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.

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.

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.

Early Prediction Model of Acute Aortic Syndrome Mortality in Emergency Departments.

Purpose: Acute aortic syndrome is a constellation of life-threatening medical conditions for which rapid assessment and targeted intervention are important for the prognosis of patients who are at high risk of in-hospital death. The current study aims to develop and externally validate an early prediction mortality model that can be used to identify high-risk patients with acute aortic syndrome in the emergency department. Patients and Methods: This retrospective multi-center observational study enrolled 1088 patients with acute aortic syndrome admitted to the emergency departments of two hospitals in China between January 2017 and March 2021 for model development. A total of 210 patients with acute aortic syndrome admitted to the emergency departments of Peking University Third Hospital between January 2007 and December 2021 was enrolled for model validation. Demographics and clinical factors were collected at the time of emergency department admission. The predictive variables were determined by referring to the results of previous studies and the baseline analysis of this study. The study's endpoint was in-hospital death. To assess internal validity, we used a fivefold cross-validation method. Model performance was validated internally and externally by evaluating model discrimination using the area under the receiver-operating characteristic curve (AUC). A nomogram was developed based on the binary regression results. Results: In the development cohort, 1088 patients with acute aortic syndromes were included, and 88 (8.1%) patients died during hospitalization. In the validation cohort, 210 patients were included, and 20 (9.5%) patients died during hospitalization. The final model included the following variables: digestive system symptoms (OR=2.25; P=0.024), any pulse deficit (OR=7.78; P<0.001), creatinine (µmol/L)(OR=1.00; P=0.018), lesion extension to iliac vessels (OR=4.49; P<0.001), pericardial effusion (OR=2.67; P=0.008), and Stanford type A (OR=10.46; P<0.001). The model's AUC was 0.838 (95% CI 0.784-0.892) in the development cohort and 0.821 (95% CI 0.750-0.891) in the validation cohort, and the Hosmer-Lemeshow test showed p=0.597. The fivefold cross-validation demonstrated a mean accuracy of 0.94, a mean precision of 0.67, and a mean recall of 0.13. Conclusion: This risk prediction tool uses simple variables to provide robust prediction of the risk of in-hospital death from acute aortic syndrome and validated well in an independent cohort. The tool can help emergency clinicians quickly identify high-risk acute aortic syndrome patients, although further studies are needed for verifying the prospective data and the results of our study.

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.

Optimal Time of Collapse to Return of Spontaneous Circulation to Apply Targeted Temperature Management for Cardiac Arrest: A Bayesian Network Meta-Analysis.

Background: Both the American Heart Association (AHA) and European Resuscitation Council (ERC) have strongly recommended targeted temperature management (TTM) for patients who remain in coma after return of spontaneous circulation (ROSC). However, the role of TTM, especially hypothermia, in cardiac arrest patients after TTM2 trials has become much uncertain. Methods: We searched four online databases (PubMed, Embase, CENTRAL, and Web of Science) and conducted a Bayesian network meta-analysis. Based on the time of collapse to ROSC and whether the patient received TTM or not, we divided this analysis into eight groups (<20 min + TTM, <20 min, 20-39 min + TTM, 20-39 min, 40-59 min + TTM, 40-59 min, ≥60 min + TTM and ≥60 min) to compare their 30-day and at-discharge survival and neurologic outcomes. Results: From an initial search of 3,023 articles, a total of 9,005 patients from 42 trials were eligible and were included in this network meta-analysis. Compared with other groups, patients in the <20 min + TTM group were more likely to have better survival and good neurologic outcomes (probability = 46.1 and 52.5%, respectively). In comparing the same time groups with and without TTM, only the survival and neurologic outcome of the 20-39 min + TTM group was significantly better than that of the 20-39 min group [odds ratio = 1.41, 95% confidence interval (1.04-1.91); OR = 1.46, 95% CI (1.07-2.00) respectively]. Applying TTM with <20 min or more than 40 min of collapse to ROSC did not improve survival or neurologic outcome [ <20 min vs. <20 min + TTM: OR = 1.02, 95% CI (0.61-1.71)/OR = 1.03, 95% CI (0.61-1.75); 40-59 min vs. 40-59 min + TTM: OR = 1.50, 95% CI (0.97-2.32)/OR = 1.40, 95% CI (0.81-2.44); ≧60 min vs. ≧60 min + TTM: OR = 2.09, 95% CI (0.70-6.24)/OR = 4.14, 95% CI (0.91-18.74), respectively]. Both survival and good neurologic outcome were closely related to the time from collapse to ROSC. Conclusion: Survival and good neurologic outcome are closely associated with the time of collapse to ROSC. These findings supported that 20-40 min of collapse to ROSC should be a more suitable indication for TTM for cardiac arrest patients. Moreover, the future trials should pay more attention to these patients who suffer from moderate injury. Systematic Review Registration: [https://inplasy.com/?s=202180027], identifier [INPLASY202180027].

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.

Detection of SHOX2 DNA methylation by methylation-specific PCR in non-small cell lung cancer.

BACKGROUND: Lung cancer is the leading cause of cancer-related death worldwide. Short stature homeobox 2 (SHOX2) methylation detected by real-time polymerase chain reaction (PCR) has recently been demonstrated to be a potential biomarker in the diagnosis of lung cancer. However, more cost-effective methods are still needed to help cancer detection in the early stage of lung cancer. The aim of this study was to examine the methylation status of the SHOX2 gene and to investigate its diagnostic value in non-small cell lung cancer (NSCLC) patients. METHODS: A total of 89 Chinese NSCLC patients and 9 non-tumor patients was enrolled in this study. The methylation status of SHOX2 gene in NSCLC tumor tissues/corresponding non-neoplastic lung tissues and lung tissues from non-tumor patients was examined by methylation-specific PCR (MSP). RESULTS: We found that SHOX2 methylation was significantly associated with NSCLC (P=0.003). We also analyzed the correlation of SHOX2 methylation with clinicopathological variables including sex, age, tumor pathologic classification, tumor differentiation degree, TNM stage, T stage, and nodal status, and found no significant correlation between them. CONCLUSIONS: These results suggested that SHOX2 gene methylation was closely associated with lung carcinogenesis. Thus, SHOX2 methylation could be used as a potential marker to help NSCLC detection. MSP might be used as a cost-effective method alternative to real-time PCR in detection of SHOX2 methylation in the early diagnosis of NSCLC.

MiR-34b-3p represses cell proliferation, cell cycle progression and cell apoptosis in non-small-cell lung cancer (NSCLC) by targeting CDK4.

Lung cancer is the most common incident cancer, with a high mortality worldwide, and non-small-cell lung cancer (NSCLC) accounts for approximately 85% of cases. Numerous studies have shown that the aberrant expression of microRNAs (miRNAs) is associated with the development and progression of cancers. However, the clinical significance and biological roles of most miRNAs in NSCLC remain elusive. In this study, we identified a novel miRNA, miR-34b-3p, that suppressed NSCLC cell growth and investigated the underlying mechanism. miR-34b-3p was down-regulated in both NSCLC tumour tissues and lung cancer cell lines (H1299 and A549). The overexpression of miR-34b-3p suppressed lung cancer cell (H1299 and A549) growth, including proliferation inhibition, cell cycle arrest and increased apoptosis. Furthermore, luciferase reporter assays confirmed that miR-34b-3p could bind to the cyclin-dependent kinase 4 (CDK4) mRNA 3'-untranslated region (3'-UTR) to suppress the expression of CDK4 in NSCLC cells. H1299 and A549 cell proliferation inhibition is mediated by cell cycle arrest and apoptosis with CDK4 interference. Moreover, CDK4 overexpression effectively reversed miR-34-3p-repressed NSCLC cell growth. In conclusion, our findings reveal that miR-34b-3p might function as a tumour suppressor in NSCLC by targeting CDK4 and that miR-34b-3p may, therefore, serve as a biomarker for the diagnosis and treatment of NSCLC.

Changes in cardiac arrest patients' temperature management after the publication of 2015 AHA guidelines for resuscitation in China.

A survey was performed to assess the current management of targeted temperature management (TTM) in patients following cardiac arrest (CA) and whether healthcare providers will change target temperature after publication of 2015 American Heart Association guidelines for resuscitation in China. 52 hospitals were selected from whole of China between August to November 2016. All healthcare providers in EMs and/or ICUs of selected hospitals participated in the study. 1952 respondents fulfilled the survey (86.8%). TTM in CA patients was declared by 14.5% of physicians and 6.7% of the nurses. Only 4 of 64 departments, 7.8% of physicians and 5.7% of the nurses had implemented TH for CA patients. Since the publication of 2015 AHA guidelines, 33.6% of respondents declared no modification of target temperature, whereas 51.5% declared a target temperature's change in future practice. Respondents were more likely to choose 35∼36 °C-TTM (54.7%) after guidelines publication, as compared to that before guidelines publication they preferred 32∼34 °C-TTM (54.0%). TTM for CA patients was still in the early stage in China. Publication of 2015 resuscitation guidelines did have impact on choice of target temperature among healthcare providers. They preferred 35∼36 °C-TTM after guidelines publication.

Pleural abrasion should not routinely preferred in treatment of primary spontaneous pneumothorax.

BACKGROUND: The aim of this study was to find out whether thoracoscopic bullectomy with pleural abrasion (BLPA) could lower the recurrence ratio in primary spontaneous pneumothorax (PSP) patients compared with bullectomy alone. METHODS: All PSP patients who underwent video assisted thoracoscopy (VATS) bullectomy (120 bullectomy cases) or BLPA (225 BLPA cases) in our department between 2008.1 and 2013.12 were retrospectively reviewed. Clinical data, perioperative data, and follow-up information were collected. Propensity score analysis was used in balancing preoperative factors between groups. RESULTS: Three hundred and forty five patients (283 men and 62 women) with an average age of 27 (27.32±11.41) years old underwent 120 bullectomy and 225 BLPA in this study. There was no mortality or significant complication in both groups. More postoperative drainage (1,170.66±904.02 vs. 528.38±491.49, P<0.01), longer chest tube removal days (6.59±4.29 vs. 4.76±2.67, P<0.01), and more medical cost (4,703.86±1,526.31 vs. 4,204.64±1,203.90, P<0.01) were observed in BLPA group. Significant difference (P=0.02) existed in recurrence rate between BLPA group (3/225, 1.3%) and bullectomy group (7/120, 5.8%). After propensity score match, 114 patients were included in both bullectomy and BLPA groups. More postoperative drainage (1,280.18±1,071.04 vs. 523.55±484.79, P<0.01), longer chest tube removal days (6.53±4.16 vs. 4.69±2.63, P<0.01), and more medical cost (4,700.69±1,591.56 vs. 4,211.45±1,207.7, P<0.01) were observed in BLPA group. There was no significant recurrence difference between BLPA group and bullectomy group (2.6% vs. 5.3%, P=0.30). CONCLUSIONS: Compared with bullectomy, BLPA could provide similar recurrence for PSP patients, but at the price of longer operation days, longer chest tube removal days, and more medical cost, and should not be performed in PSP patients.

[Effect of 1-tetrahydropalmatine on spontaneous electric discharge induced by chronic dorsal root ganglion neurons compression in rats].

OBJECTIVE: To study the effect of 1-tetrahydropalmatine (1-THP) on the spontaneous electric discharge (SED) induced by chronic dorsal root ganglion neurons compression. METHODS: Using single fiber recording method, the SED of 84 neurons class A induced by compression were recorded. The effect of 1-THP on the SEDs and its relation with concentration were observed. RESULTS: In the 84 SED of neurons, 25 showed periodical rhythmicity (PR) and 59 showed non-periodic rhythmicity (non-PR). 1-THP (100 micromol/L) inhibited SED in 16.0% (4/25) of neurons with PR and 67.8% (40/59) of neurons with non-PR (P < 0.01) in an effect-dose dependent manner, the higher the concentration of 1-THP, the more the inhibition, with quicker inhibiting in initiation and longer time needed for recovery. SED in 57.1% neurons were recovered 20 min after elution, but unrecovered even after 3 h in the others. CONCLUSION: 1-THP shows inhibitory effect on the A-fiber SED induced by chronic dorsal root ganglion neurons compression.