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    01 November 2023, Volume 14 Issue 6
    Review Article
    Blood gas analysis as a surrogate for microhemodynamic monitoring in sepsis
    Jingyi Wang, Li Weng, Jun Xu, Bin Du
    2023, 14(6):  421-427.  doi:10.5847/wjem.j.1920-8642.2023.093
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    BACKGROUND: Emergency patients with sepsis or septic shock are at high risk of death. Despite increasing attention to microhemodynamics, the clinical use of advanced microcirculatory assessment is limited due to its shortcomings. Since blood gas analysis is a widely used technique reflecting global oxygen supply and consumption, it may serve as a surrogate for microcirculation monitoring in septic treatment.

    METHODS: We performed a search using PubMed, Web of Science, and Google scholar. The studies and reviews that were most relevant to septic microcirculatory dysfunctions and blood gas parameters were identified and included.

    RESULTS: Based on the pathophysiology of oxygen metabolism, the included articles provided a general overview of employing blood gas analysis and its derived set of indicators for microhemodynamic monitoring in septic care. Notwithstanding flaws, several parameters are linked to changes in the microcirculation. A comprehensive interpretation of blood gas parameters can be used in order to achieve hemodynamic optimization in septic patients.

    CONCLUSION: Blood gas analysis in combination with clinical performance is a reliable alternative for microcirculatory assessments. A deep understanding of oxygen metabolism in septic settings may help emergency physicians to better use blood gas analysis in the evaluation and treatment of sepsis and septic shock.

    Original Article
    Computed tomography coronary angiography after excluding myocardial infarction: high-sensitivity troponin versus risk score-guided approach
    Won Jae Yoo, Shin Ahn, Bora Chae, Won Young Kim
    2023, 14(6):  428-433.  doi:10.5847/wjem.j.1920-8642.2023.094
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    BACKGROUND: Patients with suspected acute coronary syndrome (ACS) in whom myocardial infarction has been ruled out are still at risk of having obstructive coronary artery disease (CAD). This rate is higher among patients with intermediate high-sensitivity troponin I (hsTnI) concentrations (5 ng/L to 99th percentile) than low concentrations (<5 ng/L). Therefore, an intermediate concentration has been suggested as a candidate for downstream investigation with computed tomography coronary angiography (CTCA). We tried to compare the HEART score-guided vs. hsTnI-guided approach for identifying obstructive CAD.

    METHODS: From a prospective cohort study of patients presenting to the emergency department with suspected ACS, 433 patients without elevated hsTnI who also underwent CTCA were selected and analyzed. The performances of hsTnI concentration and HEART score were compared using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

    RESULTS: Overall, 120 (27.7%) patients had obstructive CAD. Patients with intermediate hsTnI concentrations were more likely to have obstructive CAD than those with low hsTnI concentrations (40.0% vs. 18.1%); patients with non-low-risk HEART scores (≥4 points) were also more likely to have obstructive CAD than those with low-risk scores (0 to 3 points) (41.0% vs. 7.6%). The HEART score had higher sensitivity and NPV for detecting obstructive CAD in each classification than hsTnI concentration (sensitivity: 89.2% vs. 63.3%; NPV: 92.4% vs. 81.9%, respectively).

    CONCLUSION: After excluding myocardial infarction in patients with suspected ACS, adding the HEART score for selecting candidates for CTCA could improve patient risk stratification more accurately than relying on hsTnI concentration.

    A nomogram based on lymphocyte percentage for predicting hospital mortality in exertional heatstroke patients: a 13-year retrospective study
    Jiale Yang, Fanghe Gong, Xuezhi Shi, Fanfan Wang, Jing Qian, Lulu Wan, Yi Chen, Huaisheng Chen, Huasheng Tong
    2023, 14(6):  434-441.  doi:10.5847/wjem.j.1920-8642.2023.101
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    BACKGROUND: Exertional heatstroke (EHS) is a life-threatening disease without ideal prognostic markers for predicting hospital mortality.

    METHODS: This is a single-center retrospective study. Clinical data from EHS patients admitted to the Intensive Care Unit (ICU) of the General Hospital of Southern Theatre Command between January 1, 2008, and December 31, 2020, were recorded and analyzed. Univariate and multivariate logistic regression were used to identify the factors for mortality. The prediction model was developed with the prognostic markers, and a nomogram was established.

    RESULTS: The study ultimately enrolled 156 patients, and 15 (9.6%) of patients died before discharge. The lymphocyte count (Lym) and percentage (Lym%) were significantly lower in non-survivors (P<0.05). The univariate and multivariate logistic regression analyses indicated that Lym% at the third day of admission (Lym% D3) (OR=0.609, 95%CI: 0.454-0.816) and hematocrit (HCT) (OR=0.908, 95%CI: 0.834-0.988) were independent protective factors for hospital mortality. A nomogram incorporating Lym% D3 with HCT was developed and demonstrated good discrimination and calibration ability. The comparison between the prediction model and scoring systems revealed that the prediction model had the largest area under the curve (AUC) (0.948, 95%CI: 0.900-0.977), with 100.00% sensitivity and 83.69% specificity, and a greater clinical net benefit.

    CONCLUSION: Severe EHS patients had a higher risk of experiencing prolonged lymphopenia. A nomogram based on Lym% D3 and HCT was developed to facilitate early identification and timely treatment of patients with potentially unfavorable prognoses.

    The effect of prophylactic antibiotics in acute upper gastrointestinal bleeding patients in the emergency department
    Miao Gan, Liang Zong, Xuezhong Yu, Jun Xu
    2023, 14(6):  442-447.  doi:10.5847/wjem.j.1920-8642.2023.062
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    BACKGROUND: Currently, prophylactic antibiotics are recommended only for cirrhotic patients with acute upper gastrointestinal bleeding (AUGIB); however, the benefit for other AUGIB patients remains undetermined. We aimed to compare the clinical outcomes between patients with AUGIB with and without prophylactic antibiotics to identify the population that requires this therapy.

    METHODS: Patients with AUGIB admitted between 1st January 2019 and 31st December 2021 in the Emergency Department of Peking Union Medical College Hospital were enrolled. Patients were divided into the antibiotic and non-antibiotic groups. The primary outcome was in-hospital mortality, and the secondary outcome was the onset of new infection. The risk factors for mortality and infection were analyzed, and stratification analysis of prophylactic antibiotics was performed. Continuous data were analyzed using the t-test or nonparametric rank sum test, and categorical data were analyzed using the Chi-square test or Fisher’s exact test. Indicators with significant differences between the groups were included for logistic regression analysis. A P-value <0.05 was considered statistically significant.

    RESULTS: A total of 392 individuals were included, among them, 281 patients received prophylactic antibiotics, and 111 patients did not receive prophylactic antibiotics. The mortality rates were significantly lower in the antibiotic group than in the non-antibiotics group (6.41% vs. 17.12%, P=0.001). The risk factors for infection were varicose veins (P=0.045) and endotracheal intubation (P=0.005) in the prophylactic antibiotic group, and endoscopic treatment (P=0.010) in the non-prophylactic antibiotic group. Stratified analyses showed that patients with age ≥ 65 years, endotracheal intubation, endoscopic treatment, and AUGIB of variceal etiologies benefited from prophylactic antibiotics.

    CONCLUSION AUGIB patients may benefit from prophylactic antibiotics to decrease mortality, especially those aged ≥ 65 years and those with endotracheal intubation, endoscopic treatment, and variceal etiologies.

    The value of prognostic markers for pediatric trauma patients
    Cansu Durak, Ebru Guney Sahin, Yasar Yusuf Can, Alican Sarisaltik, Kubra Boydag Guvenc
    2023, 14(6):  448-453.  doi:10.5847/wjem.j.1920-8642.2023.100
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    BACKGROUND: Despite the rapid development of pediatric intensive care medicine, there are still limited data in the literature regarding the follow-up of pediatric trauma patients in pediatric intensive care units (PICUs). In this study, we aim to evaluate our experience with children admitted and followed up with the diagnosis of trauma at our PICU.

    METHODS: We evaluated the retrospective data of 77 pediatric trauma patients who were admitted to the PICU at Sancaktepe Sehit Prof. Dr. IlhanVarank Training and Research Hospital from August 2020 to December 2022. The demographic data, clinical parameters and laboratory results were recorded. The primary outcome was the mortality in PICU. The performances of markers in predicting mortality were evaluated with receiver operating characteristic (ROC) curves.

    RESULTS: The median age of the patients was 70 (33-157) months, and the median duration of hospitalization in the PICU was 6 (2-11) d. Of the 77 patients, 9 died due to trauma (11,1%). Among the clinical parameters, Pediatric Risk of Mortality III (PRISM III) Score, inotrope requirement, extracorporeal treatment requirement, and mechanical ventilator requirement were significantly higher in non-survivors than in survivors. Among the laboratory parameters, procalcitonin (PCT), lactate/albumin ratio (LAR), neutrophil/lymphocyte ratio (NLR), and transfusion requirement were significantly higher in non-survivors than in survivors.

    CONCLUSION: In pediatric trauma patients, baseline PCT, LAR, and NLR values can be used to identify patients at risk for mortality.

    Prevalence and risk factors for acquired long QT syndrome in the emergency department: a retrospective observational study
    Diogo de Almeida Fernandes, Guilherme de Freitas Camões, Diana Ferreira, Carolina Queijo, Carlos Fontes-Ribeiro, Lino Gonçalves, Rui Pina, Natália António
    2023, 14(6):  454-461.  doi:10.5847/wjem.j.1920-8642.2023.104
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    BACKGROUND: Long QT syndrome (LQTS) is a heterogeneous syndrome that may be congenital or, more frequently, acquired. The real-world prevalence of acquired LQTS (aLQTS) in the emergency department (ED) remains to be determined. The aim of this study was to determine prevalence of aLQTS and its impact on symptoms on ED admissions.

    METHODS: Electrocardiograms (ECG) of 5,056 consecutively patients admitted in the ED of a tertiary hospital between January 28th and March 17th of 2020 were reviewed. All patients with aLQTS were included. Clinical data with a focus on QT prolonging drugs and clinical factors were recorded. Statistical comparison was made between the groups with and without corrected QT (QTc) interval greater than 500 ms (value that is considered severely increased).

    RESULTS: A total of 383 ECGs with prolonged QTc were recognized, corresponding to a prevalence of aLQTS at admission of 7.82%. Patients with aLQTS were more commonly men (53.3%) with an age of (73.49±14.79) years old and QTc interval of (505.3±32.4) ms. Only 20.4% of these patients with aLQTS were symptomatic. No ventricular arrhythmias were recorded. Patients with QT interval greater than 500 ms were more frequently female (59.5%; P<0.001) and were more frequently on QT prolonging drugs (77.3%; P=0.025). Main contributing factor was intake of antibiotics (odds ratio [OR] 4.680) followed by female gender (OR 2.473) and intake of antipsychotics (OR 1.925).

    CONCLUSION: aLQTS is particularly prevalent in the ED. Female patients on antibiotics and antipsychotics are at particularly high risk. Efforts must be made to avoid, detect and treat aLQTS as early as possible.

    Vagus nerve stimulation protects against cerebral injury after cardiopulmonary resuscitation by inhibiting inflammation through the TLR4/NF-κB and α7nAChR/JAK2 signaling pathways
    Shuang Xu, Lang Guo, Weijing Shao, Licai Liang, Tingting Shu, Yuhan Zhang, He Huang, Guangqi Guo, Qing Zhang, Peng Sun
    2023, 14(6):  462-470.  doi:10.5847/wjem.j.1920-8642.2023.102
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    BACKGROUND: Our previous research proved that vagus nerve stimulation (VNS) improved the neurological outcome after cardiopulmonary resuscitation (CPR) by activating α7 nicotinic acetylcholine receptor (α7nAChR) in a rat model, but the underlying mechanism of VNS in neuroprotection after CPR remains unclear.

    METHODS: In vivo, we established a mouse model of cardiac arrest (CA)/CPR to observe the survival rate, and the changes in inflammatory factors and brain tissue after VNS treatment. In vitro, we examined the effects of α7nAChR agonist on ischemia/reperfusion (I/R)-induced inflammation in BV2 cells under oxygen-glucose deprivation/reoxygenation (OGD/R) conditions. We observed the changes in cell survival rate, the levels of inflammatory factors, and the expressions of α7nAChR/Janus kinase 2 (JAK2) and toll-like receptor 4 (TLR4) /nuclear factor-κB (NF-κB).

    RESULTS: In vivo, VNS preconditioning enhanced functional recovery, improved the survival rate, and reduced hippocampal CA1 cell damage, and the levels of inflammatory mediators after CA/CPR. The application of α7nAChR agonists provided similar effects against cerebral injury after the return of spontaneous circulation (ROSC), while α7nAChR antagonists reversed these neuroprotective impacts. The in vitro results mostly matched the findings in vivo. OGD/R increased the expression of tumor necrosis factor-alpha (TNF-α), TLR4 and NF-κB p65. When nicotine was added to the OGD/R model, the expression of TLR4, NF-κB p65, and TNF-α decreased, while the phosphorylation of JAK2 increased, which was prevented by preconditioning with α7nAChR or JAK2 antagonists.

    CONCLUSION: The neuroprotective effect of VNS correlated with the activation of α7nAChR. VNS may alleviate cerebral IR injury by inhibiting TLR4/NF-κB and activating the α7nAChR/JAK2 signaling pathway.

    Effects of a closed-loop system against SARS-CoV-2 at the Beijing 2022 Olympic Winter Games: a descriptive and modeling study
    Rong Xiong, Jieping Zhou, Wenning Li, Jie Liu, Jing Lou, Sijia Tian, Huixin Lian, Shengmei Niu, Luxi Zhang, Wenhang Li, Jinjun Zhang
    2023, 14(6):  471-476.  doi:10.5847/wjem.j.1920-8642.2023.105
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    BACKGROUND: To assess the efficacy of the epidemic prevention measures of the “closed-loop” system adopted by the Beijing 2022 Olympic Winter Games (BOWG).

    METHODS: We retrospectively collected and analyzed information, including age, sex, nationality, vaccination status, date of diagnosis, and date of entry, from 280 SARS-CoV-2-positive individuals identified during the BOWG. A susceptibility-exposed-infectious-remove model was employed to evaluate the effectiveness of epidemic prevention strategies on controlling the spread of SARS-CoV-2 under different scenarios during the BOWG.

    RESULTS: Regarding SARS-CoV-2-positive cases, 97.9% were imported, and 96.4% were asymptomatic. The median age was 37 years (range: 29-47 years), and 73.9% were male, with the majority of cases being broadcasters and European attendees. Regarding vaccination status, 93.5% were fully vaccinated, and six cases were considered to have been infected in the closed-loop system during the BOWG. Assuming that the BOWG adopted a semi-closed-loop management system, the cumulative number of confirmed cases would be 1,137 for quick quarantine measures (3 d later) implemented and 5,530 for delayed quarantine measures (9 d later) implemented. This modeling revealed that stringent pandemic prevention measures and closed-loop management effectively controlled the spread of SARS-CoV-2 during the BOWG.

    CONCLUSION: Imported cases are considered the main risk factor for SARS-CoV-2 transmission during mass gatherings, but a comprehensive closed-loop system could minimize transmission among attendees and general personnel.

    Research Letter
    Case Letter
    Omadacycline for the treatment of Legionella pneumophila pneumonia caused by drowning: a case report
    Xiao Lu, Wenqi Qi, Haizhen Wang, Zhongjun Zheng, Libing Jiang, Shanxiang Xu
    2023, 14(6):  481-483.  doi:10.5847/wjem.j.1920-8642.2023.090
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    A case of pulmonary mucormycosis presented with cardiac arrest
    Haijiang Zhou, Xuan Qi, Jifei Cai, Wenxin Liu, Chenyu Kang, Guyu Zhang, Miaomiao Wang, Xuefei Xie, Chao Liang, Lihua Liu, Jie Gao, Wei Yuan, Xue Mei, Shubin Guo
    2023, 14(6):  484-487.  doi:10.5847/wjem.j.1920-8642.2023.096
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    Pyopneumothorax caused by Parvimonas micra and Prevotella oralis: a case report
    Yixuan Li, Jun Yang, Junyu Wang, Bing Wei, Le Hu
    2023, 14(6):  488-491.  doi:10.5847/wjem.j.1920-8642.2023.091
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    An unusual case of severe pneumonia caused by Tropheryma whipplei combined with Legionella pneumophila
    Zhenfeng Lu, Aiping Zhang, Jingsheng Guo, Haibin Ni
    2023, 14(6):  492-494.  doi:10.5847/wjem.j.1920-8642.2023.095
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    Hemorrhagic pancreatitis from fenofibrate and metformin toxicity: a case report
    Marcus Aik Beng Lee, Mingwei Ng, Paul Yugendra, Yiju Yao, R Ponampalam, Boon Kiat Kenneth Tan
    2023, 14(6):  495-498.  doi:10.5847/wjem.j.1920-8642.2023.106
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    Tension urinothorax as a reversible cause of cardiac arrest: a case report
    Ashutosh Wanchu, Ankur Verma, Sanjay Jaiswal, Abbas Ali Khatai, Nilesh Prasad
    2023, 14(6):  499-501.  doi:10.5847/wjem.j.1920-8642.2023.097
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    Uterine artery pseudoaneurysm after subtotal hysterectomy: a case report
    Ting Xu, Xiaobo Wang, Ruo’an Jiang, Wen Li, Shengting Yin, Haiyang Tang, Haizhen Dai, Xiaoxia Bai
    2023, 14(6):  502-504.  doi:10.5847/wjem.j.1920-8642.2023.103
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