Targeting endothelial tight junctions to predict and protect thoracic aortic aneurysm and dissection.

AIMS: Whether changes in endothelial tight junctions (TJs) lead to the formation of thoracic aortic aneurysm and dissection (TAAD) and serve as an early indicator and therapeutic target remains elusive. METHODS AND RESULTS: Single-cell RNA sequencing analysis showed aberrant endothelial TJ expressions in the thoracic aortas of patients with TAAD. In a ß-aminopropionitrile (BAPN)-induced TAAD mouse model, endothelial TJ function was disrupted in the thoracic aortas at an early stage (5 and 10 days) as observed by a vascular permeability assay, while the intercellular distribution of crucial TJ components was significantly decreased by en face staining. For the non-invasive detection of endothelial TJ function, two dextrans of molecular weights 4 and 70 kDa were conjugated with the magnetic resonance imaging (MRI) contrast agent Gd-DOTA to synthesize FITC-dextran-DOTA-Gd and rhodamine B-dextran-DOTA-Gd. MRI images showed that both probes accumulated in the thoracic aortas of the BAPN-fed mice. Particularly, the mice with increased accumulated signals from 5 to 10 days developed TAAD at 14 days, whereas the mice with similar signals between the two time points did not. Furthermore, the protease-activated receptor 2 inhibitor AT-1001, which seals TJs, alleviated the BAPN-induced impairment of endothelial TJ function and expression and subsequently reduced TAAD incidence. Notably, endothelial-targeted ZO-1 conditional knockout increased TAAD incidence. Mechanistically, vascular inflammation and edema were observed in the thoracic aortas of the BAPN-fed mice, whereas these phenomena were attenuated by AT-1001. CONCLUSION: The disruption of endothelial TJ function is an early event prior to TAAD formation, herein serving as a potential indicator and a promising target for TAAD.

A national survey on current state and development needs of clinical and academic emergency medicine in China.

BACKGROUND: To characterize the current state of emergency medicine (EM) and the requirements for advancing EM clinical practice, education and research in China. METHODS: An anonymous electronic survey was conducted by Chinese Society of Emergency Medicine during September to October 2021. The survey contained 30 questions divided into 2 sections: the current state of EM development and the requirements for EM growth. RESULTS: 722 hospitals were included, of 487 were Level III and 235 were Level II hospitals. We found that after 40 years of development, EM had established a mature disciplinary system and refined sub-specialties including critical care, cardiopulmonary resuscitation, toxicology, disaster and emergency rescue. In Level III hospitals, 70.8% of EDs were standardized training centers for EM residents, but master's degree program, Doctor Degree program and post-doctoral degree program was approved in only 37.8%, 8.4% and 2.9% of EDs respectively and postgraduate curriculum was available in 1/4 of EDs. Only 8% have national or provincial key laboratories. In addition to advance clinical practice, there was also a high demand to improve teaching and research capacities, mainly focusing on literature review, research design and delivery, paper writing, residency training. CONCLUSIONS: EM has built a mature discipline system and refined sub-specialties in China. Teaching and research developed parallel with clinical practice. However, there was still a lack of EM master's and doctoral programs and research capacities need to be improved. More outstanding clinical and academic training should be provided to promote the rapid growth of EM in China.

Cardiopulmonary resuscitation in special circumstances.

Cardiopulmonary resuscitation prioritises treatment for cardiac arrests from a primary cardiac cause, which make up the majority of treated cardiac arrests. Early chest compressions and, when indicated, a defibrillation shock from a bystander give the best chance of survival with a good neurological status. Cardiac arrest can also be caused by special circumstances, such as asphyxia, trauma, pulmonary embolism, accidental hypothermia, anaphylaxis, or COVID-19, and during pregnancy or perioperatively. Cardiac arrests in these circumstances represent an increasing proportion of all treated cardiac arrests, often have a preventable cause, and require additional interventions to correct a reversible cause during resuscitation. The evidence for treating these conditions is mostly of low or very low certainty and further studies are needed. Irrespective of the cause, treatments for cardiac arrest are time sensitive and most effective when given early-every minute counts.

Circulating plasma galectin-3 predicts new-onset atrial fibrillation in patients after acute myocardial infarction during hospitalization.

BACKGROUND: New-onset atrial fibrillation (NOAF) is a common complication in patients with acute myocardial infarction (AMI) during hospitalization. Galectin-3 (Gal-3) is a novel inflammation marker that is significantly associated with AF. The association between post-AMI NOAF and Gal-3 during hospitalization is yet unclear. OBJECTIVE: The present study aimed to investigate the predictive value of plasma Gal-3 for post-AMI NOAF. METHODS: A total of 217 consecutive patients admitted with AMI were included in this retrospective study. Peripheral venous blood samples were obtained within 24 h after admission and plasma Gal-3 concentrations were measured. RESULTS: Post-AMI NOAF occurred in 18 patients in this study. Patients with NOAF were older (p < 0.001) than those without. A higher level of the peak brain natriuretic peptide (BNP) (p < 0.001) and Gal-3 (p < 0.001) and a lower low-density lipoprotein cholesterol level (LDL-C) (p = 0.030), and an estimated glomerular filtration rate (e-GFR) (p = 0.030) were recorded in patients with post-AMI NOAF. Echocardiographic information revealed that patients with NOAF had a significantly decreased left ventricular eject fraction (LVEF) (p < 0.001) and an increased left atrial diameter (LAD) (p = 0.004) than those without NOAF. The receiver operating characteristic (ROC) curve analysis revealed a significantly higher value of plasma Gal-3 in the diagnosis of NOAF for patients with AMI during hospitalization (area under the curve (p < 0.001), with a sensitivity of 72.22% and a specificity of 72.22%, respectively. Multivariate logistic regression model analysis indicated that age (p = 0.045), plasma Gal-3 (p = 0.018), and LAD (p = 0.014) were independent predictors of post-MI NOAF. CONCLUSIONS: Plasma Gal-3 concentration is an independent predictor of post-MI NOAF.

Association and interaction of O3 and NO2 with emergency room visits for respiratory diseases in Beijing, China: a time-series study.

BACKGROUND: Ozone (O3) and nitrogen dioxide (NO2) are the two main gaseous pollutants in the atmosphere that act as oxidants. Their short-term effects and interaction on emergency room visits (ERVs) for respiratory diseases remain unclear. METHODS: We conducted a time-series study based on 144,326 ERVs for respiratory diseases of Peking University Third Hospital from 2014 to 2019 in Beijing, China. Generalized additive models with quasi-Poisson regression were performed to analyze the association of O3, NO2 and their composite indicators (Ox and Oxwt) with ERVs for respiratory diseases. An interaction model was further performed to evaluate the interaction between O3 and NO2. RESULTS: Exposure to O3, NO2, Ox and Oxwt was positively associated with ERVs for total respiratory diseases and acute upper respiratory infection (AURI). For instance, a 10 µg/m3 increase in O3 and NO2 were associated with 0.93% (95%CI: 0.05%, 1.81%) and 5.87% (95%CI: 3.92%, 7.85%) increase in AURI at lag0-5 days, respectively. Significant linear exposure-response relationships were observed in Ox and Oxwt over the entire concentration range. In stratification analysis, stronger associations were observed in the group aged < 18 years for both O3 and NO2, in the warm season for O3, but in the cold season for NO2. In interaction analysis, the effect of O3 on total respiratory emergency room visits and AURI visits was the strongest at high levels (> 75% quantile) of NO2 in the < 18 years group. CONCLUSIONS: Short-term exposure to O3 and NO2 was positively associated with ERVs for respiratory diseases, particularly in younger people (< 18 years). This study for the first time demonstrated the synergistic effect of O3 and NO2 on respiratory ERVs, and Ox and Oxwt may be potential proxies.

Monitoring cardiopulmonary resuscitation quality in emergency departments: a national survey in China on current knowledge, attitudes, and practices.

BACKGROUND: To investigate current knowledge, attitudes, and practices for CPR quality control among emergency physicians in Chinese tertiary hospitals. METHODS: Anonymous questionnaires were distributed to physicians in 75 tertiary hospitals in China between January and July 2018. RESULTS: A total of 1405 respondents answered the survey without obvious logical errors. Only 54.4% respondents knew all criteria of high-quality CPR. A total of 91.0% of respondents considered CPR quality monitoring should be used, 72.4% knew the objective method for monitoring, and 63.2% always/often monitored CPR quality during actual resuscitation. The main problems during CPR were related to chest compression: low quality due to fatigue (67.3%), inappropriate depth (57.3%) and rate (54.1%). The use of recommended monitoring methods was reported as follows, ETCO2 was 42.7%, audio-visual feedback devices was 10.1%, coronary perfusion pressure was 17.9%, and invasive arterial pressure was 31.1%. A total of 96.3% of respondents considered it necessary to participate in regular CPR retraining, but 21.4% did not receive any retraining. The ideal retraining interval was considered to be 3 to 6 months, but the actual interval was 6 to 12 months. Only 49.7% of respondents reported that feedback devices were always/often used in CPR training. CONCLUSION: Chinese emergency physicians were very concerned about CPR quality, but they did not fully understand the high-quality criteria and their impact on prognosis. CPR quality monitoring was not a routine procedure during actual resuscitation. The methods recommended in guidelines were rarely used in practice. Many physicians had not received retraining or received retraining at long intervals. Feedback devices were not commonly used in CPR training.

The first national survey on practices of neurological prognostication after cardiac arrest in China, still a lot to do.

AIMS: To investigate current awareness and practices of neurological prognostication in comatose cardiac arrest (CA) patients. METHODS: An anonymous questionnaire was distributed to 1600 emergency physicians in 75 hospitals which were selected randomly from China between January and July 2018. RESULTS: 92.1% respondents fulfilled the survey. The predictive value of brain stem reflex, motor response and myoclonus was confirmed by 63.5%, 44.6% and 31.7% respondents, respectively. Only 30.7% knew that GWR value < 1.1 indicated poor prognosis and only 8.1% know the most commonly used SSEP N20. Status epilepticus, burst suppression and suppression were considered to predict poor outcome by only 35.0%, 27.4% and 20.9% respondents, respectively. Only 46.7% knew NSE and only 24.7% knew S-100. Only a few respondents knew that neurological prognostication should be performed later than 72 hours from CA either in TTM or non-TTM patients. In practice, the most commonly used method was clinical examination (85.4%). Only 67.9% had used brain CT for prognosis and 18.4% for MRI. NSE (39.6%) was a little more widely used than S-100ß (18.0%). However, SSEP (4.4%) and EEG (11.4%) were occasionally performed. CONCLUSIONS: Neurological prognostication in CA survivors had not been well understood and performed by emergency physicians in China. They were more likely to use clinical examination rather than objective tools, especially SSEP and EEG, which also illustrated that multimodal approach was not well performed in practice.

Association of emergency room visits for respiratory diseases with sources of ambient PM2.5.

Previous studies have reported associations of short-term exposure to different sources of ambient fine particulate matter (PM2.5) and increased mortality or hospitalizations for respiratory diseases. Few studies, however, have focused on the short-term effects of source-specific PM2.5 on emergency room visits (ERVs) of respiratory diseases. Source apportionment for PM2.5 was performed with Positive Matrix Factorization (PMF) and generalized additive model was applied to estimate associations between source-specific PM2.5 and respiratory disease ERVs. The association of PM2.5 and total respiratory ERVs was found on lag4 (RR = 1.011, 95%CI: 1.002, 1.020) per interquartile range (76 µg/m3) increase. We found PM2.5 to be significantly associated with asthma, bronchitis and chronic obstructive pulmonary disease (COPD) ERVs, with the strongest effects on lag5 (RR = 1.072, 95%CI: 1.024, 1.119), lag4 (RR = 1.104, 95%CI: 1.032, 1.176) and lag3 (RR = 1.091, 95%CI: 1.047, 1.135), respectively. The estimated effects of PM2.5 changed little after adjusting for different air pollutants. Six primary PM2.5 sources were identified using PMF analysis, including dust/soil (6.7%), industry emission (4.5%), secondary aerosols (30.3%), metal processing (3.2%), coal combustion (37.5%) and traffic-related source (17.8%). Some of the sources were identified to have effects on ERVs of total respiratory diseases (dust/soil, secondary aerosols, metal processing, coal combustion and traffic-related source), bronchitis ERVs (dust/soil) and COPD ERVs (traffic-related source, industry emission and secondary aerosols). Different sources of PM2.5 contribute to increased risk of respiratory ERVs to different extents, which may provide potential implications for the decision making of air quality related policies, rational emission control and public health welfare.

Early Enteral Nutrition Could Be Associated with Improved Survival Outcome in Cardiac Arrest.

Background: Although the latest European and US guidelines recommend that early enteral nutrition (EN) be attempted in critically ill patients, there is still a lack of research on feeding strategies for patients after cardiac arrest (CA). Due to the unique pathophysiology following CA, it remains unknown whether evidence from other diseases can be applied in this condition. Objective: We aimed to explore the relationship between the timing of EN (within 48 hours or after 48 hours) and clinical outcomes and safety in CA. Method: From the MIMIC-IV (version 2.2) database, we conducted this retrospective cohort study. A 1 : 1 propensity score matching (PSM) analysis was also conducted to prevent potential interference from confounders. Moreover, adjusted proportional hazards model regression models were used to adjust for prehospital and hospitalization characteristics to verify the independence of the association between early EN initiation and patient outcomes. Results: Of the initial 1286 patients, 670 were equally assigned to the early EN or delayed EN group after PSM. Patients in the early EN group had improved survival outcomes than those in the delayed EN group within 30 days (HR = 0.779, 95% confidence interval [CI] [0.611-0.994], p = 0.041). Similar results were shown at 90 and 180 days. However, there was no significant difference in neurological outcome between the two groups at 30 days (51% vs. 57%, odds ratio [OR] = 0.786, 95% CI [0.580-1.066], p = 0.070). Patients who underwent early EN had a lower risk of ileus than patients who underwent delayed EN (4% vs. 8%, OR = 0.461, 95% CI [0.233-0.909], p = 0.016). Moreover, patients who underwent early EN had shorter hospital stays. Conclusion: Early EN could be associated with improved survival outcomes for patients after CA. Further studies are needed to verify it. However, at present, we might consider early EN to be a more suitable feeding strategy for CA.

Cardiac Arrest-Associated Coagulopathy Could Predict 30-day Mortality: A Retrospective Study from Medical Information Mart for Intensive Care IV Database.

BACKGROUND: Cardiac arrest (CA) can activate the coagulation system. Some coagulation-related indicators are associated with clinical outcomes. Early evaluation of patients with cardiac arrest-associated coagulopathy (CAAC) not only predicts clinical outcomes, but also allows for timely clinical intervention to prevent disseminated intravascular coagulation. OBJECTIVE: To assess whether CAAC predicts 30-day cumulative mortality. METHODS: From the Medical Information Mart for Intensive Care IV (MIMIC-IV) database, we conducted a retrospective cohort study from 2008 to 2019. Based on international normalized ratio (INR) value and platelet count, we diagnosed CAAC cases and made the following stratification of severity: mild CAAC was defined as 1.4 > INR≧1.2 and 100,000/µL < platelet count≦150,000/µL; moderate CAAC was defined with either 1.6 > INR≧1.4 or 80,000/µL < platelet count≦100,000/µL; severe CAAC was defined as an INR≧1.6 and platelet count≦80,000/µL. RESULTS: A total of 1485 patients were included. Crude survival analysis showed that patients with CAAC had higher mortality risk than those without CAAC (33.0% vs 52.0%, P < 0.001). Unadjusted survival analysis showed an incremental increase in the risk of mortality as the severity of CAAC increased. After adjusting confounders (prehospital characteristics and hospitalization characteristics), CAAC was independently associated with 30-day mortality (hazard rate [HR] 1.77, 95% confidence interval [CI] 1.41-2.25; P < 0.001); moderate CAAC (HR 1.48, 95% CI 1.09-2.10; P = 0.027) and severe CAAC (HR 2.22, 95% CI 1.64-2.97; P < 0.001) were independently associated with 30-day mortality. CONCLUSION: The presence of CAAC identifies a group of CA at higher risk for mortality, and there is an incremental increase in risk of mortality as the severity of CAAC increases. However, the results of this study should be further verified by multicenter study.

Systemic Characterization of the Gut Microbiota Profile after Single Mild Ischemic Stroke and Recurrent Stroke in Mice.

It has been estimated that one in four stroke patients may have recurrent stroke within five years after they experienced the first stroke. Furthermore, clinical studies have shown that recurrent stroke negatively affects patient outcomes; the risk of disability and the death rate increase with each recurrent stroke. Therefore, it is urgent to find effective methods to prevent recurrent stroke. The gut microbiota has been proven to play an essential role after ischemic stroke, while sudden ischemia disrupts microbial dysbiosis, and the metabolites secreted by the microbiota also reshape the gut microenvironment. In the present study, we established a recurrent ischemic mouse model. Using this experimental model, we compared the survival rate and ischemic infarction between single MCAO and recurrent MCAO, showing that, when two surgeries were performed, the mouse survival rate dramatically decreased, while the infarction size increased. Fecal samples were collected on day 1, day 3 and day 7 after the first MCAO and day 9 (2 days after the second MCAO) for 16S sequencing, which provided a relatively comprehensive picture of the microbiota changes. By further analyzing the potential metabolic pathways, our data also highlighted several important pathways that were significantly altered after the first and recurrent stroke. In the present study, using an experimental mouse model, we showed that acute ischemic stroke, especially recurrent ischemia, significantly decreased the diversity of the gut microbiota.

Urban-suburb disparities in pre-hospital emergency medical resources and response time among patients with out-of-hospital cardiac arrest: A mixed-method cross-sectional study.

Aim: To investigate (1) the association between pre-hospital emergency medical resources and pre-hospital emergency medical system (EMS) response time among patients with Out-of-hospital cardiac arrest (OHCA); (2) whether the association differs between urban and suburbs. Methods: Densities of ambulances and physicians were independent variables, respectively. Pre-hospital emergency medical system response time was dependent variable. Multivariate linear regression was used to investigate the roles of ambulance density and physician density in pre-hospital EMS response time. Qualitative data were collected and analyzed to explore reasons for the disparities in pre-hospital resources between urban areas and suburbs. Results: Ambulance density and physician density were both negatively associated with call to ambulance dispatch time, with odds ratios (ORs) 0.98 (95% confidence interval [CI] 0.96-0.99; P = 0.001) and 0.97 (95% CI; 0.93-0.99; P < 0.001), respectively. ORs of ambulance density and physician density in association with total response time were 0.99 (95% CI: 0.97-0.99; P = 0.013) and 0.90 (95% CI: 0.86-0.99; P = 0.048). The effect of ambulance density on call to ambulance dispatch time in urban areas was 14% smaller than that in suburb areas and that on total response time in urban areas was 3% smaller than the effect in suburbs. Similar effects were identified for physician density on urban-suburb disparities in call to ambulance dispatch time and total response time. The main reasons summarized from stakeholders for a lack of physicians and ambulances in suburbs included low income, poor personal incentive mechanisms, and inequality in financial distribution of the healthcare system. Conclusion: Improving pre-hospital emergency medical resources allocation can reduce system delay and narrow urban-suburb disparity in EMS response time for OHCA patients.

ADAMTS-7 deficiency attenuates thoracic aortic aneurysm and dissection in mice.

Thoracic aortic aneurysm and dissection (TAAD) is a life-threatening cardiovascular disease with severe extracellular matrix (ECM) remodeling that lacks efficient early stage diagnosis and nonsurgical therapy. A disintegrin and metalloproteinase with thrombospondin motif 7 (ADAMTS-7) is recognized as a novel locus for human coronary artery atherosclerosis. Previous work by us and others showed that ADAMTS-7 promoted atherosclerosis, postinjury neointima formation, and vascular calcification. However, whether ADAMTS-7 is involved in TAAD pathogenesis is unknown. We aimed to explore the alterations in ADAMTS-7 expression in human and mouse TAAD, and investigate the role of ADAMTS-7 in TAAD formation. A case-control study of TAAD patients (N = 86) and healthy participants (N = 88) was performed. The plasma ADAMTS-7 levels were markedly increased in TAAD patients within 24 h and peaked in 7 days. A TAAD mouse model was induced with 0.5% ß-aminopropionitrile (BAPN) in drinking water. ELISA analysis of mouse plasma, Western blotting, and immunohistochemical staining of aorta showed an increase in ADAMTS-7 in the early stage of TAAD. Moreover, ADAMTS-7-deficient mice exhibited significantly attenuated TAAD formation and TAAD rupture-related mortality in both male and female mice, which was accompanied by reduced artery dilation and inhibited elastin degradation. ADAMTS-7 deficiency caused repressed inflammatory response and complement system activation during TAAD formation. An increase in plasma ADAMTS-7 is a novel biomarker for human TAAD. ADAMTS-7 deficiency attenuates BAPN-induced murine TAAD. ADAMTS-7 is a potential novel target for TAAD diagnosis and therapy. KEY MESSAGES: A case-control study revealed increased plasma ADAMTS-7 is a risk factor for TAAD. ADAMTS-7 was elevated in plasma and aorta at early stage of mouse TAAD. ADAMTS-7 knockout attenuated mouse TAAD formation and mortality in both sexes.

Key elements and checklist of shared decision-making conversation on life-sustaining treatment in emergency: a multispecialty study from China.

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.

[Value of procalcitonin in the early diagnosis of sepsis in Department of Emergency].

OBJECTIVE: To investigate the value of procalcitonin (PCT) in the early diagnosis and risk stratification in sepsis. METHODS: Among 90 patients, 42 patients suffered sepsis, and 48 patients with severe sepsis. Serum PCT levels, high sensitivity C-reactive protein (hs-CRP), white blood cell (WBC) count, the percentage of neutrophils and lactate levels in sepsis and severe sepsis patients were determined. Receive operating characteristic curve (ROC curve) was drawn to evaluate the ability of PCT and related inflammatory parameters in assessing risk factors in patients with sepsis, and to analyze correlation between PCT and sequential organ failure assess (SOFA) score, WBC, lactic acid, and hs-CRP. RESULTS: Compared with sepsis patients, among severe sepsis patients, the levels of PCT (µg/L), hs-CRP (mg/L), WBC [×10(9)/L] , and SOFA score were significantly higher (PCT: 7.228±2.153 vs. 0.172±0.165, hs-CRP: 102.68±90.99 vs. 29.05±28.76, WBC: 14.15±8.14 vs. 8.15±4.55, SOFA score: 9.87±2.47 vs. 3.09±1.55), with statistical significance (all P<0.01), and the levels of percentage of neutrophils and lactic acid (mmol/L) were slightly increased (percentage of neutrophils: 0.820±0.094 vs. 0.740±0.130, lactic acid: 1.47±0.99 vs. 1.18±0.60), with no statistical significance (both P>0.05). Analysis of ROC curve displayed that area under the curve (AUC) of PCT was 0.808, which was higher than that of WBC, percentage of neutrophils, lactic acid and hs-CRP (AUC was 0.124, 0.042, 0.551 and 0.262, respectively), and when PCT was 1.000 µg/L, the sensitivity was 80.3%, specificity was 72.2%, and they were better than those of other traditional markers of inflammation. Bivariate correlation analysis showed that a positive correlation was found between PCT and SOFA score and WBC [r1=0.418, P1=0.006; r2=0.251, P2=0.011], and there was no correlation between PCT and lactic acid and hs-CRP [r1=0.186, P1=0.155; r2=0.089, P2=0.133]. CONCLUSION: Serum PCT is a reliable measure in emergency room for early diagnosis of sepsis with high sensitivity and specificity, it could be used as a routine monitoring index in critically ill patients to help assess disease severity in sepsis.

Etiology of Emergency Visit and In-Hospital Outcomes of Patients with COPD.

Backgrounds: Patients with COPD often visit the emergency department (ED) due to exacerbation of respiratory symptoms (dyspnea, cough, and sputum production). Because manifestations of acute exacerbation of COPD (AECOPD) are nonspecific, differential diagnosis is critical in this acute setting. The causes for emergency visiting and the in-hospital outcomes are varied in patients with COPD. This study aimed to investigate the distributions of etiologies and the in-hospital outcomes of patients with COPD who presented to the ED because of exacerbation of respiratory symptoms. Methods: This was a retrospective study on COPD patients who had visited the ED and been hospitalized in a tertiary hospital because of worsening respiratory symptoms including cough, sputum production, and dyspnea from January 2017 to April 2020. Demographics, clinical manifestations, and laboratory studies in the ED were collected as the baseline data. The primary diagnosis at discharge or death was recorded. The hospitalization settings (general wards and ICU), the in-hospital outcomes, and associated factors were analyzed. Results: During the study period, 392 patients with COPD (male 302 (77.0%)), with a median age of 78 years, visited the ED and hospitalized in this hospital. The first 3 causes for emergency visit were AECOPD (n = 314, 80.1%), acute coronary artery syndrome with or without congestive heart failure (n = 24, 6.1%), and pulmonary embolism (n = 13, 3.3%). For patients with AECOPD (n = 314), 51.6% (n = 162) was admitted to ICU, and 6.4% (n = 20) died. Multivariate logistic analysis showed that age, atrial fibrillation, NT-pro BNP ≥300 pg/ml, and blood pH <7.3 were independent risk factors for ICU admission. Age, comorbid malignancy, NT-pro BNP ≥1800 pg/ml, and pneumonia on CT scan were independent risk factors for hospital mortality in patients with AECOPD. Conclusion: In COPD patients visiting the ED because of worsening respiratory symptoms, nearly 20% were due to non-AECOPD causes. For those with AECOPD, age, atrial fibrillation, NT-pro BNP ≥300 pg/ml, and blood pH <7.3 were independent risk factors for ICU admission, while advanced age, underlying malignancy, elevated NT-pro BNP, and pneumonia on CT scan were risk factors for hospital mortality.

Toxic epidermal necrolysis with systemic lupus erythematosus: case report and review of the literature.

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are potentially fatal mucocutaneous diseases characterized by extensive necrosis and exfoliation of the epidermis. TEN and SJS are most often caused by various kinds of drugs. Other risk factors for SJS/TEN include pneumonia infection, HIV infection, genetic factors, underlying immune diseases, and tumors. SJS and TEN were first identified in 1922, but at present, a widely recognized view is that SJS and TEN represent phases in the continuous progress of the same disease. SJS/TEN has a very high mortality, but is rare, and cases of SJS/TEN combined with systemic lupus erythematosus (SLE) are even less common. Occasionally, acute cutaneous manifestations of SLE and SJS/TEN can be phenotypically similar, both causing extensive epidermal necrosis. In this paper, we present a recent case of a 32-year-old female SLE patient with a drug-induced (the health product, astaxanthin) TEN/SJS. To provide context to this case, we have reviewed relevant case studies published in English, accessed via PubMed databases. The search covers all published case studies from 1988 to 2019. We collected a total of 30 cases in the literature, and analyzed their characteristics from the aspects of gender, suspicious medication history, and treatment in order to expand clinicians' approach to diagnosis and treatment.

Association between air pollution and emergency room visits for eye diseases and effect modification by temperature in Beijing, China.

The growing burden of eye disease worldwide has aroused increasing concern upon its environmental etiology. This study aims to evaluate the associations of air pollutants with emergency room visits for eye diseases and the effect modification by temperature. Based on 24,389 cases from a general hospital during 2014-2019 in Beijing, China, this study used generalized additive models to examine the associations of air pollutants and emergency room visits for total eye diseases (ICD10: H00-H59) and conjunctivitis (ICD10: H10). Short-term exposures to PM2.5, PM10, CO, and NO2 were associated with increased visits for total eye diseases and conjunctivitis, and stronger effect estimates were observed in high (>75th) temperature group for PM2.5, PM10, CO, and NO2 and low (<75th) temperature group for CO and NO2. For instance, a 10 µg/m3 increase in PM2.5 at lag0-1 were associated with a 0.73% (95% CI: 0.23%, 1.24%) increase in total eye disease visits and a 1.34% (95% CI: 0.55%, 2.13%) increase in conjunctivitis visits, respectively. Meanwhile, a 10 µg/m3 increase in PM2.5 was associated with a 1.57% (95% CI: 0.49%, 2.64%) change in high temperature group and a 0.48% (95% CI: -0.24%, 1.19%) change in medium temperature group (P for interaction = 0.04) in total eye disease visits. Our study emphasizes the importance of controlling the potential hazards of air pollutants on eyes, especially on days with relatively higher or colder temperature.

Correlation between the warning symptoms and prognosis of cardiac arrest.

BACKGROUND: A low survival rate in patients with cardiac arrest is associated with failure to recognize the condition in its initial stage. Therefore, recognizing the warning symptoms of cardiac arrest in the early stage may play an important role in survival. AIM: To investigate the warning symptoms of cardiac arrest and to determine the correlation between the symptoms and outcomes. METHODS: We included all adult patients with all-cause cardiac arrest who visited Peking University Third Hospital or Beijing Friendship Hospital between January 2012 and December 2014. Data on population, symptoms, resuscitation parameters, and outcomes were analysed. RESULTS: Of the 1021 patients in the study, 65.9% had symptoms that presented before cardiac arrest, 25.2% achieved restoration of spontaneous circulation (ROSC), and 7.2% survived to discharge. The patients with symptoms had higher rates of an initial shockable rhythm (12.2% vs 7.5%, P = 0.020), ROSC (29.1% vs 17.5%, P = 0.001) and survival (9.2% vs 2.6%, P = 0.001) than patients without symptoms. Compared with the out-of-hospital cardiac arrest (OHCA) without symptoms subgroup, the OHCA with symptoms subgroup had a higher rate of calls before arrest (81.6% vs 0.0%, P < 0.001), health care provider-witnessed arrest (13.0% vs 1.4%, P = 0.001) and bystander cardiopulmonary resuscitation (15.5% vs 4.9%, P = 0.002); a shorter no flow time (11.7% vs 2.8%, P = 0.002); and a higher ROSC rate (23.8% vs 13.2%, P = 0.011). Compared to the in-hospital cardiac arrest (IHCA) without symptoms subgroup, the IHCA with symptoms subgroup had a higher mean age (66.2 ± 15.2 vs 62.5 ± 16.3 years, P = 0.005), ROSC (32.0% vs 20.6%, P = 0.003), and survival rates (10.6% vs 2.5%, P < 0.001). The top five warning symptoms were dyspnea (48.7%), chest pain (18.3%), unconsciousness (15.2%), paralysis (4.3%), and vomiting (4.0%). Chest pain (20.9% vs 12.7%, P = 0.011), cardiac etiology (44.3% vs 1.5%, P < 0.001) and survival (33.9% vs 16.7%, P = 0.001) were more common in males, whereas dyspnea (54.9% vs 45.9%, P = 0.029) and a non-cardiac etiology (53.3% vs 41.7%, P = 0.003) were more common in females. CONCLUSION: Most patients had warning symptoms before cardiac arrest. Dyspnea, chest pain, and unconsciousness were the most common symptoms. Immediately recognizing these symptoms and activating the emergency medical system prevents resuscitation delay and improves the survival rate of OHCA patients in China.