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Table of Content

    01 May 2023, Volume 14 Issue 3
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    Original Articles
    Most patients with non-hypertensive diseases at a critical care resuscitation unit require arterial pressure monitoring: a prospective observational study
    Emily Engelbrecht-Wiggans, Jamie Palmer, Grace Hollis, Fernando Albelo, Afrah Ali, Emily Hart, Dominique Gelmann, Iana Sahadzic, James Gerding, Quincy K. Tran, Daniel J. Haase
    2023, 14(3):  173-178.  doi:10.5847/wjem.j.1920-8642.2023.035
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    BACKGROUND: Blood pressure (BP) monitoring is essential for patient care. Invasive arterial BP (IABP) is more accurate than non-invasive BP (NIBP), although the clinical significance of this difference is unknown. We hypothesized that IABP would result in a change of management (COM) among patients with non-hypertensive diseases in the acute phase of resuscitation.

    METHODS: This prospective study included adults admitted to the Critical Care Resuscitation Unit (CCRU) with non-hypertensive disease from February 1, 2019, to May 31, 2021. Management plans to maintain a mean arterial pressure >65 mmHg (1 mmHg=0.133 kPa) were recorded in real time for both NIBP and IABP measurements. A COM was defined as a discrepancy between IABP and NIBP that resulted in an increase/decrease or addition/discontinuation of a medication/infusion. Classification and regression tree analysis identified significant variables associated with a COM and assigned relative variable importance (RVI) values.

    RESULTS: Among the 206 patients analyzed, a COM occurred in 94 (45.6% [94/206]) patients. The most common COM was an increase in current infusion dosages (40 patients, 19.4%). Patients receiving norepinephrine at arterial cannulation were more likely to have a COM compared with those without (45 [47.9%] vs. 32 [28.6%], P=0.004). Receiving norepinephrine (relative variable importance [RVI] 100%) was the most significant factor associated with a COM. No complications were identified with IABP use.

    CONCLUSION: A COM occurred in 94 (45.6%) non-hypertensive patients in the CCRU. Receiving vasopressors was the greatest factor associated with COM. Clinicians should consider IABP monitoring more often in non-hypertensive patients requiring norepinephrine in the acute resuscitation phase. Further studies are necessary to confirm the risk-to-benefit ratios of IABP among these high-risk patients.

    Over-expression of programmed death-ligand 1 and programmed death-1 on antigen-presenting cells as a predictor of organ dysfunction and mortality during early sepsis: a prospective cohort study
    Jia-bao Li, Miao-rong Xie, Mei-li Duan, Ya-nan Yu, Chen-chen Hang, Zi-ren Tang, Chun-sheng Li
    2023, 14(3):  179-185.  doi:10.5847/wjem.j.1920-8642.2023.041
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    BACKGROUND: This study aimed to explore the changes of programmed death-ligand 1 (PD-L1) and programmed death-1 (PD-1) expression on antigen-presenting cells (APCs) and evaluate their association with organ failure and mortality during early sepsis.

    METHODS: In total, 40 healthy controls and 198 patients with sepsis were included in this study. Peripheral blood was collected within the first 24 h after the diagnosis of sepsis. The expression of PD-L1 and PD-1 was determined on APCs, such as B cells, monocytes, and dendritic cells (DCs), by flow cytometry. Cytokines in plasma, such as interferon-γ (IFN-γ), tumor necrosis factor-α (TNF-α), interleukin-4 (IL-4), IL-6, IL-10, and IL-17A were determined by Luminex assay.

    RESULTS: PD-1 expression decreased significantly on B cells, monocytes, myeloid DCs (mDCs), and plasmacytoid DCs (pDCs) as the severity of sepsis increased. PD-1 expression was also markedly decreased in non-survivors compared with survivors. In contrast, PD-L1 expression was markedly higher on mDCs, pDCs, and monocytes in patients with sepsis than in healthy controls and in non-survivors than in survivors. The PD-L1 expression on APCs (monocytes and DCs) was weakly related to organ dysfunction and inflammation. The area under the receiver operating characteristic curve (AUC) of the PD-1 percentage of monocytes (monocyte PD-1%)+APACHE II model (0.823) and monocyte PD-1%+SOFA model (0.816) had higher prognostic value than other parameters alone. Monocyte PD-1% was an independent risk factor for 28-day mortality.

    CONCLUSION: The severity of sepsis was correlated with PD-L1 or PD-1 over-expression on APCs. PD-L1 in monocytes and DCs was weakly correlated with inflammation and organ dysfunction during early sepsis. The combination of SOFA or APACHE II scores with monocyte PD-1% could improve the prediction ability for mortality.

    Effects of continuous renal replacement therapy on inflammation-related anemia, iron metabolism and prognosis in sepsis patients with acute kidney injury
    Meng-meng An, Chen-xi Liu, Ping Gong
    2023, 14(3):  186-192.  doi:10.5847/wjem.j.1920-8642.2023.052
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    BACKGROUND: This study aims to evaluate the effect of continuous renal replacement therapy (CRRT) on inflammation-related anemia, iron metabolism, and the prognosis in sepsis patients with acute kidney injury (AKI).

    METHODS: Sepsis patients with AKI were prospectively enrolled and randomized into the CRRT and control groups. The clinical and laboratory data on days 1, 3 and 7 after intensive care unit (ICU) admission were collected. The serum interleukin (IL)-6, hepcidin, erythropoietin, ferritin, and soluble transferrin receptor (sTfR) were determined by enzyme-linked immunosorbent assay. The Sequential Organ Failure Assessment (SOFA) score and 28-day mortality were recorded. Data were analyzed using Pearson’s Chi-square test or Fisher’s exact test (categorical variables), and Mann-Whitney U-test or t-test (continuous variables).

    RESULTS: The hemoglobin and serum erythropoietin levels did not significantly differ between the CRRT and control groups though gradually decreased within the first week of ICU admission. On days 3 and 7, the serum IL-6, hepcidin, ferritin, and red blood cell distribution width significantly decreased in the CRRT group compared to the control group (all P<0.05). On day 7, the serum iron was significantly elevated in the CRRT group compared to the control group (P<0.05). However, the serum sTfR did not significantly differ between the groups over time. In addition, the SOFA scores were significantly lower in the CRRT group compared to the control group on day 7. The 28-day mortality did not significantly differ between the control and CRRT groups (38.0% vs. 28.2%, P=0.332).

    CONCLUSION: CRRT might have beneficial effects on the improvement in inflammation-related iron metabolism and disease severity during the first week of ICU admission but not anemia and 28-day mortality in sepsis patients with AKI.

    Effects of early standardized enteral nutrition on preventing acute muscle loss in the acute exacerbation of chronic obstructive pulmonary disease patients with mechanical ventilation
    Yue Li, Yong-peng Xie, Xiao-min Li, Tao Lu
    2023, 14(3):  193-197.  doi:10.5847/wjem.j.1920-8642.2023.046
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    BACKGROUND: To investigate the effects of early standardized enteral nutrition (EN) on the cross-sectional area of erector spine muscle (ESMcsa), plasma growth differentiation factor-15 (GDF-15), and 28-day mortality of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients with invasive mechanical ventilation (MV).

    METHODS: A total of 97 AECOPD patients with invasive MV were screened in the ICUs of the First People's Hospital of Lianyungang. The conventional EN group (stage I) and early standardized EN group (stage II) included 46 and 51 patients, respectively. ESMcsa loss and GDF-15 levels on days 1 and 7 of ICU admission and 28-day survival rates were analyzed.

    RESULTS: On day 7, the ESMcsa of the early standardized EN group was significantly higher than that of the conventional EN group, while the plasma GDF-15 levels were significantly lower than those in the conventional EN group (ESMcsa: 28.426±6.130 cm2 vs. 25.205±6.127 cm2; GDF-15: 1661.608±558.820 pg/mL vs. 2541.000±634.845 pg/mL; all P<0.001]. The 28-day survival rates of the patients in the early standardized EN group and conventional EN group were 80.40% and 73.90%, respectively (P=0.406).

    CONCLUSION: ESMcsa loss in AECOPD patients with MV was correlated with GDF-15 levels, both of which indicated acute muscular atrophy and skeletal muscle dysfunction. Early standardized EN may prevent acute muscle loss and intensive care unit-acquired weakness (ICU-AW) in AECOPD patients.

    Development and validation of a predictive model for the assessment of potassium-lowering treatment among hyperkalemia patients
    Cong-ying Song, Jian-yong Zhu, Wei Huang, Yuan-qiang Lu
    2023, 14(3):  198-203.  doi:10.5847/wjem.j.1920-8642.2023.048
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    BACKGROUND: Hyperkalemia is common among patients in emergency department and is associated with mortality. While, there is a lack of good evaluation and prediction methods for the efficacy of potassium-lowering treatment, making the drug dosage adjustment quite difficult. We aimed to develop a predictive model to provide early forecasting of treating effects for hyperkalemia patients.

    METHODS: Around 80% of hyperkalemia patients (n=818) were randomly selected as the training dataset and the remaining 20% (n=196) as the validating dataset. According to the serum potassium (K+) levels after the first round of potassium-lowering treatment, patients were classified into the effective and ineffective groups. Multivariate logistic regression analyses were performed to develop a prediction model. The receiver operating characteristic (ROC) curve and calibration curve analysis were used for model validation.

    RESULTS: In the training dataset, 429 patients had favorable effects after treatment (effective group), and 389 had poor therapeutic outcomes (ineffective group). Patients in the ineffective group had a higher percentage of renal disease (P=0.007), peripheral edema (P<0.001), oliguria (P=0.001), or higher initial serum K+ level (P<0.001). The percentage of insulin usage was higher in the effective group than in the ineffective group (P=0.005). After multivariate logistic regression analysis, we found age, peripheral edema, oliguria, history of kidney transplantation, end-stage renal disease, insulin, and initial serum K+ were all independently associated with favorable treatment effects.

    CONCLUSION: The predictive model could provide early forecasting of therapeutic outcomes for hyperkalemia patients after drug treatment, which could help clinicians to identify hyperkalemia patients with high risk and adjust the dosage of medication for potassium-lowering.

    The relationship between physical activity in early pregnancy and hypertensive disorders of pregnancy: a cohort study in Chinese women
    Qian Lu, Shi-jiao Yan, Huan-jun Chen, Xiong-fei Pan, Yi-xiang Ye, Xing-yue Song, Ri-xing Wang, Chuan-zhu Lyu
    2023, 14(3):  204-208.  doi:10.5847/wjem.j.1920-8642.2023.047
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    BACKGROUND: We aimed to examine prospective associations between different intensities and different types of physical activity (PA) in early pregnancy and hypertensive disorders of pregnancy (HDP) among Chinese women.

    METHODS: A total of 6,820 pregnant women from the Tongji-Shuangliu Birth Cohort were included in this study. The pregnancy physical activity questionnaire (PPAQ) was used to assess PA, including household/caregiving, occupational, sports/exercise, and transportation activities in the first trimester of pregnancy. The diagnosis of HDP was collected, including gestational hypertension (GH) and preeclampsia (PE). Data were analyzed by unconditional multivariate logistic regression, and the odds ratio (OR) and 95% confidence interval (CI) were calculated.

    RESULTS: A total of 178 (2.6%) of the 6,820 women were diagnosed with HDP, of which 126 (1.8%) were GH and 52 (0.8%) were PE. Overall, we found no association between PA in early pregnancy and PE. A trend toward lower risk was found only among women with GH and among those with higher levels of moderate-to-vigorous intensity physical activity (MVPA) (adjusted OR 0.54, 95% CI 0.31-0.96). No association was observed between PA and HDP in early pregnancy, regardless of different intensities or types of PA.

    CONCLUSION: MVPA in the first trimester is an influencing factor of HDP. Encouraging pregnant women to engage in MVPA in the first trimester may help to prevent GH.

    Mutual promotion of mitochondrial fission and oxidative stress contributes to mitochondrial-DNA-mediated inflammation and epithelial-mesenchymal transition in paraquat-induced pulmonary fibrosis
    Jie Zhang, Wen-jing Li, Shi-qiang Chen, Ze Chen, Chen Zhang, Ran Ying, Hong-bing Liu, Long-wang Chen, Ya-hui Tang, Zhong-qiu Lu, Guang-ju Zhao
    2023, 14(3):  209-216.  doi:10.5847/wjem.j.1920-8642.2023.057
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    BACKGROUND: Pulmonary fibrosis (PF) is one of the main causes of death in patients with paraquat (PQ) poisoning. This study aimed to evaluate the relationship between mitochondrial fission and oxidative stress in PQ-induced epithelial-mesenchymal transition (EMT) and PF.

    METHODS: C57BL/6 mice and MLE-12 cells were exposed to PQ to construct a PF model in vivo and in vitro. Histological changes in the lungs were examined by hematoxylin and eosin (H&E) staining. Mitochondrial morphology was detected by MitoTracker® Deep Red FM or transmission electron microscopy (TEM). Western blotting and immunofluorescence were used to determine the expression of protein. The migration ability of the cells was detected by the cell scratch test. Mitochondrial DNA (mtDNA) levels were assessed by real-time polymerase chain reaction (PCR). Enzyme-linked immunosorbent assay (ELISA) was applied to detect cytokine levels. Superoxide dismutase (SOD) activity and the levels of glutathione (GSH) and malondialdehyde (MDA) were detected by chemichromatometry.

    RESULTS: PQ exposure caused EMT and PF in vivo and in vitro. PQ destroyed mitochondrial structure and enhanced the expression of dynamin-related protein 1 (Drp1), which were accompanied by oxidative stress. Inhibiting mitochondrial fission using mitochondrial division inhibitor-1 (Mdivi-1), a selective inhibitor of Drp1, attenuated PQ-induced EMT and oxidative damage. Treatment with N-acetyl-L-cysteine (NAC), an antioxidant, reduced Drp1 expression, attenuated mitochondrial structure damage and inhibited PQ-induced EMT and PF. Both Mdivi-1 and NAC treatment markedly suppressed mtDNA release, the expression of Toll-like receptor 9 (TLR9) and phosphorylation (P)-NF-κB p65 as well as cytokines (interleukin 6 [IL-6], interleukin-1β [IL-1β], and tumor necrosis factor-α [TNF-α]) production.

    CONCLUSION: Mutual promotion of mitochondrial fission and oxidative stress contributes to EMT in PQ-induced PF, which is associated with the mtDNA/TLR9/NF-κB pathway.

    Review Article
    Effect of post-rewarming fever after targeted temperature management in cardiac arrest patients: a systematic review and meta-analysis
    Guang-qi Guo, Yan-nan Ma, Shuang Xu, Hong-rong Zhang, Peng Sun
    2023, 14(3):  217-223.  doi:10.5847/wjem.j.1920-8642.2023.056
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    BACKGROUND: Targeted temperature management (TTM), as a therapeutic temperature control strategy for cardiac arrest (CA), is recommended by guidelines. However, the relationship between post-rewarming fever (PRF) and the prognosis of CA patients is unclear. Therefore, we aim to summarize the studies regarding the influence of PRF on patients with CA.

    METHODS: EMBASE, PubMed, and Cochrane Central databases were searched from inception to March 13, 2022. Randomized clinical trials (RCTs) and cohort studies on PRF in CA patients were included. According to the heterogeneity, the meta-analysis was performed using a random effects model or fixed effects model to calculate the pooled odds ratios (ORs) and corresponding 95% confidence intervals (CIs). The outcome data were unfavorable neurological outcome and mortality.

    RESULTS: The meta-analysis included 11 observational studies involving 3,246 patients. The results of the meta-analysis show that PRF (body temperature >38.0 °C) has no effect on the neurological outcome of CA patients (OR 0.71, 95% CI 0.43-1.17, I2 82%) and has a significant relationship with lower mortality (OR 0.63; 95% CI 0.49-0.80, I2 39%). However, PRF with a stricter definition (body temperature >38.5 °C ) was associated with worse neurological outcome (OR 1.44, 95% CI 1.08-1.92, I2 45%) and higher mortality (OR 1.71, 95% CI 1.25-2.35, I2 47%).

    CONCLUSION: This study suggests that PRF >38.0 °C may not affect the neurological outcome and have a lower mortality in CA patients who completed TTM. However, PRF >38.5 °C is a potential prognostic factor for worse outcomes in CA patients.

    Research Letters
    Nonpharmaceutical interventions effectively reduced influenza spread during the COVID-19 pandemic
    Yuan Yuan, Yan Li, Jiang-shan Wang, Ye-cheng Liu, Jun Xu, Hua-dong Zhu, Lu-zhao Feng
    2023, 14(3):  224-226.  doi:10.5847/wjem.j.1920-8642.2023.049
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    Age-appropriateness of decision for brain CT scan in elderly patients with mild traumatic brain injury
    Kasamon Aramvanitch, Korawee Khachornwattanakul, Piraya Vichiensanth, Chetsadakon Jenpanitpong, Ponlawat Kanchayawong, Sorawich Watcharakitpaisan, Chaiyaporn Yuksen
    2023, 14(3):  227-230.  doi:10.5847/wjem.j.1920-8642.2023.042
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    Ultrasound-guided erector spine plane block (ESPB) utilization in managing refractory renal colic pain in the emergency department
    Mehdi Torabi, Javad Darijani, Moghaddameh Mirzaee, Amin Honarmand
    2023, 14(3):  231-234.  doi:10.5847/wjem.j.1920-8642.2023.036
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    Construction of cough reflex intensity score for critically ill patients based on the Delphi method
    Yong-kai Li, Yang Liu, Wen-bin Jia, Jian-zhong Yang, Jun Xu
    2023, 14(3):  235-237.  doi:10.5847/wjem.j.1920-8642.2023.045
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    Factors associated with the clinical outcomes of adult cardiac and non-cardiac origin cardiac arrest in emergency departments: a nationwide retrospective cohort study from China
    Yue-guo Wang, Cudjoe Obed, Yu-lan Wang, Feng-feng Deng, Shu-sheng Zhou, Yang-yang Fu, Jian Sun, Wen-wen Wang, Jun Xu, Kui Jin
    2023, 14(3):  238-240.  doi:10.5847/wjem.j.1920-8642.2023.044
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    Clinical Imaging and Techniques
    Laryngeal mask airway bougie ultrasonography guided intubation in a morbidly obese patient with difficult airway
    Rachana Bhat, Preeti Yadav, Jyothiswaroop Bhaskararayuni, Akhil Neseem, Savan Kumar Nagesh, Prakash Ranjan Mishra
    2023, 14(3):  241-243.  doi:10.5847/wjem.j.1920-8642.2023.050
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    Case Letters
    A rare case of purulent pericarditis secondary to subdiaphragmatic abscess
    Song Yang, Chao Cui, Wen-peng Yin, Yu-dong Fu, Guang-li Tang, Xiao-jun Yang, Guo-feng Qu, Zhi-jun Jia, Lin-na Cao, Ke-song Tang, Bao-jian Zhang, Xia-lei Du
    2023, 14(3):  244-246.  doi:10.5847/wjem.j.1920-8642.2023.037
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    Twelve family members with tetramine poisoning after consumption of vegetables grown in polluted soils
    Yan-qing Liu, Xiao-xia Lu, Chun-yan Wang, Ming-fei Peng, Xiao-bo Peng, Yun Jiang, Le-xin Zheng, Dan-dan Yuan, Xi-gang Zhang, Ze-wu Qiu
    2023, 14(3):  250-252.  doi:10.5847/wjem.j.1920-8642.2023.038
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    Pregnancy-related spontaneous coronary artery dissection after intravenous ritodrine infusion: a case report
    Ya-qing An, Yan-ling Dong, Yi-jiao Men, Liang Liu, Yu Gong, Jian-ling Su, Heng-bo Gao, Ying-ping Tian
    2023, 14(3):  253-254.  doi:10.5847/wjem.j.1920-8642.2023.043
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    A 94-year-old patient with severe burns: a case report
    Ying Ren, Qun-fei Yu, Fei Lu, Yao-jing Ma, Xiu-qin Feng
    2023, 14(3):  255-256.  doi:10.5847/wjem.j.1920-8642.2023.058
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