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    Approach to traumatic cardiac arrest in the emergency department: a narrative literature review for emergency providers
    Rashed Alremeithi, Quincy K. Tran, Megan T. Quintana, Soroush Shahamatdar, Ali Pourmand
    World Journal of Emergency Medicine    2024, 15 (1): 3-9.   DOI: 10.5847/wjem.j.1920-8642.2023.085
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    BACKGROUND: Traumatic cardiac arrest (TCA) is a major contributor to mortality and morbidity in all age groups and poses a significant burden on the healthcare system. Although there have been advances in treatment modalities, survival rates for TCA patients remain low. This narrative literature review critically examines the indications and effectiveness of current therapeutic approaches in treating TCA.
    METHODS: We performed a literature search in the PubMed and Scopus databases for studies published before December 31, 2022. The search was refined by combining search terms, examining relevant study references, and restricting publications to the English language. Following the search, 943 articles were retrieved, and two independent reviewers conducted a screening process.
    RESULTS: A review of various studies on pre- and intra-arrest prognostic factors showed that survival rates were higher when patients had an initial shockable rhythm. There were conflicting results regarding other prognostic factors, such as witnessed arrest, bystander cardiopulmonary resuscitation (CPR), and the use of prehospital or in-hospital epinephrine. Emergency thoracotomy was found to result in more favorable outcomes in cases of penetrating trauma than in those with blunt trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides an advantage to emergency thoracotomy in terms of occupational safety for the operator as an alternative in managing hemorrhagic shock. When implemented in the setting of aortic occlusion, emergency thoracotomy and REBOA resulted in comparable mortality rates. Veno-venous extracorporeal life support (V-V ECLS) and veno-arterial extracorporeal life support (V-A ECLS) are viable options for treating respiratory failure and cardiogenic shock, respectively. In the context of traumatic injuries, V-V ECLS has been associated with higher rates of survival to discharge than V-A ECLS.
    CONCLUSION: TCA remains a significant challenge for emergency medical services due to its high morbidity and mortality rates. Pre- and intra-arrest prognostic factors can help identify patients who are likely to benefit from aggressive and resource-intensive resuscitation measures. Further research is needed to enhance guidelines for the clinical use of established and emerging therapeutic approaches that can help optimize treatment efficacy and ameliorate survival outcomes.

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    Emergency department management of acute agitation in the reproductive age female and pregnancy
    Ariella Gartenberg, Kayla Levine, Alexander Petrie
    World Journal of Emergency Medicine    2024, 15 (2): 83-90.   DOI: 10.5847/wjem.j.1920-8642.2024.011
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    BACKGROUND: Agitation is a common presentation within emergent departments (EDs). Agitation during pregnancy should be treated as an obstetric emergency, as the distress may jeopardize both the patient and fetus. The safety of psychotropic medications in the reproductive age female has not been well established. This review aimed to explore a summary of general agitation recommendations with an emphasis on ED management of agitation during pregnancy.

    METHODS: A literature review was conducted to explore the pathophysiology of acute agitation and devise a preferred treatment plan for ED management of acute agitation in the reproductive age or pregnant female.

    RESULTS: While nonpharmacological management is preferred, ED visits for agitation often require medical management. Medication should be selected based on the etiology of agitation and the clinical setting to avoid major adverse effects. Adverse effects are common in pregnant females. For mild to moderate agitation in pregnancy, diphenhydramine is an effective sedating agent with minimal adverse effects. In moderate to severe agitation, high-potency typical psychotropics are preferred due to their neutral effects on hemodynamics. Haloperidol has become the most frequently utilized psychotropic for agitation during pregnancy. Second generation psychotropics are often utilized as second-line therapy, including risperidone. Benzodiazepines and ketamine have demonstrated adverse fetal outcomes.

    CONCLUSION: While randomized control studies cannot be ethically conducted on pregnant patients requiring sedation, animal models and epidemiologic studies have demonstrated the effects of psychotropic medication exposure in utero. As the fetal risk associated with multiple doses of psychotropic medications remains unknown, weighing the risks and benefits of each agent, while utilizing the lowest effective dose remains critical in the treatment of acute agitation within the EDs.

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    Blood gas analysis as a surrogate for microhemodynamic monitoring in sepsis
    Jingyi Wang, Li Weng, Jun Xu, Bin Du
    World Journal of Emergency Medicine    2023, 14 (6): 421-427.   DOI: 10.5847/wjem.j.1920-8642.2023.093
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    BACKGROUND: Emergency patients with sepsis or septic shock are at high risk of death. Despite increasing attention to microhemodynamics, the clinical use of advanced microcirculatory assessment is limited due to its shortcomings. Since blood gas analysis is a widely used technique reflecting global oxygen supply and consumption, it may serve as a surrogate for microcirculation monitoring in septic treatment.

    METHODS: We performed a search using PubMed, Web of Science, and Google scholar. The studies and reviews that were most relevant to septic microcirculatory dysfunctions and blood gas parameters were identified and included.

    RESULTS: Based on the pathophysiology of oxygen metabolism, the included articles provided a general overview of employing blood gas analysis and its derived set of indicators for microhemodynamic monitoring in septic care. Notwithstanding flaws, several parameters are linked to changes in the microcirculation. A comprehensive interpretation of blood gas parameters can be used in order to achieve hemodynamic optimization in septic patients.

    CONCLUSION: Blood gas analysis in combination with clinical performance is a reliable alternative for microcirculatory assessments. A deep understanding of oxygen metabolism in septic settings may help emergency physicians to better use blood gas analysis in the evaluation and treatment of sepsis and septic shock.

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    Acute hemolytic anemia in a 34-year-old man after inhalation of a volatile nitrite “popper” product
    Xiang Peng, Liuyang Cheng, Huanhuan Gong, Jie Wang, Xiaowei Ke, Xiangmin Li
    World Journal of Emergency Medicine    2023, 14 (5): 414-415.   DOI: 10.5847/wjem.j.1920-8642.2023.075
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    Hemorrhagic pancreatitis from fenofibrate and metformin toxicity: a case report
    Marcus Aik Beng Lee, Mingwei Ng, Paul Yugendra, Yiju Yao, R Ponampalam, Boon Kiat Kenneth Tan
    World Journal of Emergency Medicine    2023, 14 (6): 495-498.   DOI: 10.5847/wjem.j.1920-8642.2023.106
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    Prevalence and risk factors for acquired long QT syndrome in the emergency department: a retrospective observational study
    Diogo de Almeida Fernandes, Guilherme de Freitas Camões, Diana Ferreira, Carolina Queijo, Carlos Fontes-Ribeiro, Lino Gonçalves, Rui Pina, Natália António
    World Journal of Emergency Medicine    2023, 14 (6): 454-461.   DOI: 10.5847/wjem.j.1920-8642.2023.104
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    BACKGROUND: Long QT syndrome (LQTS) is a heterogeneous syndrome that may be congenital or, more frequently, acquired. The real-world prevalence of acquired LQTS (aLQTS) in the emergency department (ED) remains to be determined. The aim of this study was to determine prevalence of aLQTS and its impact on symptoms on ED admissions.

    METHODS: Electrocardiograms (ECG) of 5,056 consecutively patients admitted in the ED of a tertiary hospital between January 28th and March 17th of 2020 were reviewed. All patients with aLQTS were included. Clinical data with a focus on QT prolonging drugs and clinical factors were recorded. Statistical comparison was made between the groups with and without corrected QT (QTc) interval greater than 500 ms (value that is considered severely increased).

    RESULTS: A total of 383 ECGs with prolonged QTc were recognized, corresponding to a prevalence of aLQTS at admission of 7.82%. Patients with aLQTS were more commonly men (53.3%) with an age of (73.49±14.79) years old and QTc interval of (505.3±32.4) ms. Only 20.4% of these patients with aLQTS were symptomatic. No ventricular arrhythmias were recorded. Patients with QT interval greater than 500 ms were more frequently female (59.5%; P<0.001) and were more frequently on QT prolonging drugs (77.3%; P=0.025). Main contributing factor was intake of antibiotics (odds ratio [OR] 4.680) followed by female gender (OR 2.473) and intake of antipsychotics (OR 1.925).

    CONCLUSION: aLQTS is particularly prevalent in the ED. Female patients on antibiotics and antipsychotics are at particularly high risk. Efforts must be made to avoid, detect and treat aLQTS as early as possible.

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    The effect of prophylactic antibiotics in acute upper gastrointestinal bleeding patients in the emergency department
    Miao Gan, Liang Zong, Xuezhong Yu, Jun Xu
    World Journal of Emergency Medicine    2023, 14 (6): 442-447.   DOI: 10.5847/wjem.j.1920-8642.2023.062
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    BACKGROUND: Currently, prophylactic antibiotics are recommended only for cirrhotic patients with acute upper gastrointestinal bleeding (AUGIB); however, the benefit for other AUGIB patients remains undetermined. We aimed to compare the clinical outcomes between patients with AUGIB with and without prophylactic antibiotics to identify the population that requires this therapy.

    METHODS: Patients with AUGIB admitted between 1st January 2019 and 31st December 2021 in the Emergency Department of Peking Union Medical College Hospital were enrolled. Patients were divided into the antibiotic and non-antibiotic groups. The primary outcome was in-hospital mortality, and the secondary outcome was the onset of new infection. The risk factors for mortality and infection were analyzed, and stratification analysis of prophylactic antibiotics was performed. Continuous data were analyzed using the t-test or nonparametric rank sum test, and categorical data were analyzed using the Chi-square test or Fisher’s exact test. Indicators with significant differences between the groups were included for logistic regression analysis. A P-value <0.05 was considered statistically significant.

    RESULTS: A total of 392 individuals were included, among them, 281 patients received prophylactic antibiotics, and 111 patients did not receive prophylactic antibiotics. The mortality rates were significantly lower in the antibiotic group than in the non-antibiotics group (6.41% vs. 17.12%, P=0.001). The risk factors for infection were varicose veins (P=0.045) and endotracheal intubation (P=0.005) in the prophylactic antibiotic group, and endoscopic treatment (P=0.010) in the non-prophylactic antibiotic group. Stratified analyses showed that patients with age ≥ 65 years, endotracheal intubation, endoscopic treatment, and AUGIB of variceal etiologies benefited from prophylactic antibiotics.

    CONCLUSION AUGIB patients may benefit from prophylactic antibiotics to decrease mortality, especially those aged ≥ 65 years and those with endotracheal intubation, endoscopic treatment, and variceal etiologies.

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    Trends in oxycodone and oxycodone-containing analgesics administration for back pain in emergency departments in the USA (2007-2018)
    Jonathan Chabon, Jemer Garrido, Deanna Schreiber-Gregory, Jefferson Drapkin, Sergey Motov
    World Journal of Emergency Medicine    2024, 15 (3): 169-174.   DOI: 10.5847/wjem.j.1920-8642.2024.002
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    BACKGROUND: To describe trends in oxycodone and oxycodone-containing analgesic prescribing for the treatment of back pain among adults in emergency departments (EDs) in the USA from 2007 to 2018.
    METHODS: Data were gathered from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2007 to 2018. The study population included individuals of all ages presenting to USA EDs. The NHAMCS reasons for visit and oxycodone drug ID codes were used to isolate patients with back pain. The main outcome was the proportion of oxycodone and oxycodone-containing analgesics prescribed for back pain in the EDs over the specified time period.
    RESULTS: There was a relative decrease in the overall administration of oxycodone for back pain in the EDs by 62.3% from 2007 (244,000 visits) to 2018 (92,000 visits). The proportion of ED patients prescribed with oxycodone-containing analgesics for back pain increased among patients aged 45 years and older (from 43.8% to 57.6%), female patients (from 54.5% to 62.0%), black patients (from 22.5% to 30.4%), and Hispanic/Latino patients (from 9.4% to 19.6%). Oxycodone/acetaminophen was most prescribed and accounted for 90.2% of all oxycodone-containing analgesics in 2007, with a decrease to 68.5% in 2018. Pure oxycodone was the second most prescribed medication, accounting for 6.1% in 2007 and 31.5% in 2018.
    CONCLUSION: The overall number of oxycodone-containing analgesics decreased significantly from 2007 to 2018. However, that number trended upward in 45-year-old and older, female, black, or Hispanic/Latino patients from 2007 to 2018. The total amount of pure oxycodone increased significantly from 2007 to 2008.

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    Recurrent malignant hyperthermia after scoliosis correction surgery
    Junfeng Su, Man Huang
    World Journal of Emergency Medicine    2024, 15 (1): 70-72.   DOI: 10.5847/wjem.j.1920-8642.2024.006
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    Severe disseminated intravascular coagulation complicated by acute renal failure during pregnancy
    Yuqun Pu, Jingping Zhu, Baihui Zhao, Mengmeng Yang, Qiong Luo
    World Journal of Emergency Medicine    2023, 14 (5): 411-413.   DOI: 10.5847/wjem.j.1920-8642.2023.072
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    Key elements and checklist of shared decision-making conversation on life-sustaining treatment in emergency: a multispecialty study from China
    Shu Li, Jing Xie, Ziyi Chen, Jie Yan, Yuliang Zhao, Yali Cong, Bin Zhao, Hua Zhang, Hongxia Ge, Qingbian Ma, Ning Shen
    World Journal of Emergency Medicine    2023, 14 (5): 380-385.   DOI: 10.5847/wjem.j.1920-8642.2023.076
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    BACKGROUND: Shared decision-making (SDM) has broad application in emergencies. Most published studies have focused on SDM for a certain disease or expert opinions on future research gaps without revealing the full picture or detailed guidance for clinical practice. This study is to investigate the optimal application of SDM to guide life-sustaining treatment (LST) in emergencies.
    METHODS: This study was a prospective two-round Delphi consensus-seeking survey among multiple stakeholders at the China Consortium of Elite Teaching Hospitals for Residency Education. Participants were identified based on their expertise in medicine, law, administration, medical education, or patient advocacy. All individual items and questions in the questionnaire were scored using a 5-point Likert scale, with responses ranging from “very unimportant” (a score of 1) to “extremely important” (a score of 5). The percentages of the responses that had scores of 4-5 on the 5-point Likert scale were calculated. A Kendall’s W coefficient was calculated to evaluate the consensus of experts.
    RESULTS: A two-level framework consisting of 4 domains and 22 items as well as a ready-to-use checklist for the informed consent process for LST was established. An acceptable Kendall’s W coefficient was achieved.
    CONCLUSION: A consensus-based framework supporting SDM during LST in an emergency department can inform the implementation of guidelines for clinical interventions, research studies, medical education, and policy initiatives.

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    Effects of mesencephalic astrocyte-derived neurotrophic factor on sepsis-associated acute kidney injury
    Saifeng Chen, Xuewei Hao, Guo Chen, Guorong Liu, Xiaoyan Yuan, Peiling Shen, Dongfeng Guo
    World Journal of Emergency Medicine    2023, 14 (5): 386-392.   DOI: 10.5847/wjem.j.1920-8642.2023.077
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    BACKGROUND: To determine the protective role of mesencephalic astrocyte-derived neurotrophic factor (MANF) in regulating sepsis-associated acute kidney injury (S-AKI).
    METHODS: A total of 96 mice were randomly divided into the control group, control+MANF group, S-AKI group, and S-AKI+MANF group. The S-AKI model was established by injecting lipopolysaccharide (LPS) at 10 mg/kg intraperitoneally. MANF (200 μg/kg) was administered to the control+MANF and S-AKI+MANF groups. An equal dose of normal saline was administered daily intraperitoneally in the control and S-AKI groups. Serum and kidney tissue samples were obtained for biochemical analysis. Western blotting was used to detect the protein expression of MANF in the kidney, and enzyme-linked immunosorbent assay (ELISA) was used to determine expression of MANF in the serum, pro-inflammatory cytokines (tumor necrosis factor-α [TNF-α] and interleukin-6 [IL-6]). Serum creatinine (SCr), and blood urea nitrogen (BUN) were examined using an automatic biochemical analyzer. In addition, the kidney tissue was observed for pathological changes by hematoxylin-eosin staining. The comparison between two groups was performed by unpaired Student’s t-test, and statistics among multiple groups were carried out using Tukey’s post hoc test following one-way analysis of variance (ANOVA). A P-value <0.05 was considered statistically significant.
    RESULTS: At the early stage of S-AKI, MANF in the kidney tissue was up-regulated, but with the development of the disease, it was down-regulated. Renal function was worsened in the S-AKI group, and TNF-α and IL-6 were elevated. The administration of MANF significantly alleviated the elevated levels of SCr and BUN and inhibited the expression of TNF-α and IL-6 in the kidney. The pathological changes were more extensive in the S-AKI group than in the S-AKI+MANF group.
    CONCLUSION: MANF treatment may significantly alleviate renal injury, reduce the inflammatory response, and alleviate or reverse kidney tissue damage. MANF may have a protective effect on S-AKI, suggesting a potential treatment for S-AKI.

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    Inferior vena cava thrombosis in two adult patients with veno-arterial extracorporeal membrane oxygenation
    Xiao Chen, Anyu Qian, Mao Zhang, Guangju Zhou
    World Journal of Emergency Medicine    2023, 14 (5): 408-410.   DOI: 10.5847/wjem.j.1920-8642.2023.073
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    Duplicated gallbladder with acute cholecystitis: a case of unusual presentation and diagnostic challenges
    Eren Ogut, Fatos Belgin Yildirim, Osman Memis
    World Journal of Emergency Medicine    2024, 15 (2): 156-158.   DOI: 10.5847/wjem.j.1920-8642.2024.021
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    Application of multidisciplinary in situ simulation training in the treatment of acute ischemic stroke: a quality improvement project
    Ganying Huang, Huijie Yang, Huan Yao, Xinxin Fan, Wenqin Xia, Yuansheng Xu, Xiaoling Shen, Xue Zhao
    World Journal of Emergency Medicine    2024, 15 (1): 41-46.   DOI: 10.5847/wjem.j.1920-8642.2023.084
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    BACKGROUND: Ischemic stroke refers to a disorder in the blood supply to a local area of brain tissue for various reasons and is characterized by high morbidity, mortality, and disability. Early reperfusion of brain tissue at risk of injury is crucial for the treatment of acute ischemic stroke. The purpose of this study was to evaluate comfort levels in managing acute stroke patients with hypoxemia who required endotracheal intubation after multidisciplinary in situ simulation training and to shorten the door-to-image time.
    METHODS: This quality improvement project utilized a comprehensive multidisciplinary in situ simulation exercise. A total of 53 participants completed the two-day in situ simulation training. The main outcome was the self-reported comfort levels of participants in managing acute stroke patients with hypoxemia requiring endotracheal intubation before and after simulation training. A 5-point Likert scale was used to measure participant comfort. A paired-sample t-test was used to compare the mean self-reported comfort scores of participants, as well as the endotracheal intubation time and door-to-image time on the first and second days of in situ simulation training. The door-to-image time before and after the training was also recorded.
    RESULTS: The findings indicated that in situ simulation training could enhance participant comfort when managing acute stroke patients with hypoxemia who required endotracheal intubation and shorten door-to-image time. For the emergency management of hypoxemia or tracheal intubation, the mean post-training self-reported comfort score was significantly higher than the mean pre-training comfort score (hypoxemia: 4.53±0.64 vs. 3.62±0.69, t= -11.046, P<0.001; tracheal intubation: 3.98±0.72 vs. 3.43±0.72, t= -6.940, P<0.001). We also observed a decrease in the tracheal intubation and door-to-image time and a decreasing trend in the door-to-image time, which continued after the training.
    CONCLUSION: Our study demonstrates that the implementation of in situ simulation training in a clinical environment with a multidisciplinary approach may improve the ability and confidence of stroke team members, optimize the first-aid process, and effectively shorten the door-to-image time of stroke patients with emergency complications.

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    A case report of intramyocardial dissecting hematoma: a challenging diagnosis
    Yaoyao Zhu, Tong Wang, Longyuan Jiang, Lian Liang
    World Journal of Emergency Medicine    2023, 14 (5): 405-407.   DOI: 10.5847/wjem.j.1920-8642.2023.074
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    Hepatic rupture secondary to HELLP syndrome: outcomes in three cases
    Salvador Gomez-Carro, Ruben R. Lozano-Salazar, Kassandra Santos-Zaldívar, Victor Andres Villasuso-Alcocer, Nina Méndez-Domínguez
    World Journal of Emergency Medicine    2024, 15 (1): 56-58.   DOI: 10.5847/wjem.j.1920-8642.2024.003
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    Establishment and evaluation of animal models of sepsis-associated encephalopathy
    Mubing Qin, Yanxia Gao, Shigong Guo, Xin Lu, Qian Zhao, Zengzheng Ge, Huadong Zhu, Yi Li
    World Journal of Emergency Medicine    2023, 14 (5): 349-353.   DOI: 10.5847/wjem.j.1920-8642.2023.088
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    BACKGROUND: Sepsis-associated encephalopathy (SAE) is a critical disease caused by sepsis. In addition to high mortality, SAE can also adversely affect life quality and lead to significant socioeconomic costs. This review aims to explore the development of evaluation animal models of SAE, giving insight into the direction of future research in terms of its pathophysiology and therapy.
    METHODS: We performed a literature search from January 1, 2000, to December 31, 2022, in MEDLINE, PubMed, EMBASE, and Web of Science using related keywords. Two independent researchers screened all the accessible articles based on the inclusion and exclusion criteria and collected the relevant data of the studies.
    RESULTS: The animal models for sepsis are commonly induced through cecal ligation and puncture (CLP) or lipopolysaccharide (LPS) injection. SAE can be evaluated using nervous reflex scores and sepsis evaluation during the acute phase, or through Morris water maze (MWM), open-field test, fear condition (FC) test, inhibitory avoidance, and other tests during the late phase.
    CONCLUSION: CLP and LPS injection are the most common methods for establishing SAE animal models. Nervous reflexs cores, MWM, FC test, and inhibitory avoidance are widely used in SAE model analysis. Future research should focus on establishing a standardized system for SAE development and analysis.

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    Computed tomography coronary angiography after excluding myocardial infarction: high-sensitivity troponin versus risk score-guided approach
    Won Jae Yoo, Shin Ahn, Bora Chae, Won Young Kim
    World Journal of Emergency Medicine    2023, 14 (6): 428-433.   DOI: 10.5847/wjem.j.1920-8642.2023.094
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    BACKGROUND: Patients with suspected acute coronary syndrome (ACS) in whom myocardial infarction has been ruled out are still at risk of having obstructive coronary artery disease (CAD). This rate is higher among patients with intermediate high-sensitivity troponin I (hsTnI) concentrations (5 ng/L to 99th percentile) than low concentrations (<5 ng/L). Therefore, an intermediate concentration has been suggested as a candidate for downstream investigation with computed tomography coronary angiography (CTCA). We tried to compare the HEART score-guided vs. hsTnI-guided approach for identifying obstructive CAD.

    METHODS: From a prospective cohort study of patients presenting to the emergency department with suspected ACS, 433 patients without elevated hsTnI who also underwent CTCA were selected and analyzed. The performances of hsTnI concentration and HEART score were compared using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

    RESULTS: Overall, 120 (27.7%) patients had obstructive CAD. Patients with intermediate hsTnI concentrations were more likely to have obstructive CAD than those with low hsTnI concentrations (40.0% vs. 18.1%); patients with non-low-risk HEART scores (≥4 points) were also more likely to have obstructive CAD than those with low-risk scores (0 to 3 points) (41.0% vs. 7.6%). The HEART score had higher sensitivity and NPV for detecting obstructive CAD in each classification than hsTnI concentration (sensitivity: 89.2% vs. 63.3%; NPV: 92.4% vs. 81.9%, respectively).

    CONCLUSION: After excluding myocardial infarction in patients with suspected ACS, adding the HEART score for selecting candidates for CTCA could improve patient risk stratification more accurately than relying on hsTnI concentration.

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    Omadacycline for the treatment of Legionella pneumophila pneumonia caused by drowning: a case report
    Xiao Lu, Wenqi Qi, Haizhen Wang, Zhongjun Zheng, Libing Jiang, Shanxiang Xu
    World Journal of Emergency Medicine    2023, 14 (6): 481-483.   DOI: 10.5847/wjem.j.1920-8642.2023.090
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