World Journal of Emergency Medicine

The combination of creatine kinase-myocardial band isoenzyme and point-of-care cardiac troponin/ contemporary cardiac troponin for the early diagnosis of acute myocardial infarction

Guang-mei Wang, Yong Li, Shuo Wu, Wen Zheng, Jing-jing Ma, Feng Xu, Jia-qi Zheng, He Zhang, Jia-li Wang, Yu-guo Chen

2022, 13(3): 163-168. doi:10.5847/wjem.j.1920-8642.2022.033

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BACKGROUND: The early diagnosis of acute myocardial infarction (AMI) remains challenging, especially for institutions without the high-sensitive cardiac troponin (hs-cTn) assay. Herein, we aim to assess the value of creatine kinase-myocardial band isoenzyme (CK-MB) combined with different cardiac troponin (cTn) assays in AMI diagnosis.

METHODS: This multicenter, observational study included 3,706 patients with acute chest pain from September 1, 2015, to September 30, 2017. We classified the participants into three groups according to the cTn assays: the point-of-care cTn (POC-cTn) group, the contemporary cTn (c-cTn) group, and hs-cTn group. The diagnostic value was quantified using sensitivity and the area under the curve (AUC).

RESULTS: Compared to the single POC-cTn/c-cTn assays, combining CK-MB and POC-cTn/c-cTn increased the diagnostic sensitivity of AMI (56.1% vs. 63.9%, P<0.001; 82.7% vs. 84.3%, P=0.025). In contrast, combining CK-MB and hs-cTn did not change the sensitivity compared with hs-cTn alone (95.0% vs. 95.0%, P>0.999). In the subgroup analysis, the sensitivity of combining CK-MB and c-cTn increased with time from symptom onset <6 h compared with c-cTn alone (72.8% vs. 75.0%, P=0.046), while the sensitivity did not increase with time from symptom onset >6 h (97.5% vs. 98.3%, P=0.317). The AUC of the combination of CK-MB and POC-cTn significantly increased compared to the single POC-cTn assay (0.776 vs. 0.750, P=0.002). The AUC of the combined CK-MB and c-cTn/hs-cTn assays did not significantly decrease compared with that of the single c-cTn/hs-cTn assays within 6 h.

CONCLUSIONS: The combination of CK-MB and POC-cTn or c-cTn may be valuable for the early diagnosis of AMI, especially when hs-cTn is not available.

Prognostic differences of catestatin among young and elderly patients with acute myocardial infarction

Wei-xian Xu, Yuan-yuan Fan, Yao Song, Xin Liu, Hui Liu, Li-jun Guo

2022, 13(3): 169-174. doi:10.5847/wjem.j.1920-8642.2022.055

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BACKGROUND: Previous studies have reported inconsistent findings regarding the association between catestatin and outcomes of acute myocardial infarction (AMI). This study aims to investigate the prognostic value of catestatin for long-term outcomes in patients with AMI.

METHODS: One hundred and sixty-five patients with AMI were enrolled in this series. The plasma catestatin levels at baseline and clinical data were collected. All patients were followed up for four years to investigate whether there were major adverse cardiovascular events (MACEs), including cardiovascular death, recurrent AMI, rehospitalization for heart failure, and revascularization.

RESULTS: There were 24 patients who had MACEs during the follow-up period. The MACEs group had significantly lower plasma catestatin levels (0.74±0.49 ng/mL vs. 1.10±0.79 ng/mL, P=0.033) and were older (59.0±11.4 years old vs. 53.2±12.8 years old, P=0.036). The rate of MACEs was significantly higher in the elderly group (≥60 years old) than in the young group (<60 years old) (23.8% [15/63] vs. 8.8% [9/102], P=0.008). The catestatin level was significantly lower in the MACEs group than that in the non-MACEs group (0.76±0.50 ng/mL vs. 1.31±0.77 ng/mL, P=0.012), and catestatin was significantly associated with MACEs (Kaplan Meier, P=0.007) among the elderly group, but not in the young group (Kaplan Meier, P=0.893). In the Cox proportional hazards regression, high catestatin was one of the independent factors for predicting MACEs after adjustment for other risk factors (hazard ratio 0.19, 95% confidence interval 0.06-0.62, P=0.006) among elderly patients.

CONCLUSIONS: Elderly AMI patients with lower plasma catestatin levels are more likely to develop MACEs. Catestatin may be a novel marker for the long-term prognosis of AMI, especially in elderly patients.

Speckle-tracking echocardiography for detecting myocardial dysfunction in sepsis and septic shock patients: A single emergency department study

Xuan Fu, Xue Lin, Samuel Seery, Li-na Zhao, Hua-dong Zhu, Jun Xu, Xue-zhong Yu

2022, 13(3): 175-181. doi:10.5847/wjem.j.1920-8642.2022.057

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BACKGROUND: Septic cardiomyopathy (SCM) occurs in the early stage of sepsis and septic shock, which has implications for treatment strategies and prognosis. Additionally, myocardial involvement in the early stages of sepsis is difficult to identify. Here, we assess subclinical myocardial function using laboratory tests and speckle-tracking echocardiography (STE).

METHODS: Emergency department patients diagnosed with sepsis or septic shock were included for analysis. Those with other causes of acute or pre-existing cardiac dysfunction were excluded. Transthoracic echocardiography (TTE), including conventional echocardiography and STE, were performed for all patients three hours after initial resuscitation. Samples for laboratory tests were taken around the time of TTE.

RESULTS: Left ventricular functions of 60 patients were analyzed, including 21 septic shock patients and 39 sepsis patients. There was no significant difference in global longitudinal strain (GLS), global circumferential strain (GCS), or global radical strain (GRS) between patients with sepsis and septic shock (all with P>0.05). However, GLS and GCS were significantly less negative in patients with abnormal troponin levels or in patients with abnormal left ventricular ejection fraction (LVEF) values (all with P<0.05). There were also moderate correlations between GLS and levels of cTnI (r=0.40, P=0.002) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) (r=0.44, P=0.001) in sepsis and septic shock patients.

CONCLUSION: Myocardial dysfunction, e.g., lower LVEF or less negative GLS in patients with sepsis or septic shock, is more affected by myocardial injury. GLS could be incorporated into mainstream clinical practice as a supplementary LVEF parameter, especially for those with elevated troponin levels.

Trichostatin A improves the inflammatory response and liver injury in septic mice through the FoxO3a/autophagy signaling pathway

Mei-jia Shen, Li-chao Sun, Xiao-yu Liu, Meng-chen Xiong, Shan Li, A-ling Tang, Guo-qiang Zhang

2022, 13(3): 182-188. doi:10.5847/wjem.j.1920-8642.2022.056

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BACKGROUND: Sepsis-induced liver injury is a fatal complication of sepsis. Trichostatin A (TSA) regulates inflammation and autophagy in some human diseases, and forkhead box O3a (FoxO3a) has been shown to regulate autophagy. The present study aims to investigate whether TSA exerts its effects on septic liver injury through the FoxO3a/autophagy signaling pathway.

METHODS: A sepsis mouse model was constructed by the cecal ligation and puncture (CLP) method, and AML12 cells were pretreated with lipopolysaccharide (LPS) (1 μg/mL) to establish a sepsis cell model. Forty mice were divided into four groups, namely control group, TSA group, CLP group, and CLP+TSA group, with 10 mice in each group. Cells were divided into control group, TSA group, LPS group, and LPS+TSA group. Hematoxylin-eosin (H&E) staining and biochemical methods were used to evaluate liver tissue injury. Enzyme-linked immunosorbent assay (ELISA) was applied to detect the expression of proinflammatory cytokines, and Western blotting and immunofluorescence were used to measure autophagy-related protein expression.

RESULTS: Compared with the CLP group (mice), the proinflammatory cytokines (interleukin-β [IL-β] 2,665.27±324.90 pg/mL to 2,080.26±373.66 pg/mL; interleukin-6 [IL-6] 399.01±60.98 pg/mL to 221.90±46.89 pg/mL) and the hepatocyte injury markers (aspartate transaminase [AST] from 198.18±27.07 U/L to 128.42±20.55 U/L; alanine aminotransferase [ALT] from 634.98±74.10 U/L to 478.60±32.56 U/L) were notably decreased after TSA intervention. Moreover, LC3 II and FoxO3a showed an obvious increase and P62 showed an obvious decrease in the CLP+TSA group. Cell experiment results showed the similar trend. After FoxO3a gene was knocked down in AML12 cells, the promotion of autophagy and the improvement of liver enzyme index and inflammation by TSA were weakened.

CONCLUSION: TSA may improve the inflammatory response and liver injury in septic mice through FoxO3a/autophagy.

Clinical effectiveness of a pneumatic compression device combined with low-molecular-weight heparin for the prevention of deep vein thrombosis in trauma patients: A single-center retrospective cohort study

Peng-chao Guo, Nan Li, Hui-ming Zhong, Guang-feng Zhao

2022, 13(3): 189-195. doi:10.5847/wjem.j.1920-8642.2022.040

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BACKGROUND: To investigate the clinical effectiveness of a pneumatic compression device (PCD) combined with low-molecular-weight heparin (LMWH) for the prevention and treatment of deep vein thrombosis (DVT) in trauma patients.

METHODS: This study retrospectively analyzed 286 patients with mild craniocerebral injury and clavicular fractures admitted to our department from January 2016 to February 2020. Patients treated with only LMWH served as the control group, and patients treated with a PCD combined with LMWH as the observation group. The incidence of DVT, postoperative changes in the visual analogue scale (VAS) score, and coagulation function were observed and compared between the two groups. Excluding the influence of other single factors, binary logistic regression analysis was used to evaluate the use of a PCD in the patient's postoperative coagulation function.

RESULTS: After excluding 34 patients who did not meet the inclusion criteria, 252 patients were were included. The incidence of DVT in the observation group was significantly lower than that in the control group (5.6% vs. 15.1%, χ²=4.605, P<0.05). The postoperative VAS scores of the two groups were lower than those before surgery (P<0.05). The coagulation function of the observation group was significantly higher than that of the control group, with a better combined anticoagulant effect (P<0.05). There were no significant differences between the two groups in preoperative or postoperative Glasgow Coma Scale scores, intraoperative blood loss, postoperative infection rate, or length of hospital stay (P>0.05). According to logistic regression analysis, the postoperative risk of DVT in patients who received LMWH alone was 1.764 times that of patients who received LMWH+PCD (P<0.05). The area under the receiver operating characteristic (AUROC) curve of partial thromboplastin time (APTT) and platelet (PLT) were greater than 0.5, indicating that they were the influence indicators of adding PCD to prevent DVT. Excluding the influence of other variables, LMWH+PCD effectively improved the coagulation function of patients.

CONCLUSIONS: Compared with LMWH alone, LMWH+PCD could improve blood rheology and coagulation function in patients with traumatic brain injury and clavicular fracture, reduce the incidence of DVT, shorten the length of hospital stay, and improve the clinical effectiveness of treatment.

Optimal indicator for changing the filter during the continuous renal replacement therapy in intensive care unit patients with acute kidney injury: A crossover randomized trial

Cheng Hang, Li-jun Liu, Zhao-yun Huang, Jian-liang Zhu, Bao-chun Zhou, Xiao-zhen Li

2022, 13(3): 196-201. doi:10.5847/wjem.j.1920-8642.2022.046

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BACKGROUND: The study aims to investigate an optimal indicator for changing the filter during the continuous renal replacement therapy (CRRT) in intensive care unit (ICU) patients with acute kidney injury (AKI).

METHODS: Patients with AKI requiring CRRT in an ICU were randomly divided into two groups for crossover trial, i.e., groups A and B. Patients in the group A were firstly treated with continuous veno-venous hemofiltration (CVVH), followed by continuous veno-venous hemodiafiltration (CVVHDF). Patients in the group B were firstly treated with CVVHDF followed by CVVH. Delivered doses of solutes with different molecular weights at the indicated time points between groups were compared. A correlation analysis between the delivered dose and pre-filter pressure (P_PRE) and transmembrane pressure (P_TM) was performed. Receiver operating characteristic (ROC) curves were constructed to evaluate the accuracy of P_TM as an indicator for filter replacement.

RESULTS: A total of 50 cases were analyzed, 27 in the group A and 23 in the group B. Delivered doses of different molecular-weight solutes significantly decreased before changing the filter in both modalities, compared with those at the initiation of treatment (all P<0.05). In the late stage of CRRT, the possible rebound of serum medium-molecular-weight solute concentration was observed. P_TM was negatively correlated with the delivered dose of medium-molecular-weight solute in both modalities. The threshold for predicting the rebound of serum concentration of medium-molecular-weight solute by P_TM was 146.5 mmHg (1 mmHg=0.133 kPa).

CONCLUSIONS: The filter can be used as long as possible within the manufacturer's safe use time limits to remove small-molecular-weight solutes. P_TM of 146.5 mmHg may be an optimal indicator for changing the filter in CRRT therapies to remove medium-molecular-weight solutes.

The ratio of superior mesenteric artery diameter to superior mesenteric vein diameter based on non-enhanced computed tomography in the early diagnosis of spontaneous isolated superior mesenteric artery dissection

Yuan-li Lei, Wen-xing Song, Yi Lin, Hui-ping Li, He-ping Lyu, Jiao-zhen Chen, Zhang-ping Li, Jia-na Yin, Ji-ke Xue, Shou-quan Chen

2022, 13(3): 202-207. doi:10.5847/wjem.j.1920-8642.2022.045

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BACKGROUND: Spontaneous isolated superior mesenteric artery (SMA) dissection (SISMAD) is a rare cause of abdominal pain. The aim of the study is to investigate the role of a new parameter, the ratio of the SMA diameter to the superior mesenteric vein (SMV) diameter (SMA/SMV) based on non-enhanced computed tomography (CT), in the early diagnosis of SISMAD.

METHODS: In a registry study from December 2013 to June 2021, 97 abdominal pain SISMAD patients (SISMAD group) admitted to our hospital were enrolled. Meanwhile, the matched sex and age abdominal pain non-SISMAD patients at 1:2 were collected in reverse chronological order as the control group. Student's t-test, Wilcoxon rank-sum test, and Chi-square test were used to compare differences between the SISMAD and control groups. MedCalc was used to generate receiver operating characteristic (ROC) curve.

RESULTS: A total of 291 abdominal pain patients, including 97 SISMAD patients and 194 non-SISMAD patients, were included in the current study. The maximum SMA diameter, perivascular exudation, and SMA/SMV based on non-enhanced CT were significant between the two groups (all P<0.05). ROC curves showed that for the maximum SMA diameter, the area under the curve (AUC), cut-off, sensitivity, and specificity were 0.926, 9.80, 93.8%, and 79.4%, respectively. For SMA/SMV, its AUC, cut-off, sensitivity, and specificity were 0.956, 0.83, 88.7%, and 92.3%, respectively. The diagnostic efficiency of SMA/SMV was better than that of the maximum SMA diameter (P<0.05). The combined parameters of SMA/SMV and maximum SMA diameter had the best diagnostic efficiency (AUC=0.970).

CONCLUSION: SMA/SMV may be a potential marker for SISMAD.

Increasing angiotensin-converting enzyme (ACE) 2/ACE axes ratio alleviates early pulmonary vascular remodeling in a porcine model of acute pulmonary embolism with cardiac arrest

Hong-li Xiao, Lian-xing Zhao, Jun Yang, Nan Tong, Le An, Guo-xing Wang, Miao-rong Xie, Chun-sheng Li

2022, 13(3): 208-214. doi:10.5847/wjem.j.1920-8642.2022.052

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BACKGROUND: Acute pulmonary embolism (APE) with cardiac arrest (CA) is characterized by high mortality in emergency due to pulmonary arterial hypertension (PAH). This study aims to determine whether early pulmonary artery remodeling occurs in PAH caused by massive APE with CA and the protective effects of increasing angiotensin-converting enzyme (ACE) 2-angiotensin (Ang) (1-7)-Mas receptor axis and ACE-Ang II-Ang II type 1 receptor (AT1) axis (ACE2/ACE axes) ratio on pulmonary artery lesion after return of spontaneous circulation (ROSC).

METHODS: To establish a porcine massive APE with CA model, autologous thrombus was injected into the external jugular vein until mean arterial pressure dropped below 30 mmHg (1 mmHg=0.133 kPa). Cardiopulmonary resuscitation and thrombolysis were delivered to regain spontaneous circulation. Pigs were divided into four groups of five pigs each: control group, APE-CA group, ROSC-saline group, and ROSC-captopril group, to examine the endothelial pathological changes and expression of ACE2/ACE axes in pulmonary artery with or without captopril.

RESULTS: Histological analysis of samples from the APE-CA and ROSC-saline groups showed that pulmonary arterioles were almost completely occluded by accumulated endothelial cells. Western blotting analysis revealed a decrease in the pulmonary arterial ACE2/ACE axes ratio and increases in angiopoietin-2/angiopoietin-1 ratio and expression of vascular endothelial growth factor (VEGF) in the APE-CA group compared with the control group. Captopril significantly suppressed the activation of angiopoietin-2/angiopoietin-1 and VEGF in plexiform lesions formed by proliferative endothelial cells after ROSC. Captopril also alleviated endothelial cell apoptosis by increasing the B-cell lymphoma-2 (Bcl-2)/Bcl-2-associated X (Bax) ratio and decreasing cleaved caspase-3 expression.

CONCLUSION: Increasing the ACE2/ACE axes ratio may ameliorate pulmonary arterial remodeling by inhibiting the apoptosis and proliferation of endothelial cells after ROSC induced by APE.

The "July Effect" in the intensive care units revisited: A bi-institutional 6-year experience of 57,160 patients

Leon Naar, Ander D. Gallastegi, Raghu R. Seethala, B. Christian Renne, Michael E. Billington, Jasmine Kannikal, Haytham M.A. Kaafarani, Jarone Lee

2022, 13(3): 215-218. doi:10.5847/wjem.j.1920-8642.2022.039

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Feedback of inter-hospital transfer of patients under high-flow nasal cannula oxygen therapy

Emilien Arnaud, Sylvain Leclere, Martin Petitprez, Gilles Vincent, Christine Ammirati

2022, 13(3): 219-221. doi:10.5847/wjem.j.1920-8642.2022.036

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