Clinical Utility of the Tokyo Guidelines 2018 for Acute Cholangitis in the Emergency Department and Comparison with Novel Markers (Neutrophil-to-Lymphocyte and Blood Nitrogen Urea-to-Albumin Ratios).

Introduction: The Tokyo Guidelines 2018 (TG2018) is a scoring system used to recommend the clinical management of AC. However, such a scoring system must incorporate a variety of clinical outcomes of acute cholangitis (AC). In an emergency department (ED)-based setting, where efficiency and practicality are highly desired, clinicians may find the application of various parameters challenging. The neutrophil-to-lymphocyte ratio (NLR) and blood urea nitrogen-to-albumin ratio (BAR) are relatively common biomarkers used to assess disease severity. This study evaluated the potential value of TG2018 scores measured in an ED to predict a variety of clinical outcomes. Furthermore, the study also compared TG2018 scores with NLR and BAR scores to demonstrate their usefulness. Methods: This retrospective observational study was performed in an ED. In total, 502 patients with AC visited the ED between January 2016 and December 2021. The primary endpoint was to evaluate whether the TG2018 scoring system measured in the ED was a predictor of intensive care, long-term hospital stays (≥14 days), percutaneous transhepatic biliary drainage (PTBD) during admission care, and endotracheal intubation (ETI). Results: The analysis included 81 patients requiring intensive care, 111 requiring long-term hospital stays (≥14 days), 49 requiring PTBD during hospitalization, and 14 requiring ETI during hospitalization. For the TG2018 score, the adjusted OR (aOR) using (1) as a reference was 23.169 (95% CI: 9.788-54.844) for (3) compared to (1). The AUC of the TG2018 for the need for intensive care was 0.850 (95% CI: 0.815-0.881) with a cutoff of >2. The AUC for long-term hospital stays did not exceed 0.7 for any of the markers. the AUC for PTBD also did not exceed 0.7 for any of the markers. The AUC for ETI was the highest for BAR at 0.870 (95% CI: 0.837-0.899) with a cutoff value of >5.2. Conclusions: The TG2018 score measured in the ED helps predict various clinical outcomes of AC. Other novel markers such as BAR and NLR are also associated, but their explanatory power is weak.

Soft-capsule formulation of a re-esterified triglyceride omega-3 employing self-emulsifying technology and bioavailability evaluation in healthy volunteers.

Despite the superior clinical efficacy of the re-esterified triglyceride (rTG) form compared to the ethylester form, few studies have been conducted on improving the bioavailability of the rTG form of omega-3 oil. The aim of study was to evaluate the effect of self emulsifying formulation on the improvement of bioavailability of rTG form of omega-3 oil. To develop a re-esterified triglyceride (rTG) soft capsule, an rTG-loaded self-emulsifying delivery system (SEDS) was designed using coconut oil, polysorbate 80, and lecithin. Candidate formulations were designed from a phase-diagram study and optimal SEDS formulations containing 85% of high omega-3 (ω-3) oils were screened from the evaluation of droplet size distribution, measurement of oil floating area and emulsion turbidity. The selected, optimized rTG SEDS formulation was filled into a soft capsule (NOVASEDS) and applied to a sequence-randomized, double-blind, single-dose, and two-way crossover clinical study (n = 44), and the the bioavailability of NOVASEDS was compared with that of a 'raw' rTG capsule (rTG OMEGA3) as control. The droplet size (D50) formed from the candidate formulations was approximately 30-45 µm, and the optimal formulation showed a unimodal particle distribution with the smallest oil floating area and small changes in turbidity after 24 h. Cmax and AUC from 0 to 24 h for NOVASEDS, calculated from docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA), and as the sum of DHA and EPA, were significantly higher (P < 0.05) than corresponding values for rTG OMEGA3. In conclusion, NOVASEDS formulated by SEDS technology enabled the manufacture of a high rTG payload soft capsule with improved bioavailability in human subjects.

Fabrication of Assembled FeS2 Nanosheet and Application for High-Performance Supercapacitor Electrodes.

To overcome the low-energy-density limitation of supercapacitors, we aimed to achieve a material with a high specific capacitance by manipulating the nanostructure of FeS2, which comprises the most abundant and affordable elements. In this study, nanosheet-assembled FeS2 (NSA-FeS2) was fabricated using a novel method. Sub-micron droplets of sulfur particles stabilized with polyvinylpyrrolidone were formed in silicone oil medium, and Fe(CO)5 was absorbed and reacted on the surface to form core-shell particles, ES/[Fe], with a sulfur core and an iron-containing outer shell. The high temperature treatment of ES/[Fe] produced NSA-FeS2, in which pyrite FeS2 nanosheets grew and were partially interconnected. In a three-electrode system, the as-prepared NSA-FeS2 and NSA-FeS2/polyaniline (PANI) composites exhibited specific capacitances of 763 and 976 Fg-1, respectively, at a current density of 0.5 Ag-1, with corresponding capacitance retentions of 93 and 96% after 3000 charge-discharge cycles. The capacitance retention of the NSA-FeS2/PANI composites was 49% when the current density was increased from 0.5 to 5 Ag-1. Notably, the obtained specific capacitances exhibited the highest values in pure FeS2 and FeS2-based composites, indicating the significant potential for the utilization of iron sulfide in pseudocapacitive electrode materials.

Optimization of a solidified micelle formulation for enhanced oral bioavailability of atorvastatin calcium using statistical experimental design.

To enhance the oral bioavailability of atorvastatin calcium (ATV), a novel solidified micelle (S-micelle) was developed. Two surfactants, Gelucire 48/16 (G48) and Tween 20 (T20), were employed for micelle formation, and two solid carriers (SC), Florite PS-10 (FLO) and Vivapur 105 (VP105), were selected as solid carriers. The S-micelle was optimized using a Box-Behnken design with three independent variables, including G48:T20 (X1, 1.8:1), SC:G48 + T20 (X2, 0.65:1), and FLO:VP105 (X3, 1.4:0.6), resulting in a droplet size (Y1) of 198.4 nm, dissolution efficiency at 15 min in the pH 1.2 medium (Y2) of 47.6%, Carr's index (Y3) of 16.9, and total quantity (Y4) of 562.5 mg. The optimized S-micelle resulted in good correlation showing percentage prediction values less than 10%. The optimized S-micelle formed a nanosized dispersion in the aqueous phase, with a higher dissolution rate than raw ATV and crushed Lipitor®. The optimized S-micelle improved the relative bioavailability of oral ATV (25 mg equivalent/kg) in rats by approximately 509 and 271% compared to raw ATV and crushed Lipitor®, respectively. In conclusion, the optimized S-micelle possesses great potential for the development of solidified formulations for improved oral absorption of poorly water-soluble drugs.

Functionalized Lipid Nanocarriers for Simultaneous Delivery of Docetaxel and Tariquidar to Chemoresistant Cancer Cells.

The simultaneous drug delivery efficiency of a co-loaded single-carrier system of docetaxel (DTX)- and tariquidar (TRQ)-loaded nanostructured lipid carrier (NLC) functionalized with PEG and RIPL peptide (PRN) (D^T-PRN) was compared with that of a physically mixed dual-carrier system of DTX-loaded PRN (D-PRN) and TRQ-loaded PRN (T-PRN) to overcome DTX mono-administration-induced multidrug resistance. NLC samples were prepared using the solvent emulsification evaporation technique and showed homogeneous spherical morphology, with nano-sized dispersion (<220 nm) and zeta potential values of -15 to -7 mV. DTX and/or TRQ was successfully encapsulated in NLC samples (>95% encapsulation efficiency and 73-78 µg/mg drug loading). In vitro cytotoxicity was concentration-dependent; D^T-PRN exhibited the highest MDR reversal efficiency, with the lowest combination index value, and increased the cytotoxicity and apoptosis in MCF7/ADR cells by inducing cell-cycle arrest in the G2/M phase. A competitive cellular uptake assay using fluorescent probes showed that, compared to the dual nanocarrier system, the single nanocarrier system exhibited better intracellular delivery efficiency of multiple probes to target cells. In the MCF7/ADR-xenografted mouse models, simultaneous DTX and TRQ delivery using D^T-PRN significantly suppressed tumor growth as compared to other treatments. A single co-loaded system for PRN-based co-delivery of DTX/TRQ (1:1, w/w) constitutes a promising therapeutic strategy for drug-resistant breast cancer cells.

Prognostic Value of Plasma Presepsin and Pneumonia Severity Index in Patients with Community-Acquired Pneumonia in the Emergency Department.

Background and Objectives: Presepsin (PSS) is an independent predictor for estimating disease severity and prognosis in septic patients. Few studies have reported the associations between plasma PSS and the severity and prognosis in patients with community-acquired pneumonia (CAP). We investigated whether a high plasma PSS level was associated with 30-day mortality in CAP patients. Materials and Methods: This retrospective single-center study was conducted in an emergency department. The PSS level was measured in 211 adult CAP patients admitted to the hospital and followed for up to 30 days. We recorded the pneumonia severity index (PSI) and the CURB-65 score. The primary outcome was death from any cause within 30 days. Results: The plasma PSS levels were significantly elevated in the high-risk group (PSI > 130) compared with the low- (PSI < 91) or moderate-risk groups (PSI 91−130). Forty-four patients (20.9%) died within 30 days of admission. Non-survivors had significantly higher plasma PSS levels than survivors among CAP patients: 1083 (697−1736) pg/mL vs. 385 (245−554) pg/mL (p < 0.001). The area under the curve (AUC) to predict 30-day mortality was highest for PSS (0.867), followed by procalcitonin (0.728) and lactate (0.616). The cutoff level of plasma PSS for 30-day mortality was >754 pg/mL. The combination of PSI and plasma PSS level improved the predictive ability for 30-day mortality (AUC = 0.892). Cox regression analysis showed that higher PSS levels (>754 pg/mL) and higher PSI (>126) were associated with 30-day mortality in CAP patients (hazard ratios of 19.472 and 6.375, respectively). Conclusion: Elevated plasma PSS is associated with severity and 30-day mortality in hospitalized CAP patients. Combining plasma PSS level and PSI could significantly improve the predictive ability of PSS for 30-day mortality.

Plasma presepsin level predicts acute kidney injury in patients with sepsis in the emergency department.

Acute kidney injury (AKI) is a common complication in patients with sepsis. We evaluated the potential prognostic value of plasma presepsin to predict AKI in patients with sepsis in the emergency department. A total of 193 patients diagnosed with sepsis based on the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) were included in this observational study. AKI was defined according to the Kidney Disease Improving Global Outcomes clinical practice guideline. Plasma presepsin levels were measured on admission to the emergency department. We compared plasma presepsin levels between patients who did and those who did not develop AKI. AKI occurred in 100 (51.8%) patients. The median plasma presepsin level was significantly higher in patients with AKI than in those without AKI (1061 pg/mL vs 495 pg/mL, P <.001). Plasma presepsin levels were significantly increased in patients with AKI stage 3 compared with those with AKI stages 1 and 2 (P =.001). The area under the curve of presepsin for predicting AKI was 0.793 (95% confidence interval: 0.729-0.848). The optimal presepsin cutoff value for predicting AKI was >572 pg/mL, with a sensitivity of 77.0% and specificity of 81.7%. Plasma presepsin level is a valuable biomarker for the prediction of AKI in patients with sepsis in the emergency department.

Synergistic Effects of Fe2O3 Nanotube/Polyaniline Composites for an Electrochemical Supercapacitor with Enhanced Capacitance.

α-Fe2O3, which is an attractive material for supercapacitor electrodes, has been studied to address the issue of low capacitance through structural development and complexation to maximize the use of surface pseudocapacitance. In this study, the limited performance of α-Fe2O3 was greatly improved by optimizing the nanotube structure of α-Fe2O3 and its combination with polyaniline (PANI). α-Fe2O3 nanotubes (α-NT) were fabricated in a form in which the thickness and inner diameter of the tube were controlled by Fe(CO)5 vapor deposition using anodized aluminum oxide as a template. PANI was combined with the prepared α-NT in two forms: PANI@α-NT-a enclosed inside and outside with PANI and PANI@α-NT-b containing PANI only on the inside. In contrast to α-NT, which showed a very low specific capacitance, these two composites showed significantly improved capacitances of 185 Fg-1 for PANI@α-NT-a and 62 Fg-1 for PANI@α-NT-b. In the electrochemical impedance spectroscopy analysis, it was observed that the resistance of charge transfer was minimized in PANI@α-NT-a, and the pseudocapacitance on the entire surface of the α-Fe2O3 nanotubes was utilized with high efficiency through binding and conductivity improvements by PANI. PANI@α-NT-a exhibited a capacitance retention of 36% even when the current density was increased 10-fold, and showed excellent stability of 90.1% over 3000 charge-discharge cycles. This approach of incorporating conducting polymers through well-controlled nanostructures suggests a solution to overcome the limitations of α-Fe2O3 electrode materials and improve performance.

Association of Plasma Glucose to Potassium Ratio and Mortality After Aneurysmal Subarachnoid Hemorrhage.

Objectives: Hyperglycemia and hypokalemia are common problems in patients with aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to determine whether the plasma glucose to potassium ratio (GPR) predicts mortality due to aSAH. Methods: We prospectively recruited aSAH patients and healthy controls between March 2007 and May 2017. Clinical outcomes included mortality and poor outcome (modified Rankin scale score of 3-6) after 3 months. Multivariable analysis was used to determine the association between plasma GPR and 3-month mortality in aSAH patients. Results: A total of 553 patients were recruited, and the mortality rate was 11%. The GPR was significantly elevated in aSAH patients compared with controls, in patients with a poor outcome than with a good outcome and in non-survivals than in survivals. Multivariable analysis showed that the plasma GPR was an independent factor associated with 3-month mortality. The area under the curve of the GPR was 0.747 in predicting 3-month mortality. Conclusion: The plasma GPR on admission has potential as a predictor of 3-month mortality in patients with aSAH.

Comparison of ultrasonography and computed tomography for measuring optic nerve sheath diameter for the detection of elevated intracranial pressure.

OBJECTIVE: The main aim of this study was to compare optic nerve sheath diameter (ONSD) measured using ultrasonography (USG) and computed tomography (CT) almost simultaneously in the same patients with suspected elevated intracranial pressure. The other aim of this study was to evaluate the diagnostic ability for detecting elevated intracranial pressure using ONSD measured by USG (USG-ONSD) and by CT (CT-ONSD). PATIENTS AND METHODS: This prospective, observational study was undertaken from June to October 2020 in the emergency department (ED) of a tertiary medical center in Seoul. ONSD was measured by USG and CT at 3 mm behind the posterior aspect of the globe. RESULT: A total of 199 patients were enrolled. The median USG-ONSD and CT-ONSD were significantly higher in patients with elevated intracranial pressure than in patients with normal intracranial pressure. The interclass correlation coefficient between USG-ONSD and CT-ONSD was 0.785 (95% CI 0.715-0.837). A Bland-Altman plot showed significant agreement between USG and CT measurements. The optimal cutoff for detecting elevated intracranial pressure was >5.3 mm (sensitivity of 75.4% and specificity of 90.8%) for USG and >5.0 mm (sensitivity of 68.4% and specificity of 85.2%) for CT. CONCLUSION: The ONSD measured using USG and CT were increased in patients with elevated intracranial pressure. Measurement of ONSD by USG and CT showed very high agreement.

Live Imaging of Intracranial Lymphatics in the Zebrafish.

RATIONALE: The recent discovery of meningeal lymphatics in mammals is reshaping our understanding of fluid homeostasis and cellular waste management in the brain, but visualization and experimental analysis of these vessels is challenging in mammals. Although the optical clarity and experimental advantages of zebrafish have made this an essential model organism for studying lymphatic development, the existence of meningeal lymphatics has not yet been reported in this species. OBJECTIVE: Examine the intracranial space of larval, juvenile, and adult zebrafish to determine whether and where intracranial lymphatic vessels are present. METHODS AND RESULTS: Using high-resolution optical imaging of the meninges in living animals, we show that zebrafish possess a meningeal lymphatic network comparable to that found in mammals. We confirm that this network is separate from the blood vascular network and that it drains interstitial fluid from the brain. We document the developmental origins and growth of these vessels into a distinct network separated from the external lymphatics. Finally, we show that these vessels contain immune cells and perform live imaging of immune cell trafficking and transmigration in meningeal lymphatics. CONCLUSIONS: This discovery establishes the zebrafish as a important new model for experimental analysis of meningeal lymphatic development and opens up new avenues for probing meningeal lymphatic function in health and disease.

MicroRNA-mediated control of developmental lymphangiogenesis.

The post-transcriptional mechanisms contributing to molecular regulation of developmental lymphangiogenesis and lymphatic network assembly are not well understood. MicroRNAs are important post-transcriptional regulators during development. Here, we use high throughput small RNA sequencing to identify miR-204, a highly conserved microRNA dramatically enriched in lymphatic vs. blood endothelial cells in human and zebrafish. Suppressing miR-204 leads to loss of lymphatic vessels while endothelial overproduction of miR-204 accelerates lymphatic vessel formation, suggesting a critical positive role for this microRNA during developmental lymphangiogenesis. We also identify the NFATC1 transcription factor as a key miR-204 target in human and zebrafish, and show that NFATC1 suppression leads to lymphatic hyperplasia. The loss of lymphatics caused by miR-204 deficiency can be largely rescued by either endothelial autonomous expression of miR-204 or by suppression of NFATC1. Together, our results highlight a miR-204/NFATC1 molecular regulatory axis required for proper lymphatic development.

ARAF recurrent mutation causes central conducting lymphatic anomaly treatable with a MEK inhibitor.

The treatment of lymphatic anomaly, a rare devastating disease spectrum of mostly unknown etiologies, depends on the patient manifestations1. Identifying the causal genes will allow for developing affordable therapies in keeping with precision medicine implementation2. Here we identified a recurrent gain-of-function ARAF mutation (c.640T>C:p.S214P) in a 12-year-old boy with advanced anomalous lymphatic disease unresponsive to conventional sirolimus therapy and in another, unrelated, adult patient. The mutation led to loss of a conserved phosphorylation site. Cells transduced with ARAF-S214P showed elevated ERK1/2 activity, enhanced lymphangiogenic capacity, and disassembly of actin skeleton and VE-cadherin junctions, which were rescued using the MEK inhibitor trametinib. The functional relevance of the mutation was also validated by recreating a lymphatic phenotype in a zebrafish model, with rescue of the anomalous phenotype using a MEK inhibitor. Subsequent therapy of the lead proband with a MEK inhibitor led to dramatic clinical improvement, with remodeling of the patient's lymphatic system with resolution of the lymphatic edema, marked improvement in his pulmonary function tests, cessation of supplemental oxygen requirements and near normalization of daily activities. Our results provide a representative demonstration of how knowledge of genetic classification and mechanistic understanding guides biologically based medical treatments, which in our instance was life-saving.

Advantages and Challenges of Cardiovascular and Lymphatic Studies in Zebrafish Research.

Since its introduction, the zebrafish has provided an important reference system to model and study cardiovascular development as well as lymphangiogenesis in vertebrates. A scientific workshop, held at the 2018 European Zebrafish Principal Investigators Meeting in Trento (Italy) and chaired by Massimo Santoro, focused on the most recent methods and studies on cardiac, vascular and lymphatic development. Daniela Panáková and Natascia Tiso described new molecular mechanisms and signaling pathways involved in cardiac differentiation and disease. Arndt Siekmann and Wiebke Herzog discussed novel roles for Wnt and VEGF signaling in brain angiogenesis. In addition, Brant Weinstein's lab presented data concerning the discovery of endothelium-derived macrophage-like perivascular cells in the zebrafish brain, while Monica Beltrame's studies refined the role of Sox transcription factors in vascular and lymphatic development. In this article, we will summarize the details of these recent discoveries in support of the overall value of the zebrafish model system not only to study normal development, but also associated disease states.

Tracheal Rupture Related to Endotracheal Intubation during Cardiopulmonary Resuscitation.

Postintubation tracheal rupture is rare, but serious. Emergency intubation is often conducted during cardiopulmonary resuscitation (CPR), and the risk of postintubation tracheal rupture can be increased during CPR. We describe here a case of postintubation tracheal rupture in a 65-year-old female who was transferred from another hospital after CPR. Postintubation tracheal rupture in this case is thought to have been related to malposition of the endotracheal tube (ETT), elevation of the intratrachea pressure due to chest compression, and an overinflated cuff. However, the most important factor is considered to be the overinflated cuff, which is often caused by manual palpation. Therefore, emergency physicians should consider using a manometer to check the cuff pressure of the ETT, even during CPR. When spontaneous circulation is restored, the pressure of the cuff must be measured with a manometer.

Development of the larval lymphatic system in zebrafish.

The lymphatic vascular system is a hierarchically organized complex network essential for tissue fluid homeostasis, immune trafficking and absorption of dietary fats in the human body. Despite its importance, the assembly of the lymphatic network is still not fully understood. The zebrafish is a powerful model organism that enables study of lymphatic vessel development using high-resolution imaging and sophisticated genetic and experimental manipulation. Although several studies have described early lymphatic development in the fish, lymphatic development at later stages has not been completely elucidated. In this study, we generated a new Tg(mrc1a:egfp)y251 transgenic zebrafish that uses a mannose receptor, C type 1 (mrc1a) promoter to drive strong EGFP expression in lymphatic vessels at all stages of development and in adult zebrafish. We used this line to describe the assembly of the major vessels of the trunk lymphatic vascular network, including the later-developing collateral cardinal, spinal, superficial lateral and superficial intersegmental lymphatics. Our results show that major trunk lymphatic vessels are conserved in the zebrafish, and provide a thorough and complete description of trunk lymphatic vessel assembly.

A novel perivascular cell population in the zebrafish brain.

The blood-brain barrier is essential for the proper homeostasis and function of the CNS, but its mechanism of function is poorly understood. Perivascular cells surrounding brain blood vessels are thought to be important for blood-brain barrier establishment, but their roles are not well defined. Here, we describe a novel perivascular cell population closely associated with blood vessels on the zebrafish brain. Based on similarities in their morphology, location, and scavenger behavior, these cells appear to be the zebrafish equivalent of cells variably characterized as Fluorescent Granular Perithelial cells (FGPs), perivascular macrophages, or 'Mato Cells' in mammals. Despite their macrophage-like morphology and perivascular location, zebrafish FGPs appear molecularly most similar to lymphatic endothelium, and our imaging studies suggest that these cells emerge by differentiation from endothelium of the optic choroidal vascular plexus. Our findings provide the first report of a perivascular cell population in the brain derived from vascular endothelium.

Building the drains: the lymphatic vasculature in health and disease.

The lymphatic vasculature is comprised of a network of endothelial vessels found in close proximity to but separated from the blood vasculature. An essential tissue component of all vertebrates, lymphatics are responsible for the maintenance of fluid homeostasis, dissemination of immune cells, and lipid reabsorption under healthy conditions. When lymphatic vessels are impaired due to invasive surgery, genetic disorders, or parasitic infections, severe fluid build-up accumulates in the affected tissues causing a condition known as lymphedema. Malignant tumors can also directly activate lymphangiogenesis and use these vessels to promote the spread of metastatic cells. Although their first description goes back to the times of Hippocrates, with subsequent anatomical characterization at the beginning of the 20th-century, the lack of identifying molecular markers and tools to visualize these translucent vessels meant that investigation of lymphatic vessels fell well behind research of blood vessels. However, after years under the shadow of the blood vasculature, recent advances in imaging technologies and new genetic and molecular tools have accelerated the pace of research on lymphatic vessel development. These new tools have facilitated both work in classical mammalian models and the emergence of new powerful vertebrate models like zebrafish, quickly driving the field of lymphatic development back into the spotlight. In this review, we summarize the highlights of recent research on the development and function of the lymphatic vascular network in health and disease. WIREs Dev Biol 2016, 5:689-710. doi: 10.1002/wdev.246 For further resources related to this article, please visit the WIREs website.

Value of plasma neutrophil gelatinase-associated lipocalin in predicting the mortality of patients with sepsis at the emergency department.

BACKGROUND: Sepsis is a major cause of morbidity and mortality in the emergency department. This study aimed to evaluate the assessment of severity of sepsis by and prognostic value of plasma neutrophil gelatinase-associated lipocalin (NGAL) compared with other widely used biological markers of inflammation in patients with sepsis. METHODS: NGAL, procalcitonin, and C-reactive protein values were measured in 470 patients with suspected sepsis, and the Mortality in Emergency Department Sepsis (MEDS) score was obtained for all enrolled subjects, who were followed for up to 28days. RESULTS: The median plasma NGAL value was increased with sepsis severity according to the MEDS score. The plasma NGAL value was higher in nonsurvivors than in survivors. The area under the receiver operating characteristic curve of NGAL (0.797) was greater than that of procalcitonin (0.599) and MEDS score (0.774) in predicting 28-day hospital mortality. Multivariable logistic regression found that the plasma NGAL value was an independent predictor for hospital mortality in patients with sepsis. The plasma NGAL values were positively correlated with C-reactive protein and procalcitonin levels, and MEDS scores. CONCLUSIONS: Plasma NGAL is a valuable biological marker in the assessment of severity and prediction of prognosis of patients with sepsis in the emergency department.

A case report of bittern intoxication.

Bittern is made from marine water after extraction of salt, and its major components include magnesium chloride, magnesium sulfate, potassium chloride, sodium chloride and magnesium bromide. For a long time, it has been used as the main ingredient of tofu coagulant and chemical weapons. A 73-year-old woman arrived to the emergency department after a suicide attempt by drinking an unknown amount bittern. She complained of dizziness, general weakness, and altered mental state (Glasgow Coma Scale (GCS) 13/15). The brain computed tomography (CT) and magnetic resonance imaging (MRI) showed no abnormality. But blood chemistry showed hypermagnesemia ([Mg(2+)] 7.8 mEq/L) and hypernatremia ([Na(+)] 149 mEq/L). Electrocardiograph showed QT prolongation of 0.482 s. Electrolyte imbalances were corrected following adequate fluid therapy and injection of calcium gluconate. The patient recovered/was subsequently discharged without any complications. Electrolyte imbalances are a common presentation following bittern poisoning. Severe side effects like respiratory depression, hypotension, arrhythmia, bradycardia, and cardiac arrest can also occur. Patients will require immediate fluid therapy and correction of electrolyte imbalances. The symptoms vary depending on the electrolyte levels. It is mandatory to closely monitor the electrolyte levels and electrocardiograph in these patients.