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    15 December 2013, Volume 4 Issue 4
    Review Articles
    Safety of epinephrine for anaphylaxis in the emergency setting
    Joseph P Wood, Stephen J Traub, Christopher Lipinski
    2013, 4(4):  245-251.  doi:10.5847/wjem.j.issn.1920-8642.2013.04.001
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    BACKGROUND: While epinephrine is the recommended first-line therapy for the reversal of anaphylaxis symptoms, inappropriate use persists because of misunderstandings about proper dosing and administration or misconceptions about its safety. The objective of this review was to evaluate the safety of epinephrine for patients with anaphylaxis, including other emergent conditions, treated in emergency care settings.
    METHODS: A MEDLINE search using PubMed was conducted to identify articles that discuss the dosing, administration, and safety of epinephrine in the emergency setting for anaphylaxis and other conditions.
    RESULTS: Epinephrine is safe for anaphylaxis when given at the correct dose by intramuscular injection. The majority of dosing errors and cardiovascular adverse reactions occur when epinephrine is given intravenously or incorrectly dosed.
    CONCLUSION: Epinephrine by intramuscular injection is a safe therapy for anaphylaxis but training may still be necessary in emergency care settings to minimize drug dosing and administration errors and to allay concerns about its safety.

    Traumatic brain injury: A case-based review
    Liza Victoria S Escobedo, Joseph Habboushe, Haytham Kaafarani, George Velmahos, Kaushal Shah, Jarone Lee
    2013, 4(4):  252-259.  doi:10.5847/wjem.j.issn.1920-8642.2013.04.002
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    BACKGROUND: Traumatic brain injuries are common and costly to hospital systems. Most of the guidelines on management of traumatic brain injuries are taken from the Brain Trauma Foundation Guidelines. This is a review of the current literature discussing the evolving practice of traumatic brain injury.
    DATA SOURCES: A literature search using multiple databases was performed for articles published through September 2012 with concentration on meta-analyses, systematic reviews, and randomized controlled trials.
    RESULTS: The focus of care should be to minimize secondary brain injury by surgically decompressing certain hematomas, maintain systolic blood pressure above 90 mmHg, oxygen saturations above 93%, euthermia, intracranial pressures below 20 mmHg, and cerebral perfusion pressure between 60-80 mmHg.
    CONCLUSION: Much is still unknown about the management of traumatic brain injury. The current practice guidelines have not yet been sufficiently validated, however equipoise is a major issue when conducting randomized control trials among patients with traumatic brain injury.

    Original Articles
    Therapeutic benefits of mild hypothermia in patients successfully resuscitated from cardiac arrest:A meta-analysis
    Xiao-ping Wang, Qing-ming Lin, Shen Zhao, Shi-rong Lin, Feng Chen
    2013, 4(4):  260-265.  doi:10.5847/wjem.j.issn.1920-8642.2013.04.003
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    BACKGROUND: Good neurological outcome after cardiac arrest (CA) is hard to achieve for clinicians. Experimental and clinical evidence suggests that therapeutic mild hypothermia is beneficial. This study aimed to assess the effectiveness and safety of therapeutic mild hypothermia in patients successfully resuscitated from CA using a meta-analysis.
    METHODS: We searched the MEDLINE (1966 to April 2012), OVID (1980 to April 2012), EMBASE (1980 to April 2012), Chinese bio-medical literature & retrieval system (CBM) (1978 to April 2012), Chinese medical current contents (CMCC) (1995 to April 2012), and Chinese medical academic conference (CMAC) (1994 to April 2012). Studies were included if 1) the study design was a randomized controlled trial (RCT); 2) the study population included patients successfully resuscitated from CA, and received either standard post-resuscitation care with normothermia or mild hypothermia; 3) the study provided data on good neurologic outcome and survival to hospital discharge. Relative risk (RR) and 95% confidence interval (CI) were used to pool the effect.
    RESULTS: The study included four RCTs with a total of 417 patients successfully resuscitated from CA. Compared to standard post-resuscitation care with normothermia, patients in the hypothermia group were more likely to have good neurologic outcome (RR=1.43, 95% CI 1.14-1.80, P=0.002) and were more likely to survive to hospital discharge (RR=1.32, 95% CI 1.08-1.63,P=0.008). There was no significant difference in adverse events between the normothermia and hypothermia groups (P>0.05), nor heterogeneity and publication bias.
    CONCLUSION: Therapeutic mild hypothermia improves neurologic outcome and survival in patients successfully resuscitated from CA.

    Active compression-decompression cardiopulmonary resuscitation (CPR) versus standard CPR for cardiac arrest patients: a meta-analysis
    Xu-rui Luo, Hui-li Zhang, Geng-jin Chen, Wen-shu Ding, Liang Huang
    2013, 4(4):  266-272.  doi:10.5847/wjem.j.issn.1920-8642.2013.04.004
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    BACKGROUND: Active compression-decompression cardiopulmonary resuscitation (ACD-CPR) has been popular in the treatment of patients with cardiac arrest (CA). However, the effect of ACD-CPR versus conventional standard CPR (S-CRP) is contriversial. This study was to analyze the efficacy and safety of ACD-CPR versus S-CRP in treating CA patients.
    METHODS: Randomized or quasi-randomized controlled trials published from January 1990 to March 2011 were searched with the phrase "active compression-decompression cardiopulmonary resuscitation and cardiac arrest" in PubMed, EmBASE, and China Biomedical Document Databases. The Cochrane Library was searched for papers of meta-analysis. Restoration of spontaneous circulation (ROSC) rate, survival rate to hospital admission, survival rate at 24 hours, and survival rate to hospital discharge were considered primary outcomes, and complications after CPR were viewed as secondary outcomes. Included studies were critically appraised and estimates of effects were calculated accordingto the model of fixed or random effects. Inconsistency across the studies was evaluated using the I2 statistic method. Sensitivity analysis was made to determine statistical heterogeneity.
    RESULTS: Thirteen studies met the criteria for this meta-analysis. The studies included 396 adult CA patients treated by ACD-CPR and 391 patients by S-CRP. Totally 234 CA patients were found out hospitals, while the other 333 CA patients were in hospitals. Two studies were evaluated with high-quality methodology and the rest 11 studies were of poor quality. ROSC rate, survival rate at 24 hours and survival rate to hospital discharge with favorable neurological function indicated that ACD-CPR is superior to S-CRP, with relative risk (RR) values of 1.39 (95% CI 0.99-1.97), 1.94 (95% CI 1.45-2.59) and 2.80 (95% CI 1.60-5.24). No significant differences were found in survival rate to hospital admission and survival rate to hospital discharge for ACD-CPR versus S-CRP with RR values of 1.06 (95% CI 0.76-1.60) and 1.00 (95% CI 0.73-1.38).
    CONCLUSION: Quality controlled studies confirmed the superiority of ACD-CPR to S-CRP in terms of ROSC rate and survival rate at 24 hours. Compared with S-CRP, ACD-CPR could not improve survival rate to hospital admission or survival rate to hospital discharge.

    Poor performance of the modified early warning score for predicting mortality in critically ill patients presenting to an emergency department
    Le Onn Ho, Huihua Li, Nur Shahidah, Zhi Xiong Koh, Papia Sultana, Marcus Eng Hock Ong
    2013, 4(4):  273-278.  doi:10.5847/wjem.j.issn.1920-8642.2013.04.005
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    BACKGROUND: This study was undertaken to validate the use of the modified early warning score (MEWS) as a predictor of patient mortality and intensive care unit (ICU)/ high dependency (HD) admission in an Asian population.
    METHODS: The MEWS was applied to a retrospective cohort of 1 024 critically ill patients presenting to a large Asian tertiary emergency department (ED) between November 2006 and December 2007. Individual MEWS was calculated based on vital signs parameters on arrival at ED. Outcomes of mortality and ICU/HD admission were obtained from hospital records. The ability of the composite MEWS and its individual components to predict mortality within 30 days from ED visit was assessed. Sensitivity, specificity, positive and negative predictive values were derived and compared with values from other cohorts. A MEWS of ≥4 was chosen as the cut-off value for poor prognosis based on previous studies.
    RESULTS: A total of 311 (30.4%) critically ill patients were presented with a MEWS ≥4. Their mean age was 61.4 years (SD 18.1) with a male to female ratio of 1.10. Of the 311 patients, 53 (17%) died within 30 days, 64 (20.6%) were admitted to ICU and 86 (27.7%) were admitted to HD. The area under the receiver operating characteristic curve was 0.71 with a sensitivity of 53.0% and a specificity of 72.1% in addition to a positive predictive value (PPV) of 17.0% and a negative predictive value (NPV) of 93.4% (MEWS cut-off of ≥4) for predicting mortality.
    CONCLUSION: The composite MEWS did not perform well in predicting poor patient outcomes for critically ill patients presenting to an ED.

    The prevalence of methicillin-resistant Staphylococcus aureus colonization in emergency department fast track patients
    Kelly Williamson, April Bisaga, Katherine Paquette, Elise Lovell
    2013, 4(4):  278-279.  doi:10.5847/wjem.j.issn.1920-8642.2013.04.006
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    BACKGROUND: Over the past two decades, methicillin-resistantStaphylococcus aureus (MRSA) has evolved from a hospital-associated infection to a significant public health threat in the community, causing outbreaks of soft tissue infections in otherwise healthy individuals. The goal of this study was to determine the prevalence of nasal MRSA colonization in low acuity Emergency Department (ED) Fast Track patients in order to better characterize the epidemiology of this pathogen.
    METHODS: We conducted a cross-sectional study of a convenience sample of adult patients from our ED Fast Track. Nasal swabs were analyzed for MRSA using a polymerase chain reaction assay. Study participants completed a survey assessing traditional risk factors for CA-MRSA colonization.
    RESULTS: A total of 106 ED Fast Track patients were tested. Four (3.8%, 95% CI 1.5%-9.3%) were MRSA positive. Three traditional CA-MRSA risk factors (personal history of abscess, family history of abscess, and participation in contact sports) were examined. In patients with a positive MRSA nasal swab, only a personal prior history of abscess retained significance (OR 33, 95% CI1.7-676, P=0.02).
    CONCLUSION: This study found a higher prevalence of nasal MRSA colonization in low acuity ED Fast Track patients compared with historical community surveillance studies. A personal history of prior abscess was a significant risk for CA-MRSA carriage.

    Comparing lignocaine-adrenaline-tetracaine gel with lignocaine infiltration for anesthesia during repair of lacerations: A randomized trial
    Jean MH Lee, Nina Laxmikantha, Marcus E H Ong, Evelyn Wong, Jeremy CP Wee
    2013, 4(4):  281-284.  doi:10.5847/wjem.j.issn.1920-8642.2013.04.007
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    BACKGROUND: This study aimed to compare the topical anesthetic lignocaine, adrenaline, and tetracaine (LAT) (4% lignocaine, 1:2 000 adrenaline, 1% tetracaine) with the conventional lignocaine infiltration(LI) for repair of minor lacerations, for the comfort of anesthetic administration, efficacy, adverse effects and cost.
    METHODS: This was a prospective randomized clinical trial. Forty Asian patients who required toilet and suture for minor lacerations in the emergency department of the Singapore General Hospital over a 4-month period. The patients were assigned randomly to 2 arms of treatment. The first was the LAT gel group who had LAT gel applied to the laceration prior to suturing. The second was the control group in whom the anesthetic administered was lignocaine infiltration (LI) via a syringe. The pain of the process of administering anesthetic and efficacy of anesthesia were scored using the visual pain scale included within. The efficacy of LAT vs. lignocaine infiltration as an anesthetic prior to the toilet and suture of minor lacerations and complications of therapy.
    RESULTS: Twenty patients were randomized to LAT gel and 16 to LI on an intention to treat analysis. The mean pain score by patients in the LAT gel group was 2.5 (0.52 SE), and 2.5 (0.58 SE) in the LI group. The pain score for pain during application of the anesthetic was 1.5 (0.40) in the LAT gel group, and 3.5 (0.46) in the LI group. There was no difference in complications between the LAT and LI groups.
    CONCLUSION: LAT gel prior to the toilet and suture of minor lacerations is proven to be as efficacious as LI in terms of patient comfort and effectiveness of anesthesia. The complications are also comparable to those treated with LI.

    Endothelial cell injury with inflammatory cytokine and coagulation in patients with sepsis
    Huan Ding, Xiang-yuan Cao, Xi-gang Ma, Wen-jie Zhou
    2013, 4(4):  285-289.  doi:10.5847/wjem.j.issn.1920-8642.2013.04.008
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    BACKGROUND: Current studies on CD62P have focused mainly on cardiovascular diseases, while only few studies have evaluated the effects of CD62P on the development of sepsis and the association between endothelial cell injury with inflammation and coagulation. This study attended to explore the association between endothelial cell injury with inflammation and coagulation by evaluating the expression of soluble CD62P (s-CD62P) in plasma and its mechanism in patients with sepsis, thus to provide the evidence of effective treatment of sepsis with anti-adhesion therapy targeted CD62P.
    METHODS: A total of 70 critically ill patients with systemic inflammatory response syndrome (SIRS) admitted to intensive care unit (ICU) between September 2009 and February 2010 were enrolled for a prospective and control study. According to the diagnostic criteria of sepsis/SIRS, the patients were divided into two groups: a sepsis group (n=38) and a SIRS group (n=32). Another 20 healthy volunteers served as a control group. Patients in the sepsis group and SIRS group were matched by clinical signs of high blood pressure, diabetes and its complications. The demographics of the patients including age, sex, body mass index (BMI), smoking and alcohol addict were compared among the groups. Six mL peripheral blood samples were collected within 24-hour admission in ICU for enzyme-linked immunosorbent assay (ELISA) to detect the plasma levels of s-CD62P, TNF-α, and hs-CRP. And variables of coagulation function such as platelet (PLT), prothrombin (PT), activated partial thromboplastin time (APTT), D-dimer and antithrombin-III (AT-III) were analyzed during 24 hours after admission to ICU. Meanwhile sequential organ failure assessment (SOFA) score of critically ill patients was evaluated. Data were expressed as mean±standard deviation and were statistically analyzed by using SPSS 17.0 statistical software. The differences in plasma levels of s-CD62P of patients in each group were analyzedby ANOVA and the Kruskal-Wallis test. The relations between s-CD62P and inflammatory cytokines as well as with coagulation were determined by Pearson's product moment correlation coefficient analysis. Changes were considered as statistically significant if P value was less than 0.05.
    RESULTS: Compared with the control group and SIRS group, the sepsis group demonstrated significantly higher levels of s-CD62P, TNF-α and highly sensitive C-reactive protein (hs-CRP) (P<0.05). The plasma levels of D-dimer, PT, and APTT in the sepsis and SIRS groups were significantly higher than those in the control group, while the platelet count and the activity of AT-III were obviously lower (P<0.05). In the sepsis group, the plasma levels of hs-CRP and TNF-α were positively correlated with PT, APTT, and D-dimer, and negatively correlated with AT-III and PLT (P<0.05). The plasma levels of s-CD62P were significantly correlated with the plasma levels of TNF-α, hs-CRP, D-dimer, PT, and APTT, whereas they were correlated negatively well with PLT and AT-III (P<0.05).
    CONCLUSIONS: The concentration of plasma s-CD62P is elevated as a early biomarker in patients with sepsis, and it serves as one of the pathogenic factors responsible for endothelial cell damage. Coagulation and mediators of inflammation promote each other, aggravating the severity of sepsis. Plasma s-CD62P may be an important factor for the development of coagulation and inflammatory reaction.

    Effect of hemoperfusion cartridge on different internal environmental indicators
    Li-jun Wang, Nyirimigabo Eric, Mu-ming Yu, Yan-fen Chai
    2013, 4(4):  290-293.  doi:10.5847/wjem.j.issn.1920-8642.2013.04.009
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    BACKGROUND: This study aimed to observe the effect of hemoperfusion (HP) cartridge on different internal environment indicators at different time points in patients with acute blood poisoning and to find alternative indicators for the detection of blood poisoning.
    METHODS: The levels of internal environment indicators (blood pH, PvCO2, PvO2, blood lactate, potassium, free calcium, bicarbonate, and blood glucose) before and after HP treatment were recorded for patients with acute poisoning at time points of 30 minutes and 120 minutes. After calculating thedifference value δ, the statistical software was used to analyze the statistical difference of the influence caused by HP cartridge at two time points. According to the formula, adsorption rate %=$\frac{a-v}{a}$ ×100, the adsorption rate of each indicator was calculated respectively.
    RESULTS: The difference of indicators at different time points in inlet and outlet such as blood glucose, free-calcium, and lactate was statistically significant (P<0.05), but the difference in indicators such as pH, PvCO2, PvO2, potassium, sodium, and bicarbonate was not statistically significant (P>0.05).
    CONCLUSION: During HP treatment, the indicators of blood glucose, free-calcium and lactate were significantly affected by HP cartridge, and the effect varies with time.

    Discrepancy of blood pressure between the brachial artery and radial artery
    Wen-yuan Li, Xiao-hai Wang, Li-chong Lu, Hao Li
    2013, 4(4):  294-297.  doi:10.5847/wjem.j.issn.1920-8642.2013.04.010
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    BACKGROUND: In this study, we attempted to find the relations between blood pressure (BP) measured on the brachial artery (bBP) and BP assessed on the radial artery (rBP) in the right arm.
    METHODS: Three hundred and fifteen patients were enrolled in this study. Those who had peripheral vascular disease, wounds of arm skin or subcutaneous tissue infection were excluded. After a 15-minute equilibration and stabilization period after inducation of anesthesia, three bBP and rBP records were obtained sequentially using an oscillometric device with an adult cuff and infant cuff, respectively. Order for each BP was randomized.
    RESULTS: The bBP was significantly lower than the rBP (P<0.05). The difference between the two values varied from 13 to 18 mmHg in systolic BP (SBP), diastolic BP (DBP) and mean blood pressure (MAP) respectively. And the rBP was positively correlated with the bBP (r=0.872, 0.754, 0.765; P<0.001, <0.001, <0.001; SBP, DBP, MAP, respectively).
    CONCLUSION: The bBP value can be evaluated by the noninvasive measurements of rBP using an appropriate cuff in clinical practice.

    Effects of hypothermia on the liver in a swine model of cardiopulmonary resuscitation
    Yi Han, Zhen-ju Song, Chao-yang Tong, Chun-sheng Li
    2013, 4(4):  298-303.  doi:10.5847/wjem.j.issn.1920-8642.2013.04.011
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    BACKGROUND: The study aimed to explore the effects of hypothermia state induced by 4 ºC normal saline (NS) on liver biochemistry, enzymology and morphology after restoration of spontaneous circulation (ROSC) by cardiopulmonary resuscitation (CPR) in swine.
    METHODS: After 4 minutes of ventricular fibrillation (VF), standard CPR was carried out. Then the survivors were divided into two groups: low temperature group and normal temperature group. The low temperature (LT) group (n=5) received continuously 4 ºC NS at the speed of 1.33 mL/kg per minute for 22 minutes, then at the speed lowering to 10 mL/kg per hour. The normal temperature (NT) group (n=5) received NS with normal room temperature at the same speed of the LT group. Hemodynamic status and oxygen metabolism were monitored and the levels of serum alanine aminotransferase (ALT), aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) were measured in blood samples obtained at baseline and at 10 minutes, 2 hours and 4 hours after ROSC. At 24 hours after ROSC, the animals were killed and the liver was removed to determine the Na+-K+-ATPase and Ca2+-ATPase enzyme activities and histological changes under a light or electron microscope.
    RESULTS: Core temperature was decreased in the LT group (P<0.05), while HR, MAP and CPP were not significantly decreased (P>0.05) compared with the NT group (P>0.05). The oxygen extraction ratio was lower in the LT group than in the NT group (P<0.05). The serum levels of ALT, AST and LDH increased in both groups but not significantly in the LT group. The enzyme activity of liver ATP was much higher in the LT group (Na+-K+-ATP enzyme: 8.64±3.32 U vs. 3.28±0.71 U; Ca2+-ATP enzyme: 10.92±2.12 U vs. 2.75±0.78 U, P<0.05). The LT group showed less cellular edema, inflammation and few damaged mitochondria as compared with the NT group.
    CONCLUSION: These data suggested that infusing 4 ºC NS continuously after ROSC could quickly lower the core body temperature, while maintaining a stable hemodynamic state and balancing oxygen metabolism, which protect the liver in terms of biochemistry, enzymology and histology after CPR.

    Effect of transplantation of bone marrow stem cells on myocardial infarction size in a rabbit model
    Li-li Ji, Xiao-feng Long, Hui Tian, Yu-fei Liu
    2013, 4(4):  304-310.  doi:10.5847/wjem.j.issn.1920-8642.2013.04.012
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    BACKGROUND: Intravenous transplantation has been regarded as a most safe method in stem cell therapies. There is evidence showing the homing of bone marrow stem cells (BMSCs) into the injured sites, and thus these cells can be used in the treatment of acute myocardial infarction (MI). This study aimed to investigate the effect of intravenous and epicardial transplantion of BMSCs on myocardial infarction size in a rabbit model.
    METHODS: A total of 60 New Zealand rabbits were randomly divided into three groups: control group, epicardium group (group I) and ear vein group (group II). The BMSCs were collected from the tibial plateau in group I and group II, cultured and labeled. In the three groups, rabbits underwent thoracotomy and ligation of the middle left anterior descending artery. The elevation of ST segment >0.2 mV lasting for 30 minutes on the lead II and III of electrocardiogram suggested successful introduction of myocardial infarction. Two weeks after myocardial infarction, rabbits in group I were treated with autogenous BMSCs at the infarct region and those in group II received intravenous transplantation of BMSCs. In the control group, rabbits were treated with PBS following thoracotomy. Four weeks after myocardial infarction, the heart was collected from all rabbits and the infarct size was calculated. The heart was cut into sections followed by HE staining and calculation of infarct size with an image system.
    RESULTS: In groups I and II, the infarct size was significantly reduced after transplantation with BMSCs when compared with the control group (P<0.05). However, there was no significant difference in the infarct size between groups I and II (P>0.05).
    CONCLUSION: Transplantation of BMSCs has therapeutic effect on MI. Moreover, epicardial and intravenous transplantation of BMSCs has comparable therapeutic efficacy on myocardial infarction.

    Case Report
    Acute hyperlipidemic pancreatitis in a pregnant woman
    Ying Hang, Yi Chen, Li-xiong Lu, Chang-qing Zhu
    2013, 4(4):  311-313.  doi:10.5847/wjem.j.issn.1920-8642.2013.04.013
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    BACKGROUND: Acute pancreatitis is a serious complication during pregnancy, however the incidence of hyperlipidemia induced by pancreatitis is lower.
    METHODS: We treated a pregnant woman with hypertriglyceridemia-associated acute gestational pancreatitis who simultaneously developed hypoxemic acute respiratory failure (ARF).
    RESULTS: The woman was successfully treated through noninvasive positive pressure ventilation (NPPV), emergent caesarean delivery, drainage of chylous ascites, and peritoneal lavage.
    CONCLUSION: The signs and symptoms of ARF were greatly improved in this patient after NPPV and conventional therapies. Early NPPV may be related to good prognosis of the disease.

    Instructions for Authors
     Instructions for Authors
    Editorial Office
    2013, 4(4):  317. 
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    World Journal of Emergency Medicine (WJEM), a peerreviewed quarterly journal based at the Second Affiliated Hospital of Zhejiang University School of Medicine, China, publishes articles of interest to both clinicians and researchers involving emergency medicine around the world. It focuses on content relevant to clinical practice and research, laboratory studies, continuing education about emergency medicine.