versus rear exit [2.13(1.43–3.23)], night versus day jumping[2.19(0.81–5.90)], and presence of motion sickness [3.43(1.93–6.92)].Conclusions:To prevent military static line parachute injuries, the following factors should be taken into consideration: type of aircraft, aircraft exit, time of the day, equipment, motion sickness and wind speed.Trial registration:The project was certified by the Research Ethics Committee, Faculty of Medicine, Chulalongkorn University (IRB No. 697/60).Keywords：Injuries;Parachute;Paratroopers4|0|0Updated：2023-06-05 -
Abstract：Background:LL-37 peptide is a member of the human cathelicidin family, and has been shown to promote the healing of pressure ulcers. However, the low stability of this peptide within the wound environment limits its clinical use. Chitosan (CS) hydrogel is commonly used as a base material for wound dressing material.Methods:CS hydrogel (2.5% w/v) was encapsulated with LL-37. Cytotoxicity of the product was examined in cultured NIH3T3 fibroblasts. Effects on immune response was examined by measuring tumor necrosis factor-α (TNF-α) release from RAW 264.7 macrophages upon exposure to lipopolysaccharides. Antibacterial activity was assessed using Staphylococcus aureus. Potential effect on pressure ulcers was examined using a mouse model. Briefly, adult male C57BL/6 mice were subjected to skin pressure using magnets under a 12/12 h schedule for 21 days. Mice were randomized to receive naked LL-37 (20 μg), chitosan gel containing 20 μg LL-37 (LL-37/CS hydrogel) or hydrogel alone under the ulcer bed (n=6). A group of mice receiving no intervention was also included as a control.Results:LL-37/CS hydrogel did not affect NIH3T3 cell viability. At a concentration of 1–5 μg/ml, LL-37/CS inhibited TNF-α release from macrophage. At 5 μg/ml, LL-37/CS inhibited the growth of Staphylococcus aureus. The area of the pressure ulcers was significantly lower in mice receiving LL-37/CS hydrogel in comparison to all other 3 groups on days 11 (84.24%±0.25%), 13 (56.22%±3.91%) and 15 (48.12%±0.28%). Histological examination on days 15 and 21 showed increased epithelial thickness and density of newly-formed capillary with naked LL-37 and more so with LL-37/CS. The expression of key macromolecules in the process of angiogenesis (i.e., hypoxia inducible factor-1α(HIF-1α) and vascular endothelial growth factor-A (VEGF-A)) in wound tissue was increased at both the mRNA and protein levels.Conclusion:Chitosan hydrogel encapsulated with LL-37 is biocompatible and could promote the healing of pressure ulcers.Keywords：LL-37;Chitosan hydrogel;Deep tissue injury;Pressure ulcer;Cathelicidin4|0|0Updated：2023-06-05 -
Abstract：Background:Many healthcare workers were infected by coronavirus disease 2019 (COVID-19) early in the epidemic posing a big challenge for epidemic control. Hence, this study aims to explore perceived infection routes, influencing factors, psychosocial changes, and management procedures for COVID-19 infected healthcare workers.Methods:This is a cross-sectional, single hospital-based study. We recruited all 105 confirmed COVID-19 healthcare workers in the Zhongnan Hospital of Wuhan University from February 15 to 29, 2020. All participants completed a validated questionnaire. Electronic consent was obtained from all participants. Perceived causes of infection, infection prevention, control knowledge and behaviour, psychological changes, symptoms and treatment were measured.Results:Finally, 103 professional staff with COVID-19 finished the questionnaire and was included (response rate:98.1%). Of them, 87 cases (84.5%) thought they were infected in working environment in hospital, one (1.0%) thought their infection was due to the laboratory environment, and 5(4.9%) thought they were infected in daily life or community environment. Swab of throat collection and physical examination were the procedures perceived as most likely causing their infection by nurses and doctors respectively. Forty-three (41.8%) thought their infection was related to protective equipment, utilization of common equipment (masks and gloves). The top three first symptoms displayed before diagnosis were fever (41.8%), lethargy (33.0%) and muscle aches (30.1%). After diagnosis, 88.3% staff experienced psychological stress or emotional changes during their isolation period, only 11.7% had almost no emotional changes. Arbidol (Umifenovir; an anti-influza drug; 69.2%) was the drug most commonly used to target infection in mild and moderate symptoms.Conclusion:The main perceived mode of transmission was not maintaining protection when working at a close distance and having intimate contact with infected cases. Positive psychological intervention is necessary.Keywords：COVID-19;SARS-CoV-2;2019-nCoV;Healthcare worker;Healthcare professional;Infection transmission route;Psychosocial status4|0|0Updated：2023-06-05
RESEARCH
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Abstract：Background:Systematic evaluation of the successful heartbeat recovery rate (HRR) in patients during the platinum ten minutes after cardiac arrest.Methods:The databases of CNKI (January 1979–March 2019), Chongqing VIP (January 1989–March 2019), Wanfang(January 1990–March 2019) and Web of Science (January 1900-May 2020) were searched. To collect the clinical data of patients with cardiac arrest before hospitalization and analyze the cardiopulmonary resuscitation (CPR) at different times. Literature selection and data extraction were carried out by two researchers independently, and the meta package of R software (version 3. 61) was used for analysis.Results:A total of 116 papers met the inclusion criteria, including 37,181 patients. Of these patients, 3367 had their heartbeats successfully restored. The results showed a high degree of heterogeneity (χ2=6999.21, P<0.01, I2=97.6%). The meta-analysis was conducted using a random-effects model. The combined effect size was 0.199 (0.157–0.250).(1) According to the five CPR groups (International Cardiopulmonary Resuscitation Guide 2000, 2005, 2010, 2015 and other versions), the HRR of other versions [0.264(0.176–0.375)] was higher than the International Cardiopulmonary Resuscitation 2005 edition [0.121(0.092–0.158)]. (2) The rescue time was divided into the 0 to ≤5 min group, the 5 to≤10 min group, the 10 to ≤15 min group, and the >15 min group. The HRR were 0.417(0.341–0.496), 0.143(0.104–0.193),0.049 (0.034–0.069), and 0.022 (0.009–0.051), respectively. The HRR was higher in the 0 to ≤5 min group than in the 5 to ≤10 min group, the 10 to ≤15 min group and the >15 min group. There was no difference between the 10 to ≤15 min group and the >15 min group. (3) When the groups were stratified with the cutoff of 10 min, the ≤10 min group HRR[0.250(0.202–0.306)] was higher than the >10 min group rate [0.041(0.029–0.057)]. (4) The HRR of the telephone guidance group was [0.273(0.227–0.325)] lower than that of the 0 to ≤5 min group [0.429(0.347–0.516)] but higher than that of the 5 to ≤10 min group, the 10 to ≤15 min group, and the >15 min group. (5) The HRR of the witness group[0.325(0.216–0.458)] was not different from that of the 0 to ≤5 min group, but it was higher than those of the 5 to≤10 min group, the 10 to ≤15 min group and the >15 min group. (6) There was no significant difference HRR between the witnessed group, the telephone guidance group and the ≤10 min group.Conclusions:(1) The HRR is time-sensitive, and early rescue can improve it. (2) CPR performed within the platinum ten minutes must be executed by the public, and other forces are auxiliary. (3) The concept of peri-cardiac arrest period (PCAP) should be established and improved to guide CPR.Keywords：Sudden cardiac arrest;cardiopulmonary resuscitation;Peri-cardiac arrest period;Platinum 10 min;Meta-analysis4|0|0Updated：2023-06-05 -
Abstract：Background:Intracranial infection after craniotomy is one of the most serious postoperative complications, especially multidrug-resistant (MDR) or extensively drug-resistant (XDR) bacterial meningitis, and strongly affects the prognosis of patients. Current treatment experience regarding these infections is scarce.Case presentation:We report a case of severe intracranial infection of XDR Acinetobacter baumannii (A. baumannii) that was treated by intravenous (IV) injection, sequential intraventricular (IVT) injection of tigecycline and polymyxin B, and other anti-infective drugs. Good results were obtained, and the patient was eventually discharged from the hospital. This case is characterized by intracranial infection.Conclusions:The polymyxin B IV+IVT pathway is an ideal treatment strategy for XDR A. baumannii. The tigecycline IVT pathway is also a safe treatment option.Keywords：Intraventricular injection of tigecycline;Polymyxin B;Intracranial infection;Acinetobacter baumannii5|0|0Updated：2023-06-05
CASE REPORT
- Abstract：Hemorrhage is the leading cause of preventable death in combat trauma and the secondary cause of death in civilian trauma. A significant number of deaths due to hemorrhage occur before and in the first hour after hospital arrival. A literature search was performed through PubMed, Scopus, and Institute of Scientific Information databases for English language articles using terms relating to hemostatic agents, prehospital, battlefield or combat dressings, and prehospital hemostatic resuscitation, followed by cross-reference searching. Abstracts were screened to determine relevance and whether appropriate further review of the original articles was warranted. Based on these findings, this paper provides a review of a variety of hemostatic agents ranging from clinically approved products for human use to newly developed concepts with great potential for use in prehospital settings. These hemostatic agents can be administered either systemically or locally to stop bleeding through different mechanisms of action. Comparisons of current hemostatic products and further directions for prehospital hemorrhage control are also discussed.Keywords：Hemostatic agent;Hemorrhage control;Trauma4|0|0Updated：2023-06-05
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Abstract：Neuronal networks, especially those in the central nervous system (CNS), evolved to support extensive functional capabilities while ensuring stability. Several physiological "brakes" that maintain the stability of the neuronal networks in a healthy state quickly become a hinderance postinjury. These "brakes" include inhibition from the extracellular environment, intrinsic factors of neurons and the control of neuronal plasticity. There are distinct differences between the neuronal networks in the peripheral nervous system (PNS) and the CNS. Underpinning these differences is the trade-off between reduced functional capabilities with increased adaptability through the formation of new connections and new neurons. The PNS has "facilitators" that stimulate neuroregeneration and plasticity, while the CNS has "brakes" that limit them. By studying how these "facilitators" and "brakes" work and identifying the key processes and molecules involved, we can attempt to apply these theories to the neuronal networks of the CNS to increase its adaptability. The difference in adaptability between the CNS and PNS leads to a difference in neuroregenerative properties and plasticity. Plasticity ensures quick functional recovery of abilities in the short and medium term. Neuroregeneration involves synthesizing new neurons and connections, providing extra resources in the long term to replace those damaged by the injury, and achieving a lasting functional recovery. Therefore, by understanding the factors that affect neuroregeneration and plasticity, we can combine their advantages and develop rehabilitation techniques. Rehabilitation training methods, coordinated with pharmacological interventions and/or electrical stimulation, contributes to a precise, holistic treatment plan that achieves functional recovery from nervous system injuries. Furthermore, these techniques are not limited to limb movement, as other functions lost as a result of brain injury, such as speech, can also be recovered with an appropriate training program.Keywords：Neuroregeneration;Plasticity;Neuronal systems;Postinjury;central nervous system;Peripheral nervous system;Rehabilitation6|0|0Updated：2023-06-05
REVIEW
- Abstract：This paper reviews the historical evolution of the language and organization surrounding the health of personnel in the British Army from 'hygiene’ through to 'wellbeing’. It starts by considering the health of the army in the mid-nineteenth century and the emergence of military hygiene as a professional subject. It continues by looking at advances in military hygiene in the two world wars. Hygiene was replaced by the term 'health’ in the 1950s as the collective noun used by professionals working in this field. This unity split when the professions of occupational medicine and public health established separate faculties and training pathways. However, the health issues for the armed forces remain fundamentally unchanged. Going forward, the term 'wellbeing’ is helping to refresh the close relationships between executives, their medical advisers and those within the population of health professions charged with keeping the British Army healthy. The core theme is the collaborations between civil society, executive leadership and medical services in maximizing the health of the military population from recruitment through to life as a veteran.Keywords：Public health;Hygiene;Occupational medicine5|0|0Updated：2023-06-05
PERSPECTIVE
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Abstract：Background:Limb loss has a drastic impact on a patient's life. Severe trauma to the extremities is common in current military conflicts. Among other aspects, "life before limb" damage control surgery hinders immediate replantation within the short post-traumatic timeframe, which is limited in part by the ischemic time for successful replantation. Ex vivo limb perfusion is currently being researched in animal models and shows promising results for its application in human limb replantation and allotransplantation.Presentation of the hypothesis:The current lack of replantation possibilities in military operations with high rates of amputation can be addressed with the development of a portable ex vivo limb perfusion device, as there are several opportunities present with the introduction of this technique on the horizon. We hypothesize that ex vivo limb perfusion will enable overcoming the critical ischemic time, provide surgical opportunities such as preparation of the stump and limb, allow for spare-part surgery, enable rigorous antibiotic treatment of the limb, reduce ischemia-reperfusion injuries, enable a tissue function assessment before replantation, and enable the development of large limb transplant programs.Testing the hypothesis:Data from in vivo studies in porcine models are limited by the relatively short perfusion time of 24 h. In the military setting, notably longer perfusion times need to be realized. Therefore, future animal studies must focus especially on long-term perfusion, since this represents the military setting, considering the time for stabilization of the patient until evacuation to a tertiary treatment center.Implications of the hypothesis:The development and clinical introduction of ex vivo limb perfusion in the military setting could lead to a drastic reduction in the number of limb amputations among service members. Ex vivo limb perfusion enables replantation surgery in Role 4 facilities and changes the clinical setting from a highly urgent, life-threatening situation to a highly methodical, well-prepared starting point for optimal treatment of the wounded service member. With its introduction, the principle of "life before limb" will change to "life before limb before elective replantation/allotransplantation after ex vivo limb perfusion".Keywords：Ex vivo limb perfusion;traumatic amputation;ischemia and reperfusion-related injuries;hypothesis4|0|0Updated：2023-06-05
HYPOTHESIS
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Abstract：In this Commentary, we would like to comment on the article titled "A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version)" as a featured article in Military Medical Research. In the guideline, except for "confirmed cases", "suspected cases", "close contact" and "suspicious exposure" were defined by clinical perspective based on epidemiological risk, clinical symptoms and auxiliary examination. Combined with our experience, we introduced a simple scoring proposal additionally based on not only CT imaging as strongly recommended by the guideline but also blood routine test, especially for primary screening of such patients in the out-patient department.Keywords：COVID-19;Suspected cases;Primary screening;CT imaging;Blood test6|0|0Updated：2023-06-05
COMMENTARY
- Abstract：On 6 February 2020, our team had published a rapid advice guideline for diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infection, and this guideline provided our experience and make well reference for fighting against this pandemic worldwide. However, the coronavirus disease 2019 (COVID-19) is a new disease, our awareness and knowledge are gradually increasing based on the ongoing research findings and clinical practice experience; hence, the strategies of diagnosis and treatment are also continually updated. In this letter, we answered one comment on our guideline and provided the newest diagnostic criteria of "suspected case" and "confirmed case" according to the latest Diagnosis and Treatment Guidelines for COVID-19 (seventh version) that issued by the National Health Committee of the People's Republic of China.Keywords：COVID-19;SARS-CoV-2;2019-nCoV;Guideline;prevention;diagnosis;Treatment;Novel coronavirus5|0|0Updated：2023-06-05
LETTER TO THE EDITOR
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