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Table of Content

    15 December 2012, Volume 3 Issue 4
    Review Articles
    Immigrants and the utilization of hospital emergency departments
    Ibrahim Mahmoud, Xiang-yu Hou
    2012, 3(4):  245-250.  doi:10.5847/wjem.j.issn.1920-8642.2012.04.001
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    BACKGROUND: Immigrants with language barriers are at high risk of having poor access to health care services. However, several studies have indicated that immigrants tend to use emergency departments (EDs) as their primary source of care at the expense of primary care. This may place an additional burden on already overcrowded EDs and lead to a low level of patient satisfaction with ED care. The study was to review if immigrants utilize ED care differently from host populations and to assess immigrants’ satisfaction with ED care.

    DATA SOURCES: Studies about immigrants' utilization of EDs in Australia and worldwide were reviewed.

    RESULTS: There are conflicting results in the literature about the pattern of ED care use among immigrants. Some studies have shown higher utilization by immigrants compared to host populations and others have shown lower utilization. Overall, immigrants use ED care heavily, make inappropriate visits to EDs, have a longer length of stay in EDs, and are less satisfied with ED care as compared to host populations.

    CONCLUSIONS: Immigrants might use ED care differently from host populations due to language and cultural barriers. There is sparse Australian literature regarding immigrants' access to health care including ED care. To ensure equity, further research is needed to inform policy when planning health care provision to immigrants.

    Overview of the Shenzhen Emergency Medical Service Call Pattern
    Shuk Man Lo, Yi Min Yu, Lap Yip Larry Lee, Mi Ling Eliza Wong, Sek Ying Chair, Edward J Kalinowski, Tak Shing Jimmy Chan
    2012, 3(4):  251-256.  doi:10.5847/wjem.j.issn.1920-8642.2012.04.002
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    BACKGROUND: In Shenzhen, the Emergency Medical Service (EMS) system has been in service since 1997. This study aims to examine the operation of Shenzhen 120 EMS center and to identify the reasons of calling EMS.

    METHODS: In this retrospective quantitative descriptive study, the data from the Shenzhen 120 EMS registry in 2011 were analyzed.

    RESULTS: Shenzhen 120 EMS center is a communication command center. When the number of 120 are dialed, it is forwarded to the closest appropriate hospital for ambulance dispatch. In 2011, the Shenzhen 120 EMS center received 153 160 ambulance calls, with an average of 420 calls per day. Calling emergency services was mainly due to traffic accidents. Trauma and other acute diseases constituted a majority of ambulance transports. The adult patients aged 15-60 years are the principal users of EMS. There are no recognized 'paramedic' doctors and nurses. The pre-hospital emergency service is under the operation of emergency departments of hospitals. Shenzhen at present does not have specialized pre-hospital training for doctors and nurses in post-trauma management. Moreover, specialized pre-hospital training, financial support, and public health education on proper use of EMS should be emphasized.

    CONCLUSION: The Shenzhen 120 EMS center has its own epidemiology characteristics. Traumatic injury and traffic accident are the main reasons for calling ambulance service. In-depth study emphasizing the distribution and characteristics of trauma patients is crucial to the future development of EMS.

    Circulating microRNAs, novel biomarkers of acute myocardial infarction: a systemic review
    Yan Chen, Wei Yang, Gan-nan Wang, Jun Li, Xiao-rong Li, Jian Zhang, Wei Yuan, Dao-wu Wang, Jin-song Zhang, Ke-jiang Cao
    2012, 3(4):  257-260.  doi:10.5847/wjem.j.issn.1920-8642.2012.04.003
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    BACKGROUND: MicroRNAs (MiRNA) are a novel class of non-coding RNAs involved in the regulation of gene expression post-transcriptionally by cleavage or translational repression of their specific target miRNAs. Numerous studies have demonstrated that circulating miRNAs are stable and abundant in blood and aberrantly expressed under pathological conditions, including cardiovascular diseases. The implications of circulating miRNAs in acute myocardial infarction have recently been recognized. This review will highlight the potential role of miRNA as a novel class of biomarkers in acute myocardial infarction.

    METHODS: This systemic review is based on our own work and other related reports.

    RESULTS: During diseases circulating miRNAs are derived from not only circulating blood cells but also other tissues affected by ongoing diseases. These disease-related miRNAs in the blood can serve as potential biomarkers.

    CONCLUSION: The circulating miRNAs can be used as novel biomarkers potentially offering more sensitive and specific tests than those currently available for diagnosis of acute myocardial infarction.

    Original Articles
    Error reporting in the emergency department: do we do what we say we do?
    Rebecca Jeanmonod, Benjamin Katz
    2012, 3(4):  261-264.  doi:10.5847/wjem.j.issn.1920-8642.2012.04.004
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    BACKGROUND: The Joint Commission accreditation manual contains standards in improving organization performance related to report and review of patient care issues causing unexpected harm. In spite of regulations mandating reporting, it remains inconsistent, varying by provider type and hospital. Our purpose was to determine current attitudes, knowledge, and practice of error reporting among emergency department (ED) providers.

    METHODS: We administered a survey assessing ED staff practice regarding error reporting. Questions involved reporting of errors in which the practitioner was directly involved, errors the practitioner observed, and general awareness of reporting mandates. We also questioned individuals regarding fear of repercussions for reporting.

    RESULTS: Fifty-two surveys were returned. For most errors, providers were more likely to tell their supervisor about the issue than to tell the patient. Seventeen percent of respondents did not think that referring errors for review was their job. Only 31% of respondents were aware of standardized institution-wide pathways to report errors. Any respondent who was aware of the institution-wide pathway also felt responsibility for error reporting. Thirty-three percent of the respondents were concerned about negative repercussions from reporting errors. In querying the hospital reporting system, 263 cases were referred for quality issues over the previous year, 51% of them were referred by nurses, 27% by medical technicians (MTs), 2% by mid-level providers (MLPs), 1% by physicians, and 19% by other personnel.

    CONCLUSION: Although most of the ED staff are responsible for patient safety, most are not aware of systems available to assist in reporting, and even many do not utilize those systems.

    Do mannequin chests provide an accurate representation of a human chest for simulated decompression of tension pneumothoraxes?
    Malcolm J Boyle, Brett Williams, Simon Dousek
    2012, 3(4):  265-269.  doi:10.5847/wjem.j.issn.1920-8642.2012.04.005
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    BACKGROUND: Tension pneumothorax (TPX) is an uncommon but life-threatening condition. It is important that this uncommon presentation, managed by needle decompression, is practised by paramedics using a range of educationally sound and realistic mannequins. The objective of this study is to identify if the chest wall thickness (CWT) of training mannequins used for chest decompression is an anatomically accurate representation of a human chest.

    METHODS: This is a two-part study. A review of the literature was conducted to identify chest wall thickness in humans and measurement of chest wall thickness on two commonly used mannequins. The literature search was conducted using the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, and EMBASE databases from their beginning until the end of May 2012. Key words included chest wall thickness, tension pneumothorax, pneumothorax, thoracostomy, needle thoracostomy, decompression, and needle test. Studies were included if they reported chest wall thickness.

    RESULTS: For the literature review, 4 461 articles were located with 9 meeting the inclusion criteria. Chest wall thickness in adults varied between 1.3 cm and 9.3 cm at the area of the second intercostal space mid clavicular line. The Laerdal® manikin in the area of the second intercostal space mid clavicular line, right side of the chest was 1.1 cm thick with the left 1.5 cm. The MPL manikin in the same area or on the right side of the chest was 1.4 cm thick but on the left 1.0 cm.

    CONCLUSION: Mannequin chests are not an accurate representation of the human chest when used for decompressing a tension pneumothorax and therefore may not provide a realistic experience.

    Evaluation and treatment of altered mental status patients in the emergency department: Life in the fast lane
    Hai-yu Xiao, Yu-xuan Wang, Teng-da Xu, Hua-dong Zhu, Shu-bin Guo, Zhong Wang, Xue-zhong Yu
    2012, 3(4):  270-277.  doi:10.5847/wjem.j.issn.1920-8642.2012.04.006
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    BACKGROUND: Altered mental status (AMS) is a very common emergency case, but the exact etiology of many AMS patients is unknown. Patients often manifest vague symptoms, thus, AMS diagnosis and treatment are highly challenging for emergency physicians. The aim of this study is to provide a framework for the assessment of AMS patients. This assessment should allow providers to better understand the etiology of mental status changes and therefore improve diagnostic skills and management.

    METHODS: This is a prospective cohort observational study. We recruited all adult patients with undifferentiated AMS at a single center tertiary care academic emergency department over 24 months (June 2009 to June 2011). Demographic characteristics, clinical manifestations, assessment approaches, causative factors, emergency treatments and outcomes were collected prospectively.

    RESULTS: In 1934 patients with AMS recruited, accounting for 0.93% of all emergency department (ED) patients, 1 026 (53.1%) were male, and 908 (46.9%) female. Their average age was 51.95±15.71 years. Etiologic factors were neurological (n=641; 35.0%), pharmacological and toxicological (n=421; 23.0%), systemic and organic (n=266; 14.5%), infectious (n=167; 9.1%), endocrine/metabolic (n=145; 7.9%), psychiatric (n=71; 3.9%), traumatic (n=38; 2.1%), and gynecologic and obstetric (n=35; 1.9%). Total mortality rate was 8.1% (n=156). The death rate was higher in elderly patients (≥60) than in younger patients (10.8% vs. 6.9%, P=0.003).

    CONCLUSIONS: Patients with AMS pose a challenge for ED physicians. The most frequently encountered diagnostic categories causing AMS were primary CNS disorders, intoxication, organ system dysfunction, and endocrine/metabolic diseases. AMS has a high fatality rate in the ED. AMS is an important warning signal for ED patients because of its potentially fatal and reversible effects. Prompt evaluation and treatment are essential to decreasing morbidity and mortality associated with AMS.

    Two acute kidney injury risk scores for critically ill cancer patients undergoing non-cardiac surgery
    Xue-zhong Xing, Hai-jun Wang, Chu-lin Huang, Quan-hui Yang, Shi-ning Qu, Hao Zhang, Hao Wang, Yong Gao, Qing-ling Xiao, Ke-lin Sun
    2012, 3(4):  278-281.  doi:10.5847/wjem.j.issn.1920-8642.2012.04.007
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    BACKGROUND: Several risk scoures have been used in predicting acute kidney injury (AKI) of patients undergoing general or specific operations such as cardiac surgery. This study aimed to evaluate the use of two AKI risk scores in patients who underwent non-cardiac surgery but required intensive care.

    METHODS: The clinical data of patients who had been admitted to ICU during the first 24 hours of ICU stay between September 2009 and August 2010 at the Cancer Institute, Chinese Academy of Medical Sciences & Peking Union Medical College were retrospectively collected and analyzed. AKI was diagnosed based on the acute kidney injury network (AKIN) criteria. Two AKI risk scores were calculated: Kheterpal and Abelha factors.

    RESULTS: The incidence of AKI was 10.3%. Patients who developed AKI had a increased ICU mortality of 10.9% vs. 1.0% and an in-hospital mortality of 13.0 vs. 1.5%, compared with those without AKI. There was a significant difference between the classification of Kheterpal's AKI risk scores and the occurrence of AKI (P<0.001). There was no significant difference between the number of Abelha's AKI risk scores and the occurrence of AKI (P=0.499). Receiver operating characteristic curves demonstrated an area under the curve of 0.655±0.043 (P=0.001, 95% confidence interval: 0.571-0.739) for Kheterpal's AKI risk score and 0.507±0.044 (P=0.879, 95% confidence interval: 0.422-0.592) for Abelha's AKI risk score.

    CONCLUSION: Kheterpal's AKI risk scores are more accurate than Abelha's AKI risk scores in predicting the occurrence of AKI in patients undergoing non-cardiac surgery with moderate predictive capability.

    PKCα signaling pathway involves in TNF-α-induced IP3R1 expression in human mesangial cells
    Yu-rong Wang, Huan Zhang, Hui Sun, Pei Liu
    2012, 3(4):  282-286.  doi:10.5847/wjem.j.issn.1920-8642.2012.04.008
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    BACKGROUND: This study aimed to explore the effects of TNF-α on the expression of IP3R1 mRNA and protein in human mesangial cells (HMCs), and to elucidate the mechanism of TNF-α relating to IP3R1 expression in the occurrence of hepatorenal syndrome (HRS).

    METHODS: HMCs were stimulated by tumor (TNF-α) with 100 ng/mL for different hours (2, 4, 8, and 24 hours). The expression changes of IP3R1 mRNA and protein were detected by quantitative real-time polymerase chain reaction and immunoblotting. Several inhibitors including D609, U73122, PP1, safingol, rottlerin and non-radioactive protein kinase C (PKC) were used to examine the mechanism of signal transduction of TNF-α-regulated IP3R1 in HMCs.

    RESULTS: The levels of IP3R1 mRNA at 2 hours after TNF-α exposure were significantly enhanced and peaked at 8 hours in HMCs (P<0.01), then descended at 24 hours (P<0.01). The levels of IP3R1 protein at 4 hours after TNF-α exposure were obviously increased and peaked at 24 hours after TNF-α exposure (P<0.01). Compared to the control group, safingol (PKCα inhibitor) and D609 (phosphatidylcholine-specific phospholipase C inhibitor) significantly blocked the TNF-α-induced expression of IP3R1 mRNA (3.30±0.81 vs. 1.95±0.13, P<0.05; 2.10±0.49, P<0.01) and IP3R1 protein (3.09±0.13 vs. 1.86+0.39, P<0.01; 1.98±0.02, P<0.01). TNF-α promoted PKCα activation with maximal PKCα phosphorylation that occurred 8 hours after stimulation measured by non-radioactive PKC assay, and the effect was markedly attenuated by pretreatment with D609 or safingol.

    CONCLUSION: TNF-α increased the expression of IP3R1 and this was mediated, at least in part, through the PC-PLC/PKCα signaling pathways in HMCs.

    Effects of dynamic ventilatory factors on ventilator-induced lung injury in acute respiratory distress syndrome dogs
    Rui-lan Wang, Kan Xu, Kang-long Yu, Xue Tang, Hui Xie
    2012, 3(4):  287-293.  doi:10.5847/wjem.j.issn.1920-8642.2012.04.009
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    BACKGROUND: Mechanical ventilation is a double-edged sword to acute respiratory distress syndrome (ARDS) including lung injury, and systemic inflammatory response high tidal volumes are thought to increase mortality. The objective of this study is to evaluate the effects of dynamic ventilatory factors on ventilator induced lung injury in a dog model of ARDS induced by hydrochloric acid instillation under volume controlled ventilation and to investigate the relationship between the dynamic factors and ventilator-induced lung injuries (VILI) and to explore its potential mechanisms.

    METHODS: Thirty-six healthy dogs were randomly divided into a control group and an experimental group. Subjects in the experimental group were then further divided into four groups by different inspiratory stages of flow. Two mL of alveolar fluid was aspirated for detection of IL-8 and TNF-α. Lung tissue specimens were also extracted for total RNA, IL-8 by western blot and observed under an electronic microscope.

    RESULTS: IL-8 protein expression was significantly higher in group B than in groups A and D. Although the IL-8 protein expression was decreased in group C compared with group B, the difference was not statistically significant. The TNF-α ray degree of group B was significantly higher than that in the other groups (P<0.01), especially in group C (P>0.05). The alveolar volume of subjects in group B was significantly smaller, and cavity infiltration and cell autolysis were marked with a significant thicker alveolar septa, disorder of interval structures, and blurring of collagenous and elastic fiber structures. A large number of necrotic debris tissue was observed in group B.

    CONCLUSION: Mechanical ventilation with a large tidal volume, a high inspiratory flow and a high ventilation frequency can cause significant damage to lung tissue structure. It can significantly increase the expression of TNF-α and IL-8 as well as their mRNA expression. Furthermore, the results of our study showed that small tidal ventilation significantly reduces the release of pro-inflammatory media. This finding suggests that greater deterioration in lung injury during ARDS is associated with high inspiratory flow and high ventilation rate.

    Effects of pituitary adenylate cyclase activating polypeptide on CD4+/CD8+ T cell levels after traumatic brain injury in a rat model
    Rong Hua, Shan-shan Mao, Yong-mei Zhang, Fu-xing Chen, Zhong-hai Zhou, Jun-quan Liu
    2012, 3(4):  294-298.  doi:10.5847/wjem.j.issn.1920-8642.2012.04.010
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    BACKGROUND: The effect of pituitary adenylate cyclase activating polypeptide (PACAP) during traumatic brain injury (TBI) and whether it can modulate secondary injury has not been reported previously. The present study evaluated the potential protective effects of ventricular infusion of PACAP in a rat model of TBI.

    METHODS: Male Sprague Dawley rats were randomly divided into 3 treatment groups (n=6, each): sham-operated, vehicle (normal saline)+TBI, and PACAP+TBI. Normal saline or PACAP (1 μg/5 μL) was administered intracerebroventricularly 20 minutes before TBI. Right parietal cortical contusion was produced via a weight-dropping method. Brains were extracted 24 hours after trauma. Histological changes in brains were examined by HE staining. The numbers of CD4+ and CD8+ T cells in blood and the spleen were detected via flow cytometry.

    RESULTS: In injured brain regions, edema, hemorrhage, inflammatory cell infiltration, and swollen and degenerated neurons were observed under a light microscope, and the neurons were disorderly arrayed in the hippocampi. Compared to the sham group, average CD4+ CD8- lymphocyte counts in blood and the spleen were significantly decreased in rats that received TBI+vehicle, and CD4- CD8+ were increased. In rats administered PACAP prior to TBI, damage was attenuated as evidenced by significantly increased CD4+, and decreased CD8+, T lymphocytes in blood and the spleen.

    CONCLUSION: Pretreatment with PACAP may protect against TBI by influencing periphery T cellular immune function.

    Prospective experimental studies on the renal protective effect of ulinastatin after paraquat poisoning
    Zhi-jian Zhang, Li-bo Peng, Ya-juan Luo, Cong-yang Zhou
    2012, 3(4):  299-304.  doi:10.5847/wjem.j.issn.1920-8642.2012.04.011
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    BACKGROUND: Paraquat (PQ) is an effective herbicide and is widely used in agricultural production, but PQ poisoning is frequently seen in humans with the lung as the target organ. Currently, there are many studies on lung injury after PQ poisoning. But the kidney as the main excretory organ after PQ poisoning is rarely studied and the mechanisms of this poisoning is not very clear. In this study, we observed the expression of caspase-3 and livin protein in rat renal tissue after PQ poisoning as well as the therapeutic effects of ulinastatin.

    METHODS: Fifty-four Sprague-Dawley (SD) rats were randomly divided into three experimental groups: control group (group A), paraquat poisoning group (group B) and ulinastatin group (group C), with 18 rats in each group. Rats in group B and group C were administered intragastrically with 80 mg/kg PQ, rats in group C were injected peritoneally with 100 000 U/kg ulinastatin once a day, while rats in group A were administered intragastrically with the same volume of saline as PQ. At 24, 48, 72 hours after poisoning, the expression of livin in renal tissue was detected by Westen blotting, the expression of caspase-3 was detected by immunohistochemistry, and the rate of renal cell apoptosis was tested by TUNEL detection. The histopathological changes were observed at the same time.

    RESULTS: Compared to group A, the expression of caspase-3 in the renal tissue of rats in groups B and C increased significantly at any time point. Compared with group B, the expression of caspase-3 in renal tissue of rats in group C decreased. Compared with group A, the expression of livin in renal tissue in rats of groups B and C increased significantly at any time point (P<0.01), especially in group C (P<0.01). TUNEL method showed that the rate of renal cell apoptosis index was higher in group B at corresponding time points than in group A (P<0.01), and was lower in group C at corresponding time points than in group B (P<0.01).

    CONCLUSION: UTI has a protective effect on the renal tissue of rats after paraquat poisoning through up-regulating the expression of livin and down-regulating the expression of caspase-3, but the regulation path still needs a further research.

    Case Reports
    ST elevation myocardial infarction in a young patient after ingestion of caffeinated energy drink and ecstasy
    Shlomo Hanan Israelit, Algxander Strizevsky, Bennidor Raviv
    2012, 3(4):  305-307.  doi:10.5847/wjem.j.issn.1920-8642.2012.04.012
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    BACKGROUND: Caffeinated energy drinks are widely used worldwide. They are associated with a variety of adverse effects and are of concern to health authorities, yet there is still scarce information about their adverse effects and inadequate awareness among medical personnel.

    METHODS: Case description and discussion of a patient presenting to the emergency room after overdose of energy drinks in combination with 3,4-methylenedioxymethamphetamine (MDMA).

    RESULTS: Despite best medical efforts, the patient died of fatal cardiac arrhythmias. There is a paucity of information about adverse effects of energy drinks.

    CONCLUSION: Although energy drinks are widely used, there is a lack of awareness in the population and medical staff about their hazards.

    Ultrasound-guided percutaneous drainage of a traumatic abdominal wall hematoma in the emergency department
    Laura Trujillo, Sara Naranjo, Alejandro Cardozo, Bryan Alvarez
    2012, 3(4):  308-310.  doi:10.5847/wjem.j.issn.1920-8642.2012.04.013
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    BACKGROUND: Abdominal wall hematoma is due to trauma, coagulation disorders or anticoagulation therapy complications.

    METHODS: In this report we present a case of a 44-year-old female who suffered from blunt abdominal trauma and presented to the emergency department with sharp abdominal pain and ecchymosis. FAST and abdominal computerized tomography (CT) revealed an abdominal wall hematoma. Treatment with an ultrasound-guided percutaneous drainage was performed successfully.

    RESULTS: The patient remained under observation for six hours with serial ultrasound scans, and no signs of hematoma recurrence were present. She was discharged the same day with clinical improvement.

    CONCLUSION: Complete history investigation and clinical examination help to make a correct diagnosis of abdominal wall hematoma, select a prompt treatment, and reduce complications.

    Combined bilateral asymmetric hip dislocation and anterior shoulder dislocation
    Mustafa Uslu, Mehmet Arican, Ayhan Saritas, Ramazan Buyukkaya, Hayati Kandis
    2012, 3(4):  311-313.  doi:10.5847/wjem.j.issn.1920-8642.2012.04.014
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    BACKGROUND: Traumatic bilateral hip dislocation is a rare condition. Anterior shoulder dislocation combined with this condition is even a rare occurrence. A 57-year-old man had bilateral asymmetric hip dislocation with a posterior wall fracture of the left acetabulum associated with right shoulder anterior dislocation caused by falling down from a cherry tree. Traumatic hip dislocation and anterior shoulder dislocation represent a true orthopedic emergency.

    METHODS: Closed reduction was performed immediately for three of the dislocated joints. Posterior wall fracture of the left acetabulum was treated with open reduction and internal fixation by screws. Because of the severity of associated complications like aseptic necrosis or posttraumatic osteoarthritis, efforts were made to ensure prompt diagnosis, therapy and prognosis.

    RESULTS: The patient was successfully treated by open reduction and internal fixation of the left acetabulum, and discharged from the hospital.

    CONCLUSION: Traumatic asymmetric hip dislocation and anterior shoulder dislocation are an orthopedic emergency and early diagnosis with immediate reduction of the dislocation is the key determinants of excellent result of treatment.

    Instructions for Authors
    Instructions for Authors
    Editorial Office
    2012, 3(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.