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Table of Content

    01 October 2020, Volume 11 Issue 4
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    Original Article
    Improving antibiotic prescribing in the emergency department for uncomplicated community-acquired pneumonia
    Rebekah Shaw, Erica Popovsky, Alyssa Abo, Marni Jacobs, Nicole Herrera, James Chamberlain, Andrea Hahn
    2020, 11(4):  199-205.  doi:10.5847/wjem.j.1920-8642.2020.04.001
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    BACKGROUND: The Pediatric Infectious Disease Society (PIDS) and Infectious Disease Society of America (IDSA) published an evidence-based guideline for the treatment of uncomplicated community-acquired pneumonia (CAP) in children, recommending aminopenicillins as the first-line therapy. Poor guideline compliance with 10%-50% of patients admitted to the hospital receiving narrow-spectrum antibiotics has been reported. A new clinical practice guideline (CPG) was implemented in our emergency department (ED) for uncomplicated CAP. The aim of this study was to examine baseline knowledge and ED provider prescribing patterns pre- and post-CPG implementation.

    METHODS: Prior to CPG-implementation, an anonymous case-based survey was distributed to evaluate knowledge of the current PIDS/IDSA guideline. A retrospective chart review of patients treated in the ED for CAP from January 2015 to February 2017 was performed to assess prescribing patterns for intravenous (IV) antibiotics in the ED at Children’s National Health System pre- and post-CPG implementation.

    RESULTS: ED providers were aware of the PIDS/IDSA guideline recommendations, with 86.4% of survey responders selecting ampicillin as the initial antibiotic of choice. However, only 41.2% of patients admitted to the hospital with uncomplicated CAP pre-CPG received ampicillin (P<0.01). There was no statistically significant increase in ampicillin prescribing post-CPG (P=0.40).

    CONCLUSIONS: Providers in the ED are aware of the PIDS/IDSA guideline regarding the first-line therapy for uncomplicated CAP; however, this knowledge does not translate into clinical practice. Implementation of a CPG in isolation did not significantly change prescribing patterns for uncomplicated CAP.

    Outcome prediction value of National Early Warning Score in septic patients with community-acquired pneumonia in emergency department: A single-center retrospective cohort study
    Hai-jiang Zhou, Tian-fei Lan, Shu-bin Guo
    2020, 11(4):  206-215.  doi:10.5847/wjem.j.1920-8642.2020.04.002
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    BACKGROUND:To evaluate the accuracy of National Early Warning Score (NEWS) in predicting clinical outcomes (28-day mortality, intensive care unit [ICU] admission, and mechanical ventilation use) for septic patients with community-acquired pneumonia (CAP) compared with other commonly used severity scores (CURB65, Pneumonia Severity Index [PSI], Sequential Organ Failure Assessment [SOFA], quick SOFA [qSOFA], and Mortality in Emergency Department Sepsis [MEDS]) and admission lactate level.

    METHODS: Adult patients diagnosed with CAP admitted between January 2017 and May 2019 with admission SOFA ≥2 from baseline were enrolled. Demographic characteristics were collected. The primary outcome was the 28-day mortality after admission, and the secondary outcome included ICU admission and mechanical ventilation use. Outcome prediction value of parameters above was compared using receiver operating characteristics (ROC) curves. Cox regression analyses were carried out to determine the risk factors for the 28-day mortality. Kaplan-Meier survival curves were plotted and compared using optimal cut-off values of qSOFA and NEWS.

    RESULTS: Among the 340 enrolled patients, 90 patients were dead after a 28-day follow-up, 62 patients were admitted to ICU, and 84 patients underwent mechanical ventilation. Among single predictors, NEWS achieved the largest area under the receiver operating characteristic (AUROC) curve in predicting the 28-day mortality (0.861), ICU admission (0.895), and use of mechanical ventilation (0.873). NEWS+lactate, similar to MEDS+lactate, outperformed other combinations of severity score and admission lactate in predicting the 28-day mortality (AUROC 0.866) and ICU admission (AUROC 0.905), while NEWS+lactate did not outperform other combinations in predicting mechanical ventilation (AUROC 0.886). Admission lactate only improved the predicting performance of CURB65 and qSOFA in predicting the 28-day mortality and ICU admission.

    CONCLUSIONS: NEWS could be a valuable predictor in septic patients with CAP in emergency departments. Admission lactate did not predict well the outcomes or improve the severity scores. A qSOFA ≥2 and a NEWS ≥9 were strongly associated with the 28-day mortality, ICU admission, and mechanical ventilation of septic patients with CAP in the emergency departments.

    Effects of fluid balance on prognosis of acute respiratory distress syndrome patients secondary to sepsis
    Yu-ming Wang, Yan-jun Zheng, Ying Chen, Yun-chuan Huang, Wei-wei Chen, Ran Ji, Li-li Xu, Zhi-tao Yang, Hui-qiu Sheng, Hong-ping Qu, En-qiang Mao, Er-zhen Chen
    2020, 11(4):  216-222.  doi:10.5847/wjem.j.1920-8642.2020.04.003
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    BACKGROUND: Fluid management is crucial to acute respiratory distress syndrome (ARDS) secondary to sepsis. However, choices of fluid resuscitation strategies and fluid input volumes remain a thorny problem. Our study aimed to elucidate the relationship between fluid balance and prognosis of ARDS patients secondary to sepsis.

    METHODS: Our study included 322 sepsis patients from Ruijin Hospital between 2014 and 2018, and 84 patients were diagnosed as ARDS within 72 hours after onset of sepsis according to Berlin ARDS Definition.

    RESULTS: Among the 322 sepsis patients, 84 (26.1%) were complicated with ARDS within 72 hours. ARDS patients had a lower oxygenation index (PaO2/FiO2 166.4±71.0 vs. 255.0±91.2, P<0.05), longer duration of mechanical ventilation (11 [6-24] days vs. 0 [0-0] days, P<0.05) than those without ARDS. Sepsis patients with ARDS showed daily positive net fluid balance during seven days compared with those without ARDS who showed daily negative net fluid balance since the second day with significant statistical differences. Among the 84 sepsis patients with ARDS, 58 (69.0%) died. Mean daily fluid input volumes were much lower in survivors than in non-survivors (43.2±16.7 mL/kg vs. 51.0±25.2 mL/kg, P<0.05) while output volumes were much higher in survivors (45.2±19.8 mL/kg vs. 40.2±22.7 mL/kg, P<0.05). Using binary logistic regression analysis, we found that the mean daily fluid balance was independently associated with mortality of sepsis patients complicating with ARDS (P<0.05).

    CONCLUSIONS: Early negative fluid balance is independently associated with a better prognosis of sepsis patients complicated with ARDS.

    Effects of sepsis on hippocampal volume and memory function
    Miao Yuan, Ding-yi Yan, Fang-shi Xu, Yi-di Zhao, Yang Zhou, Long-fei Pan
    2020, 11(4):  223-230.  doi:10.5847/wjem.j.1920-8642.2020.04.004
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    BACKGROUND: This study aimed to determine the effects of sepsis on brain integrity, memory, and executive function.

    METHODS: Twenty sepsis patients who were not diagnosed with sepsis-associated encephalopathy (SAE) but had abnormal electroencephalograms (EEGs) were included. The control group included twenty healthy persons. A neuropsychological test of memory and executive function and a brain magnetic resonance imaging scan were performed. The volumes of cortex and subcortex were measured using the FreeSurfer software. Acute Physiology and Chronic Health Evaluation II (APACHE II) score was used to determine the disease severity.

    RESULTS: In the sepsis group, the levels of immediate free recall, immediate cued recall, and delayed cued recall in the California Verbal Learning Test-II (CVLT-II) were significantly lower; the explicit memory (recollection process) in the process dissociation procedure test was lower; and the volumes of the left and right hippocampi were significantly lower compared with the control group. The volume of the presubiculum in the hippocampus of sepsis patients showed statistically significant decrease. In the sepsis group, the volumes of the left and right hippocampi were negatively correlated with the APACHE II score and positively with immediate free recall, immediate cued recall, and delayed cued recall in the CVLT-II; moreover, the hippocampal volume was significantly correlated with recollection but not with familiarity.

    CONCLUSIONS: Patients with abnormal EEGs during hospitalization but with no SAE still have reduced hippocampal volume and memory deficits. This finding indicates that sepsis leads to damage to specific parts of the hippocampus.

    Death and do-not-resuscitate order in the emergency department: A single-center three-year retrospective study in the Chinese mainland
    Chuan-qi Ding, Yu-ping Zhang, Yu-wei Wang, Min-fei Yang, Sa Wang, Nian-qi Cui, Jing-fen Jin
    2020, 11(4):  231-237.  doi:10.5847/wjem.j.1920-8642.2020.04.005
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    BACKGROUND: Consenting to do-not-resuscitate (DNR) orders is an important and complex medical decision-making process in the treatment of patients at the end-of-life in emergency departments (EDs). The DNR decision in EDs has not been extensively studied, especially in the Chinese mainland.

    METHODS: This retrospective chart study of all deceased patients in the ED of a university hospital was conducted from January 2017 to December 2019. The patients with out-of-hospital cardiac arrest were excluded.

    RESULTS: There were 214 patients’ deaths in the ED in the three years. Among them, 132 patients were included in this study, whereas 82 with out-of-hospital cardiac arrest were excluded. There were 99 (75.0%) patients’ deaths after a DNR order medical decision, 64 (64.6%) patients signed the orders within 24 hours of the ED admission, 68 (68.7%) patients died within 24 hours after signing it, and 97 (98.0%) patients had DNR signed by the family surrogates. Multivariate analysis showed that four independent factors influenced the family surrogates’ decisions to sign the DNR orders: lack of referral (odds ratio [OR] 0.157, 95% confidence interval [CI] 0.047-0.529, P=0.003), ED length of stay (ED LOS) ≥72 hours (OR 5.889, 95% CI 1.290-26.885, P=0.022), acute myocardial infarction (AMI) (OR 0.017, 95% CI 0.001-0.279, P=0.004), and tracheal intubation (OR 0.028, 95% CI 0.007-0.120, P<0.001).

    CONCLUSIONS: In the Chinese mainland, the proportion of patients consenting for DNR order is lower than that of developed countries. The decision to sign DNR orders is mainly affected by referral, ED LOS, AMI, and trachea intubation.

    The general public’s ability to operate automated external defibrillator: A controlled simulation study
    Xue-jie Dong, Lin Zhang, Yue-lin Yu, Shu-xiao Shi, Xiao-chen Yang, Xiao-qian Zhang, Shuang Tian, Helge Myklebust, Guo-hong Li, Zhi-jie Zheng
    2020, 11(4):  238-245.  doi:10.5847/wjem.j.1920-8642.2020.04.006
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    BACKGROUND: Automated external defibrillators (AEDs) enable laypeople to provide early defibrillations to patients undergoing cardiac arrest, but scant information is available on the general public’s ability to use AEDs. This study assessed the ability of laypeople to operate AEDs, the effect of a 15-minute training, and whether skills differed by age.

    METHODS: From May 1 to December 31, 2018, a prospective simulation study was conducted with 94 laypeople aged 18-65 years (32 aged 18-24 years, 34 aged 25-54 years, and 28 aged 55-65 years) with no prior AED training. The participants’ AED skills were assessed individually pre-training, post-training, and at a three-month follow-up using a simulated cardiac arrest scenario. The critical actions and time intervals were evaluated during the AED operating process.

    RESULTS: Only 14 (14.9%) participants (eight aged 18-24 years, four aged 25-54 years, and two aged 55-65 years) successfully delivered defibrillations before training. AED operation errors were more likely to occur among the participants aged 55-65 years than among other age groups. After training, the proportion of successful defibrillations increased significantly (18-24 years old: 25.0% vs. 71.9%, P<0.01; 25-54 years old: 11.8% vs. 70.6%, P<0.01; 55-65 years old: 7.1% vs. 67.9%, P<0.01). After three months, 26.1% of the participants aged 55-65 years successfully delivered defibrillations, which was significantly lower than that of participants aged 18-24 years (54.8%) and 25-54 years (64.3%) (P=0.02). There were no differences in time measures among three age groups in each test.

    CONCLUSIONS: The majority of untrained laypeople cannot effectively operate AEDs. More frequent training and refresher courses are crucial to improve AED skills.

    Aldehyde dehydrogenase 2 preserves mitochondrial morphology and attenuates hypoxia/reoxygenation-induced cardiomyocyte injury
    Rui Zhang, Meng-yang Xue, Bao-shan Liu, Wen-jun Wang, Xin-hui Fan, Bo-yuan Zheng, Qiu-huan Yuan, Feng Xu, Jia-li Wang, Yu-guo Chen
    2020, 11(4):  246-254.  doi:10.5847/wjem.j.1920-8642.2020.04.007
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    BACKGROUND: Disturbance of mitochondrial fission and fusion (termed mitochondrial dynamics) is one of the leading causes of ischemia/reperfusion (I/R)-induced myocardial injury. Previous studies showed that mitochondrial aldehyde dehydrogenase 2 (ALDH2) conferred cardioprotective effect against myocardial I/R injury and suppressed I/R-induced excessive mitophagy in cardiomyocytes. However, whether ALDH2 participates in the regulation of mitochondrial dynamics during myocardial I/R injury remains unknown.

    METHODS: In the present study, we investigated the effect of ALDH2 on mitochondrial dynamics and the underlying mechanisms using the H9c2 cells exposed to hypoxia/reoxygenation (H/R) as an in vitro model of myocardial I/R injury.

    RESULTS: Cardiomyocyte apoptosis was significantly increased after oxygen-glucose deprivation and reoxygenation (OGD/R), and ALDH2 activation largely decreased the cardiomyocyte apoptosis. Additionally, we found that both ALDH2 activation and overexpression significantly inhibited the increased mitochondrial fission after OGD/R. Furthermore, we found that ALDH2 dominantly suppressed dynamin-related protein 1 (Drp1) phosphorylation (Ser616) and adenosine monophosphate-activated protein kinase (AMPK) phosphorylation (Thr172) but not interfered with the expression levels of mitochondrial shaping proteins.

    CONCLUSIONS: We demonstrate the protective effect of ALDH2 against cardiomyocyte H/R injury with a novel mechanism on mitochondrial fission/fusion.

    Case Letter
    Venous thromboembolism in a healthy young man: An unintended consequence of coronavirus disease 2019 pandemic lockdown
    Jenshen Cheng, Susmita Roy Chowdhury, Aliviya Dutta, R Ponampalam
    2020, 11(4):  255-257.  doi:10.5847/wjem.j.1920-8642.2020.04.008
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    Coronavirus disease 2019 (COVID-19) and prosthetic heart valve: An additional coagulative challenge
    Attilio Allione, Jacopo Davide Giamello, Sara Bernardi, Giulia Paglietta, Giulia Lucia Massimina Cavalot, Luca Alessio Dutto, Daniela Caruso, Andrea Tortore, Giuseppe Lauria
    2020, 11(4):  258-259.  doi:10.5847/wjem.j.1920-8642.2020.04.009
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    Severe bacteremia community-acquired methicillin-resistant Staphylococcus aureus pneumonia in a young adult
    Dan-li Cai, Xia-qing Zhou, Ye-song Wang, Ling-cong Wang
    2020, 11(4):  263-266.  doi:10.5847/wjem.j.1920-8642.2020.04.011
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    Andersen-Tawil syndrome associated with myopathy
    Lei Wu, Yi Fang, Bao-rong Zhang
    2020, 11(4):  267-269.  doi:10.5847/wjem.j.1920-8642.2020.04.012
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    A primary pulmonary artery sarcoma associated with multiple lesions
    Jing Wang, Tian-lang Li, Shu Zheng
    2020, 11(4):  270-273.  doi:10.5847/wjem.j.1920-8642.2020.04.013
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    Letter to the Editor
    Headache may not be linked with severity of coronavirus disease 2019 (COVID-19)
    Kamleshun Ramphul, Stephanie G. Mejias, Yogeshwaree Ramphul
    2020, 11(4):  274-274.  doi:10.5847/wjem.j.1920-8642.2020.04.014
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