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    01 September 2023, Volume 14 Issue 5
    Review Article
    Emergency department approach to monkeypox
    Catherine V. Levitt, Quincy K. Tran, Hashem Hraky, Maryann Mazer-Amirshahi, Ali Pourmand
    2023, 14(5):  341-348.  doi:10.5847/wjem.j.1920-8642.2023.098
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    BACKGROUND: Monkeypox (mpox) is a viral infection that is primarily endemic to countries in Africa, but large outbreaks outside of Africa have been historically rare. In June 2022, mpox began to spread across Europe and North America, causing the World Health Organization (WHO) to declare mpox a public health emergency of international concern. This article aims to review clinical presentation, diagnosis, and prevention and treatment strategies on mpox, providing the basic knowledge for prevention and control for emergency providers.
    METHODS: We conducted a review of the literature using PubMed and SCOPUS databases from their beginnings to the end of July 2023. The inclusion criteria were studies on adult patients focusing on emerging infections that described an approach to a public health emergency of international concern, systematic reviews, clinical guidelines, and retrospective studies. Studies that were not published in English were excluded.
    RESULTS: We included 50 studies in this review. The initial symptoms of mpox are non-specific: fever, malaise, myalgias, and sore throat. Rash, a common presentation of mpox, usually occurs 2-4 weeks after the prodrome, but the presence of lymphadenopathy may distinguish mpox from other infections from the Poxviridae family. Life-threatening complications such as pneumonia, sepsis, encephalitis, myocarditis, and death can occur. There are documented co-occurrences of human immunodeficiency virus (HIV) and other sexually transmitted infections that can worsen morbidity.
    CONCLUSION: The initial presentation of mpox is non-specific. The preferred treatment included tecovirimat in patients with severe illness or at high risk of developing severe disease and vaccination with two doses of JYNNEOS. However, careful history and physical examination can raise the clinicians’ suspicion and point toward a prompt diagnosis. There are different modalities to prevent and treat mpox infection.

    Establishment and evaluation of animal models of sepsis-associated encephalopathy
    Mubing Qin, Yanxia Gao, Shigong Guo, Xin Lu, Qian Zhao, Zengzheng Ge, Huadong Zhu, Yi Li
    2023, 14(5):  349-353.  doi:10.5847/wjem.j.1920-8642.2023.088
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    BACKGROUND: Sepsis-associated encephalopathy (SAE) is a critical disease caused by sepsis. In addition to high mortality, SAE can also adversely affect life quality and lead to significant socioeconomic costs. This review aims to explore the development of evaluation animal models of SAE, giving insight into the direction of future research in terms of its pathophysiology and therapy.
    METHODS: We performed a literature search from January 1, 2000, to December 31, 2022, in MEDLINE, PubMed, EMBASE, and Web of Science using related keywords. Two independent researchers screened all the accessible articles based on the inclusion and exclusion criteria and collected the relevant data of the studies.
    RESULTS: The animal models for sepsis are commonly induced through cecal ligation and puncture (CLP) or lipopolysaccharide (LPS) injection. SAE can be evaluated using nervous reflex scores and sepsis evaluation during the acute phase, or through Morris water maze (MWM), open-field test, fear condition (FC) test, inhibitory avoidance, and other tests during the late phase.
    CONCLUSION: CLP and LPS injection are the most common methods for establishing SAE animal models. Nervous reflexs cores, MWM, FC test, and inhibitory avoidance are widely used in SAE model analysis. Future research should focus on establishing a standardized system for SAE development and analysis.

    Original Article
    The neuro-prognostic value of the ion shift index in cardiac arrest patients following extracorporeal cardiopulmonary resuscitation
    Gannan Wang, Zhe Wang, Yi Zhu, Zhongman Zhang, Wei Li, Xufeng Chen, Yong Mei
    2023, 14(5):  354-359.  doi:10.5847/wjem.j.1920-8642.2023.087
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    BACKGROUND: The ion shift index (ISI) as a prognostic indicator that can show the severity of hypoxic-ischemic injury. We aimed to evaluate the performance of the ISI in predicting unfavorable neurological outcomes at hospital discharge in cardiac arrest (CA) patients following extracorporeal cardiopulmonary resuscitation (ECPR) and to compare its performance to other prognostic predictors.
    METHODS: This was a retrospective observational study including adult CA patients treated with ECPR between January 2018 and December 2022 in a tertiary hospital. Data regarding clinical characteristics and laboratory parameters were collected from medical records. The ISI was determined based on the first available serum electrolyte levels after ECPR. The primary outcome was unfavorable neurological status at hospital discharge, defined as Cerebral Performance Categories 3-5. Comparisons of the characteristics between the two groups were made using the χ2 test for categorical variables and the t-test or non-parametric Mann-Whitney U-test for continuous variables, as appropriate. Correlation analysis was performed using Spearman’s rank correlation coefficient. A two-tailed P-value <0.05 was considered statistically significant.
    RESULTS: Among the 122 patients involved, 46 (37.7%) had out-of-hospital CA, and 88 had unfavorable neurological outcomes. The ISI was significantly higher in the unfavorable outcome group than in the favorable outcome group (3.74 [3.15-4.57] vs. 2.69 [2.51-3.07], P<0.001). A higher ISI level was independently related to unfavorable outcome (odds ratio=6.529, 95% confidence interval 2.239-19.044, P=0.001). An ISI level >3.12 predicted unfavorable outcomes with a sensitivity and specificity of 74.6% and 85.2%, respectively (P<0.001). The prognostic performance of ISI (area under the curve [AUC]=0.887) was similar to that of other predictors, such as gray-to-white matter ratio (AUC=0.850, P=0.433) and neuron-specific enolase (AUC=0.925, P=0.394).
    CONCLUSION: ISI may be used as a prognostic biomarker to predict neurological outcomes in CA patients following ECPR.

    A prospective cohort study on serum A20 as a prognostic biomarker of aneurysmal subarachnoid hemorrhage
    Tian Yan, Ziyin Chen, Shengdong Zou, Zefan Wang, Quan Du, Wenhua Yu, Wei Hu, Yongke Zheng, Keyi Wang, Xiaoqiao Dong, Shuangyong Dong
    2023, 14(5):  360-366.  doi:10.5847/wjem.j.1920-8642.2023.079
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    BACKGROUND: A20 may be a neuroprotective factor. Herein, we aimed to investigate whether serum A20 levels were associated with disease severity, delayed cerebral ischemia (DCI), and outcome after aneurysmal subarachnoid hemorrhage (aSAH).
    METHODS: In this prospective cohort study containing 112 aSAH patients and 112 controls, serum A20 levels were quantified. At 90 d poststroke, Modified Rankin Scale (MRS) scores ≥3 were defined as a poor outcome. All correlations and associations were assessed using multivariate analysis.
    RESULTS: Compared with controls, there was a significant elevation of serum A20 levels in patients (median 123.7 pg/mL vs. 25.8 pg/mL; P<0.001). Serum A20 levels were independently correlated with Hunt-Hess scores (β 9.854; 95% confidence interval [95% CI] 2.481-17.227, P=0.009) and modified Fisher scores (β 10.349, 95% CI 1.273-19.424, P=0.026). Independent associations were found between serum A20 levels and poor outcome (odds ratio [OR] 1.015, 95% CI 1.000-1.031, P=0.047) and DCI (OR 1.018, 95% CI 1.001-1.035, P=0.042). Areas under the curve for predicting poor outcome and DCI were 0.771 (95% CI 0.682-0.845) and 0.777 (95% CI 0.688-0.850), respectively. Serum A20 levels ≥128.15 pg/mL predicted poor outcome, with a sensitivity of 73.9% and specificity of 74.2%, and A20 levels ≥160.55 pg/mL distinguished the risk of DCI with 65.5% sensitivity and 89.2% specificity. Its ability to predict poor outcome and DCI was similar to those of Hunt-Hess scores and modified Fisher scores (both P>0.05).
    CONCLUSION: Enhanced serum A20 levels are significantly associated with stroke severity and poor clinical outcome after aSAH, implying that serum A20 may be a potential prognostic biomarker for aSAH.

    Mendelian randomization study to investigate the causal relationship between plasma homocysteine and chronic obstructive pulmonary disease
    Yanlan Hu, Ping Tan, Juntao Wang, Jun Zeng, Quan Li, Shijiao Yan, Wenjie Hao, Lanfen He, Xingyue Song, Caihong Zhang, Chuanzhu Lyu
    2023, 14(5):  367-371.  doi:10.5847/wjem.j.1920-8642.2023.078
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    BACKGROUND: Several observational studies have shown an association between homocysteine (Hcy) levels and chronic obstructive pulmonary disease (COPD), but causal relationships are not clear. Our study aimed to explore the causal relationship between plasma Hcy and COPD by two-sample Mendelian randomization (MR).
    METHODS: A two-sample MR study was performed to infer the causal link. Genetically predicted plasma Hcy was selected as an instrumental variable (IV) from published genome-wide association study (GWAS) meta-analyses. COPD with different etiologies was extracted as outcome variables from other GWAS meta-analyses. The main MR analysis was performed using the inverse-variance weighted (IVW) method. Additional analyses were further performed using Cochran's Q-test and MR-Egger regression to evaluate the heterogeneity or horizontal pleiotropy of our findings.
    RESULTS: MR analysis showed no significant association between plasma Hcy and COPD. The results of the groups were consistent with the sensitivity analysis and repeated analysis, without heterogeneity or horizontal pleiotropy. The IVW results showed COPD hospital admissions (odds ratio [OR] 1.06, 95% confidence interval [CI] 0.91-1.24, P=0.42), asthma/COPD (OR 0.97, 95% CI 0.89-1.06, P=0.55), COPD-related chronic infection (OR 1.50, 95% CI 0.57-3.99, P=0.41), COPD/asthma/interstitial lung disease (ILD)-related pneumonia or pneumonia-derived septicemia (OR 0.93, 95% CI 0.86-1.02, P=0.13), and COPD-related respiratory insufficiency (OR 1.00, 95% CI 0.7-1.44, P=0.99).
    CONCLUSION: There is no direct causal relationship between plasma Hcy and COPD in our study. As Hcy is known to have deleterious effects on endothelial function and vascular homeostasis, further studies are needed to investigate whether additional factors mediate the association between Hcy and COPD.

    Cardiopulmonary prognosis of prophylactic endotracheal intubation in patients with upper gastrointestinal bleeding undergoing endoscopy
    Yufang Lin, Fei’er Song, Weiyue Zeng, Yichi Han, Xiujuan Chen, Xuanhui Chen, Yu Ouyang, Xueke Zhou, Guoxiang Zou, Ruirui Wang, Huixian Li, Xin Li
    2023, 14(5):  372-379.  doi:10.5847/wjem.j.1920-8642.2023.080
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    BACKGROUND: It is controversial whether prophylactic endotracheal intubation (PEI) protects the airway before endoscopy in critically ill patients with upper gastrointestinal bleeding (UGIB). The study aimed to explore the predictive value of PEI for cardiopulmonary outcomes and identify high-risk patients with UGIB undergoing endoscopy.
    METHODS: Patients undergoing endoscopy for UGIB were retrospectively enrolled in the eICU Collaborative Research Database (eICU-CRD). The composite cardiopulmonary outcomes included aspiration, pneumonia, pulmonary edema, shock or hypotension, cardiac arrest, myocardial infarction, and arrhythmia. The incidence of cardiopulmonary outcomes within 48 h after endoscopy was compared between the PEI and non-PEI groups. Logistic regression analyses and propensity score matching analyses were performed to estimate effects of PEI on cardiopulmonary outcomes. Moreover, restricted cubic spline plots were used to assess for any threshold effects in the association between baseline variables and risk of cardiopulmonary outcomes (yes/no) in the PEI group.
    RESULTS: A total of 946 patients were divided into the PEI group (108/946, 11.4%) and the non-PEI group (838/946, 88.6%). After propensity score matching, the PEI group (n=50) had a higher incidence of cardiopulmonary outcomes (58.0% vs. 30.3%, P=0.001). PEI was a risk factor for cardiopulmonary outcomes after adjusting for confounders (odds ratio [OR] 3.176, 95% confidence interval [95% CI] 1.567-6.438, P=0.001). The subgroup analysis indicated the similar results. A shock index >0.77 was a predictor for cardiopulmonary outcomes in patients undergoing PEI (P=0.015). The probability of cardiopulmonary outcomes in the PEI group depended on the Charlson Comorbidity Index (OR 1.465, 95% CI 1.079-1.989, P=0.014) and shock index >0.77 (compared with shock index ≤0.77 [OR 2.981, 95% CI 1.186-7.492, P=0.020, AUC=0.764]).
    CONCLUSION: PEI may be associated with cardiopulmonary outcomes in elderly and critically ill patients with UGIB undergoing endoscopy. Furthermore, a shock index greater than 0.77 could be used as a predictor of a worse prognosis in patients undergoing PEI.

    Key elements and checklist of shared decision-making conversation on life-sustaining treatment in emergency: a multispecialty study from China
    Shu Li, Jing Xie, Ziyi Chen, Jie Yan, Yuliang Zhao, Yali Cong, Bin Zhao, Hua Zhang, Hongxia Ge, Qingbian Ma, Ning Shen
    2023, 14(5):  380-385.  doi:10.5847/wjem.j.1920-8642.2023.076
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    BACKGROUND: Shared decision-making (SDM) has broad application in emergencies. Most published studies have focused on SDM for a certain disease or expert opinions on future research gaps without revealing the full picture or detailed guidance for clinical practice. This study is to investigate the optimal application of SDM to guide life-sustaining treatment (LST) in emergencies.
    METHODS: This study was a prospective two-round Delphi consensus-seeking survey among multiple stakeholders at the China Consortium of Elite Teaching Hospitals for Residency Education. Participants were identified based on their expertise in medicine, law, administration, medical education, or patient advocacy. All individual items and questions in the questionnaire were scored using a 5-point Likert scale, with responses ranging from “very unimportant” (a score of 1) to “extremely important” (a score of 5). The percentages of the responses that had scores of 4-5 on the 5-point Likert scale were calculated. A Kendall’s W coefficient was calculated to evaluate the consensus of experts.
    RESULTS: A two-level framework consisting of 4 domains and 22 items as well as a ready-to-use checklist for the informed consent process for LST was established. An acceptable Kendall’s W coefficient was achieved.
    CONCLUSION: A consensus-based framework supporting SDM during LST in an emergency department can inform the implementation of guidelines for clinical interventions, research studies, medical education, and policy initiatives.

    Effects of mesencephalic astrocyte-derived neurotrophic factor on sepsis-associated acute kidney injury
    Saifeng Chen, Xuewei Hao, Guo Chen, Guorong Liu, Xiaoyan Yuan, Peiling Shen, Dongfeng Guo
    2023, 14(5):  386-392.  doi:10.5847/wjem.j.1920-8642.2023.077
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    BACKGROUND: To determine the protective role of mesencephalic astrocyte-derived neurotrophic factor (MANF) in regulating sepsis-associated acute kidney injury (S-AKI).
    METHODS: A total of 96 mice were randomly divided into the control group, control+MANF group, S-AKI group, and S-AKI+MANF group. The S-AKI model was established by injecting lipopolysaccharide (LPS) at 10 mg/kg intraperitoneally. MANF (200 μg/kg) was administered to the control+MANF and S-AKI+MANF groups. An equal dose of normal saline was administered daily intraperitoneally in the control and S-AKI groups. Serum and kidney tissue samples were obtained for biochemical analysis. Western blotting was used to detect the protein expression of MANF in the kidney, and enzyme-linked immunosorbent assay (ELISA) was used to determine expression of MANF in the serum, pro-inflammatory cytokines (tumor necrosis factor-α [TNF-α] and interleukin-6 [IL-6]). Serum creatinine (SCr), and blood urea nitrogen (BUN) were examined using an automatic biochemical analyzer. In addition, the kidney tissue was observed for pathological changes by hematoxylin-eosin staining. The comparison between two groups was performed by unpaired Student’s t-test, and statistics among multiple groups were carried out using Tukey’s post hoc test following one-way analysis of variance (ANOVA). A P-value <0.05 was considered statistically significant.
    RESULTS: At the early stage of S-AKI, MANF in the kidney tissue was up-regulated, but with the development of the disease, it was down-regulated. Renal function was worsened in the S-AKI group, and TNF-α and IL-6 were elevated. The administration of MANF significantly alleviated the elevated levels of SCr and BUN and inhibited the expression of TNF-α and IL-6 in the kidney. The pathological changes were more extensive in the S-AKI group than in the S-AKI+MANF group.
    CONCLUSION: MANF treatment may significantly alleviate renal injury, reduce the inflammatory response, and alleviate or reverse kidney tissue damage. MANF may have a protective effect on S-AKI, suggesting a potential treatment for S-AKI.

    Research Letter
    Synchronized ventilation during resuscitation in pigs does not necessitate high inspiratory pressures to provide adequate oxygenation
    Miriam Renz, Raphael René Cinto Noack, René Rissel, Katja Mohnke, Julian Riedel, Bastian Dunges, Alexander Ziebart, Erik Kristoffer Hartmann, Robert Ruemmler
    2023, 14(5):  393-396.  doi:10.5847/wjem.j.1920-8642.2023.089
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    Uncovering the potential pathological mechanism of acute pancreatitis in patients with COVID-19 by bioinformatics methods
    Zhaodi Wang, Ping Wang, Xuan Lu, Congying Song, Shuai Jiang, Li Li, Yuanqiang Lu
    2023, 14(5):  397-401.  doi:10.5847/wjem.j.1920-8642.2023.099
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    Case Letter
    Acute adrenal insufficiency caused by antiphospholipid syndrome
    Yunfei Feng, Weibin Zhou, Daiqiong Fang
    2023, 14(5):  402-404.  doi:10.5847/wjem.j.1920-8642.2023.082
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    A case report of intramyocardial dissecting hematoma: a challenging diagnosis
    Yaoyao Zhu, Tong Wang, Longyuan Jiang, Lian Liang
    2023, 14(5):  405-407.  doi:10.5847/wjem.j.1920-8642.2023.074
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    Inferior vena cava thrombosis in two adult patients with veno-arterial extracorporeal membrane oxygenation
    Xiao Chen, Anyu Qian, Mao Zhang, Guangju Zhou
    2023, 14(5):  408-410.  doi:10.5847/wjem.j.1920-8642.2023.073
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    Severe disseminated intravascular coagulation complicated by acute renal failure during pregnancy
    Yuqun Pu, Jingping Zhu, Baihui Zhao, Mengmeng Yang, Qiong Luo
    2023, 14(5):  411-413.  doi:10.5847/wjem.j.1920-8642.2023.072
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    Acute hemolytic anemia in a 34-year-old man after inhalation of a volatile nitrite “popper” product
    Xiang Peng, Liuyang Cheng, Huanhuan Gong, Jie Wang, Xiaowei Ke, Xiangmin Li
    2023, 14(5):  414-415.  doi:10.5847/wjem.j.1920-8642.2023.075
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    Progressive eschar-like wound and peripheral neurological dysfunction with severe inflammatory status: infection or unnatural immune response?
    Hanghui Cen, Pengqin Xu, Hong Zou, Jialiang Wang, Xingang Wang, Chunmao Han
    2023, 14(5):  416-418.  doi:10.5847/wjem.j.1920-8642.2023.086
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