Effect of Agkistrodon halys antivenom in patients bit by green pit viper and the prognostic role of the disease - a retrospective cohort study.

BACKGROUND AND AIMS: In Mainland China and Hong Kong, health authorities utilize Agkistrodon halys antivenom in the treatment of patients who sustained bites from green pit vipers. However, the treatment benefit of Agkistrodon halys antivenom among such patients is still controversial. The purpose of this study is to evaluate the coagulation parameters normalization time of Agkistrodon halys antivenom in patients who sustained green pit viper bites and explore independent risk factors of patient prognosis. METHODS: Data were extracted from the Donghua Hospital Information System. Comparison of the two groups of patients - who used antivenom (GPUA) and who did not use antivenom (GPNUA) were performed using stratified analysis, univariate and multivariate ordered logistic regression models to evaluate the coagulation parameters normalization time. Univariate and multivariate ordered logistic regression models were used to explore independent risk factors of patient prognosis. RESULTS: Between the GPUA and GPNUA groups, there is no significant difference in the coagulation parameters normalization time with the treatment of Agkistrodon halys antivenom. GPNUA consumed more cryoprecipitate and platelets and had a lower cost. The patient's severity of the bite, first coagulation profile, and dosages of fresh frozen plasma, platelet, and red cell suspension was found to be risk factors for the normalization time of coagulation parameters. CONCLUSIONS: The therapeutic effect of Agkistrodon halys antivenom in green pit vipers bite patients is not quite satisfying. In addition, more attention should be paid to the first coagulation profile, blood clotting factors indices, platelet count (PLT), and hemoglobin when treating such patients.

Development of an intensive simulating training program in emergency medicine for medical students in China.

BACKGROUND: A national standardized emergency medicine (EM) curriculum for medical students, including specific competencies in procedural skills, are absent in many countries. The development of an intensive simulating training program in EM, based on a tight schedule, is anticipated to enhance the competency of medical students. METHODS: A 3-day intensive EM training program, consisting of four procedural skills and 8-hour case-based learning (CBL), was developed by experienced physicians from the EM department in Peking Union Medical College Hospital (PUMCH). Medical students from Peking Union Medical College (PUMC) and Tsinghua University (THU) participated in the training. Three written tests were cautiously designed to examine the short-term (immediately after the program) and long-term (6 months after the program) efficacy of the training. After completion of the training program, an online personal appraisal questionnaire was distributed to the students on WeChat (a mobile messaging App commonly used in China) to achieve anonymous self-evaluation. RESULTS: Ninety-seven out of 101 students completed the intensive training and took all required tests. There was a significant increase in the average score after the intensive simulating training program (pre-training 13.84 vs. 15.57 post-training, P<0.001). Compared with the pre-training test, 63 (64.9%) students made progress. There was no significant difference in scores between the tests taken immediately after the program and 6 months later (15.57±2.22 vs. 15.38±2.37, P=0.157). Students rated a higher score in all diseases and procedural skills, and felt that their learning was fruitful. CONCLUSIONS: The introduction of a standardized intensive training program in EM focusing on key competencies can improve clinical confidence, knowledge, and skills of medical students toward the specialty. In addition, having such a program can also enhance student's interest in EM as a career choice which may enhance recruitment into the specialty and workplace planning.

Efficacy and safety of corticosteroids in immunocompetent patients with septic shock.

BACKGROUND: The use of corticosteroids in septic shock has been studied for many decades but yielded conflicting results. We conducted a systematic review to evaluate the efficacy and the safety of corticosteroids in immunocompetent patients with septic shock. METHODS: Medline via PubMed, Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, and EMBASE were searched from inception to March 2020. Two reviewers independently identified randomized controlled trials (RCTs) comparing corticosteroids with a control group for immunocompetent patients with septic shock. Data were abstracted and reported following the Cochrane Handbook for Systematic Review of Intervention and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The efficacy outcome included mortality and shock reversal. The safety outcomes were infection, gastrointestinal bleeding, and hyperglycemia. RESULTS: Nine RCTs with a total of 1,298 patients were included. Compared with the control group, corticosteroid group did not lower the short-term (28 or 30 days) mortality (risk ratio [RR] 0.95, 95% confidence interval (CI) 0.85 to 1.06, inconsistency [I 2]=0%, trial sequential analysis [TSA]-adjusted CI 0.83 to 1.09, moderate-certainty evidence). Corticosteroids significantly shortened the time to shock reversal compared with the control group (mean difference [MD] -21.56 hours; 95% CI -32.95 to -10.16, I 2=0%; TSA-adjusted CI -33.33 to -9.78, moderate-certainty evidence). The corticosteroid treatment was associated with an increased risk of hyperglycemia but not the infection or gastrointestinal bleeding. CONCLUSIONS: The corticosteroid treatment is not associated with lower short- or long- term mortality compared with placebo in immunocompetent patients with septic shock. However, corticosteroids significantly shorten the time to shock reversal without increasing the risk of infection. The patient's immune status should also be considered during clinical treatment and clinical trials in future.

Comparison of the anterior and posterior approach in treating four-level cervical spondylotic myelopathy.

BACKGROUND: The optimal surgical approach for four-level cervical spondylotic myelopathy remains controversial. The purpose of this study was to compare clinical and radiological outcomes and complications between the anterior and posterior approaches for four-level cervical spondylotic myelopathy. METHODS: A total of 19 patients underwent anterior decompression and fusion and 25 patients underwent posterior laminoplasty and instrumentation in this study. Perioperative information, intraoperative blood loss, clinical and radiological outcomes, and complications were recorded. Japanese Orthopedic Association (JOA) score, 36-item short form survey (SF-36) score and cervical alignment were assessed. RESULTS: There were no significant differences in JOA scores between the anterior and posterior group preoperatively (11.6 ±â€Š1.6 vs. 12.1 ±â€Š1.5), immediately postoperatively (14.4 ±â€Š1.1 vs. 13.8 ±â€Š1.3), or at the last follow-up (14.6 ±â€Š1.0 vs. 14.2 ±â€Š1.1) (P > 0.05). The JOA scores significantly improved immediately postoperatively and at the last follow-up in both groups compared with their preoperative values. The recovery rate was significantly higher in the anterior group both immediately postoperatively and at the last follow-up. The SF-36 score was significantly higher in the anterior group at the last follow-up compared with the preoperative value (69.4 vs. 61.7). Imaging revealed that there was no significant difference in the Cobb angle at C2-C7 between the two groups preoperatively (-2.0°â€Š±â€Š7.3° vs. -1.4°â€Š±â€Š7.5°). The Cobb angle significantly improved immediately postoperatively (12.3°â€Š±â€Š4.2° vs. 9.2°â€Š±â€Š3.6°) and at the last follow-up (12.4°â€Š±â€Š3.5° vs. 9.0°â€Š±â€Š2.6°) in both groups compared with their preoperative values (P = 0.00). Three patients had temporary dysphagia in the anterior group and four patients had persistent axial symptoms in the posterior group. CONCLUSIONS: Both the anterior and posterior approaches were effective in treating four-level cervical spondylotic myelopathy in terms of neurological clinical outcomes and radiological features. However, the JOA score recovery rate and SF-36 score in the anterior group were significantly higher. Persistent axial pain could be a major concern when undertaking the posterior approach.

Venous thromboembolism in the emergency department: A survey of current best practice awareness in physicians and nurses in China.

BACKGROUND: For emergency department (ED) patients, risk assessment, prophylaxis, early diagnosis and appropriate treatment of venous thromboembolism (VTE) are essential for preventing morbidity and mortality. This study aimes to investigate knowledge amongst emergency medical staff in the management of VTE. METHODS: We designed a questionnaire based on multiple scales. The questionnaire was distributed to the medical and nursing clinical staff in the large urban ED of a medical center in Northern China. Data was described with percentages and the Kruskal-Wallis test was used to compare ranked data between different groups. The statistical analysis was done using the SPSS 22.0 software. RESULTS: In this survey, 180 questionnaires were distributed and 174 valid responses (response rate of 96.67%) were collected and analyzed. In scores of VTE knowledge, no significant differences were found with respect to job (doctor vs. nurse), the number of years working in clinical medicine, education level, and current position, previous hospital experience and nurses' current work location within the ED. However, in pair wise comparison, we found participants who worked in ED for more than 5 years (n=83) scored significantly higher on the questionnaire than those under 5 years (n=91) (95.75 vs. 79.97, P=0.039). There was a significant difference in some questions based on gender, age, job, and nurse work location, number of working years, education level, and different ED working lifetime. CONCLUSION: Our survey has shown deficiencies among ED medical staff in knowledge and awareness of the management of VTE. We recommend several changes be considered, such as the introduction of an interdisciplinary workshop for medical staff; the introduction of a standardized VTE protocol; a mandatory study module on VTE for new physicians and nurses; the introduction of a mandatory reporting system for adverse events (including VTE).

Transforaminal thoracic interbody fusion : Treatment of thoracic myelopathy caused by anterior compression.

BACKGROUND: The aim of this study was to evaluate the early clinical safety and efficacy of transforaminal thoracic interbody fusion (TTIF) with interbody cage application for thoracic myelopathy caused by anterior compression (TMAC). METHODS: A total of 10 patients who underwent TTIF for TMAC from July 2009 to July 2014 were retrospectively reviewed. Thoracic spinal lesions included thoracic disc herniation, thoracic ossification of posterior longitudinal ligament, thoracic vertebral compression fracture, and thoracic spine fracture dislocation. Demographic data, radiological findings as well as operative information were collected. Postoperative functional outcomes evaluated by the modified Japanese Orthopedic Association (mJOA) score and complications were analyzed. RESULTS: The mean operation time was 186.5 min (range 110-315 min), the mean operative blood loss was 845.0 ml (range 400-2000 ml), and the mean recumbent period was 2.7 days (range 1-8 days). During the follow-up period all patients exhibited significant improvements in neurological deficits. The mJOA score improved from a mean of 6.1 ± 1.7 preoperatively to 7.4 ± 1.6 postoperatively and to 9.3 ± 1.6 at final follow-up (P <0.01), with an overall recovery rate of 69.0 ± 26.1%. Solid fusion was observed in all cases. A wound infection was found in one case, in which the patient recovered with no residual neurological deficits after surgical debridement and administration of intravenous antibiotics. No cage-related complications were found in this study. CONCLUSION: The use of TTIF with cage application can be an effective treatment method of thoracic myelopathy caused by anterior compression, with favorable efficacy and safety.

Microstructure study of normal lunates with micro-computed tomography.

In order to study the microstructure characteristics of normal lunate bones, eight fresh cadaver normal lunates were scanned with micro-computed tomography. High-resolution images of the micro-structure of normal lunates were obtained and we analyzed the nutrient foramina. Then nine regions of interest (ROI) were chosen in the central sagittal plane so that we could obtain the parameters of trabecular bones of ROIs. The distal lamellar-like compact structure had statistically significant differences when it was compared with the ROIs in the volar and dorsal ends of the distal cortex. The difference of diameter between the volar and dorsal foramina was significant (P<0.05). However, there was no significant difference regarding the number. The trabecular bones of the volar and dorsal distal ends had lower intensity than those of the distal central subchondral bone plate. The diameters of the nutrient foramina on the volar cortex were larger than those on the dorsal. This research provided more detailed information about microstructure of normal lunate and the nutrient foramina on cortex, and a reference for further study about diseased lunate.

The effect of growing Rod treatment on coronal balance during serial lengthening surgeries in early onset scoliosis.

BACKGROUND: Gaining and maintaining spinal balance after surgery is of great importance for early onset scoliosis (EOS). However, tendency of balance on the coronal plane after growing rod surgery has not been studied before. This study evaluated the effect of growing rod treatment on coronal balance (CB) during serial lengthening surgeries in EOS. METHODS: All EOS patients treated with growing rod technique in our hospital from August 2002 to June 2014 were retrospectively reviewed. Radiographic data before the sixth lengthening surgery were measured on the posteroanterior X-ray images, including global CB (C7 plumbline-central sacral vertical line, C7PL-CSVL), regional CB (apical vertebrae-CSVL), Cobb angle of the main curve and pelvic inlet width (PIW). Global CB index and regional CB index were calculated as dividing global CB and regional CB by PIW, respectively. The changes of these parameters during repeated lengthening surgeries were analyzed. RESULTS: Five hundred seventy Radiographs of 67 patients, including 134 images before and after growing rod insertion surgeries and 436 images pre- and post-lengthening surgeries were measured. Global CB and global CB index did not show significant differences between every two set points during lengthening procedures (P > 0.05). The percentage of patients with C7PL-CSVL distance more than 20 mm roughly ranged from 30 to 45 % during the lengthening process. With regards to regional CB and main curve Cobb angles, there were significant differences between every two adjacent set points during the first five lengthening surgeries (P < 0.05). CONCLUSIONS: Global CB did not significantly change during serial lengthening surgeries and C7PL-CSVL distances of greater than 20 mm comprised of over one third of patients during growing rod treatment. However, worsening regional CB and Cobb angles of the main curve during lengthening intervals were corrected by lengthening manipulation and maintained at a stable level.

Effect of Resveratrol on Preventing Steroid-induced Osteonecrosis in a Rabbit Model.

BACKGROUND: Prevention of osteonecrosis (ON) has seldom been addressed. The purpose of this study was to evaluate the effect of resveratrol on preventing steroid-induced ON in rabbits. METHODS: Seventy-two rabbits were divided into four groups: (1) NEC (ON) group: thirty rabbits were treated with lipopolysaccharide (LPS) once, then with methylprednisolone (MPS) daily for 3 days; (2) PRE (prevention) group: thirty rabbits were given one dose of LPS, then MPS daily for 3 days, and resveratrol on day 0 and daily for 2 weeks; (3) RES (resveratrol) group: six rabbits were given resveratrol for 2 weeks but without LPS/MPS; (4) CON (control) group: six rabbits were given alcohol for 2 weeks but without LPS/MPS. Levels of plasma tissue-type plasminogen activator (t-PA), plasminogen activator inhibitor 1 (PAI-1), thrombomodulin (TM), vascular endothelial growth factor (VEGF), maximum enhancement (ME) by magnetic resonance imaging, and ON incidence were evaluated. RESULTS: The PRE group had a lower ON incidence than the NEC group, but with no significant differences at 2 weeks and 12 weeks. The RES and CON groups did not develop ON. TM and VEGF were significantly higher in the NEC group compared with the PRE group at weeks 1, 2, and 4 (TM: 1 week, P = 0.029; 2 weeks, P = 0.005; and 4 weeks, P = 0.047; VEGF: 1 week, P = 0.039; 2 weeks, P = 0.021; 4 weeks, P = 0.014), but the difference disappeared at 12 weeks. The levels of t-PA and PAI-1 were not significantly different between the NEC and PRE groups. The TM, t-PA, PAI-1, and VEGF concentrations in the RES and CON groups did not change over time. Compared to the baseline, ME in the NEC group decreased significantly (P = 0.025) at week 1, increased significantly (P = 0.021) at week 2, and was decreased at week 12. The variance was insignificant in the PRE group. CONCLUSIONS: Resveratrol may improve blood supply to bone in a rabbit model of ON of the femoral head via anti-inflammatory effects to protect the vascular endothelium and reduce thrombosis.

Surgical Fixation of Fourth and Fifth Metacarpal Shaft Fractures with Flexible Intramedullary Absorbable Rods: Early Clinical Outcomes and Implications.

BACKGROUND: To avoid the irritation of tendons and soft tissues as well as hardware-related problems, we designed an intramedullary fixation with bioabsorbable rods for the treatment of the metacarpal shaft fractures. METHODS: Five patients with nine shaft fractures of the fourth and fifth metacarpi were treated with intramedullary absorbable implants and followed up with an average of 4.2 months postoperatively. RESULTS: At final follow-up, all patients achieved fracture union with no signs of inflammatory or subcutaneous effusion. There was no shortening, angulatory, or rotatory deformity. There was almost full active extension range of motion (ROM) of the metacarpophalangeal joints while the active flexion ROM of these joints was 80.7 ± 9.6°. Compared with the contralateral hand, the grip strength of the injured hand was 94.0 ± 9.6%. X-rays showed that the arch of the second to fifth metacarpal heads was smooth. There were no intramedullary lytic changes and soft tissue swellings. CONCLUSION: The intramedullary absorbable implants are a safe, simple, and practical treatment for fourth and fifth metacarpal fractures with good early clinical outcomes and no significant complications.

Multilevel thoracic ossification of ligamentum flavum coexisted with/without lumbar spinal stenosis: staged surgical strategy and clinical outcomes.

BACKGROUND: Thoracic ossification of ligamentum flavum (TOLF) is a progressively disabling disease. Isolated or continuous TOLF has been frequently reported in literature, however there are very few reports of multilevel or non-continuous TOLF. The purpose of the study was to discuss the surgical strategy of multilevel TOLF and evaluate safety and efficacy of a two-stage operation regimen. METHODS: From October 2007 to May 2014, eleven patients (4 males, 7 females) that underwent two-stage surgery for multilevel spinal stenosis were retrospectively reviewed. The follow-up period lasted at least 12 months. Demographic data, radiological findings as well as operative data were collected. Postoperative functional outcomes evaluated by the modified Japanese Orthopedic Association score (mJOA) and complications were analyzed. RESULTS: The patients ranged in age from 30 to 65 years (average, 50.2 ± 11.8 years), and comprised 4 men and 7 women. All patients exhibited significant improvements in neurological deficits. The mJOA score improved from a mean of 3.5 ± 2.2 preoperatively to 4.6 ± 2.3 before second-stage surgery and to 7.5 ± 2.2 at final follow-up. The improvement was statistically significant in the average mJOA improvement rate at final follow-up. No staging-related complications were noted in this study. CONCLUSIONS: Staged surgery can effectively achieve neurological functional recovery in patients with multi-segment spinal stenosis in thoracic and lumbar regions, with favorable efficacy and safety. Yet, slight neurological deterioration was observed during the intervals of these two index surgeries.

Dual growing rod treatment in early onset scoliosis: the effect of repeated lengthening surgeries on thoracic growth and dimensions.

PURPOSE: To investigate changes in thoracic dimensions (TDs) following repeated lengthening surgeries after dual growing rod treatment of early onset scoliosis and thereby its effect on thoracic growth. METHODS: All EOS patients treated with dual growing rod technique in Peking Union Medical College Hospital from June 2004 to June 2014 were retrospectively reviewed. Thoracic spine height (T1-T12), total spine height (T1-S1), maximal coronal chest width and pelvic inlet width (PIW) were measured on the posteroanterior X-ray images after initial growing rod insertion surgery and after each lengthening surgery. Absolute TDs measurements were normalized by PIW. Changes of absolute and normalized TDs measurements with age and number of lengthening surgeries were analyzed. RESULTS: Radiographs of 229 surgeries of 53 EOS patients were measured, including 49 images after initial growing rod insertion surgery and 180 images of lengthening surgeries. Significant positive correlations between age and all three absolute TDs were found (P < 0.01) whereas significant negative correlations between age and all three normalized TDs (P < 0.01) were identified. Similarly, negative correlations were also identified between number of lengthening surgeries and the three normalized TDs (P < 0.01). Significant differences of normalized TDs were identified between initial surgery and the first lengthening through covariance analysis (P < 0.01). Yet, such differences were seldom seen between every two adjacent lengthening surgeries. CONCLUSIONS: Growing rod technique could maintain TDs growth through repeated lengthening procedures but the growth rate was compromised as the number of lengthening procedures increased.

Role of corticotrophin releasing hormone in cerebral infarction-related gastrointestinal barrier dysfunction.

BACKGROUND: Corticotrophin releasing hormone (CRH) is believed to mediate stress-induced behaviors, implying a broader, integrative role for the hormone in the psychological stress response, and studies on CRH in physical stress are few. This study was undertaken to investigate whether CRH plays an important role in cerebral infarction-related gastrointestinal barrier dysfunction. METHODS: Thirty male Wistar rats were randomly divided into a pseudo-operation group (group C, n=10), a cerebral infarction group (group I, n=10), and a cerebral infarction + ic α-helical-CRH (9-41) group (group Aic, n=10). Urine samples were collected to determine the levels of epinephrine, norepinephrine, cortisol, and sucrose. At 24 hours after establishment of the models, blood samples were taken to determine the activity of diamine oxidase (DAO) and the concentration of D-lactic acid (D-lac). The stomach was taken to determine gastric Guth score, and the hypothalamus was also taken to determine tissue CRH protein expression using Western blotting. RESULTS: The hypothalamus CRH protein, the indicators of stress, the plasma DAO activity and plasma D-lac, urine sucrose exertion and gastric Guth score in group I were higher than those in groups Aic and C. CONCLUSIONS: After cerebral infarction, CRH in the hypothalamus was increased, the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system were activated, gastrointestinal permeability was increased, and gastrointestinal barrier function was destroyed. CRH receptor antagonist alleviated the gastrointestinal barrier function.