Libing Jiang

Comparison of whole-body computed tomography vs selective radiological imaging on outcomes in major trauma patients: a meta-analysis

IntroductionThe purpose of this meta-analysis was to explore the value of whole-body computed tomography (WBCT) in major trauma patients (MTPs).MethodsA comprehensive search for articles from Jan 1, 1980 to Dec 31, 2013 was conducted through PubMed, Cochrane Library database, China biology medical literature database, Web of knowledge, ProQuest, EBSCO, OvidSP, and ClinicalTrials.gov. Studies which compared whole-body CT with conventional imaging protocol (X-ray of the pelvis and chest, trans-abdominal sonography, and/or selective CT) in MTPs were eligible. The primary endpoint was all-cause mortality. The second endpoints included: time spent in the emergency department (ED), the duration of mechanical ventilation, ICU and hospital length of stay (LOS), the incidence of Multiple Organ Dysfunction Syndrome (MODS) /Multiple Organ Failure (MOF). Analysis was performed with Review Manager 5.2.10 and Stata 12.0.ResultsEleven trials enrolling 26371 patients were analyzed. In MTPs, the application of WBCT was associated with lower mortality rate (pooled OR: 0.66, 95% CI: 0.52 to 0.85) and a shorter stay in the ED (weighted mean difference (WMD), –27.58 min; 95% CI, –43.04 to –12.12]. There was no effect of WBCT on the length of ICU stay (WMD, 0.95 days; 95% CI: –0.08 to 1.98) and the length of hospital stay (WMD, 0.56 days; 95% CI: –0.03 to 1.15). Patients in the WBCT group had a longer duration of mechanical ventilation (WMD, 0.96 days, 95% CI: 0.32 to 1.61) and higher incidence of MODS/MOF (OR, 1.44, 95% CI: 1.35-1.54; P = 0.00001).ConclusionsThe present meta-analysis suggests that the application of whole-body CT significantly reduces the mortality rate of MTPs and markedly reduces the time spent in the emergency department.

Albumin versus other fluids for fluid resuscitation in patients with sepsis: a meta-analysis.

Background Early fluid resuscitation is vital to patients with sepsis. However, the choice of fluid has been a hot topic of discussion. The objective of this study was to evaluate whether the use of albumin-containing fluids for resuscitation in patients with sepsis was associated with a decreased mortality rate. Methods We systematically searched PubMed, EMBASE and Cochrane library for eligible randomized controlled trials (RCTs) up to March 2014. The selection of eligible studies, assessment of methodological quality, and extraction of all relevant data were conducted by two authors independently. Results In total, 15 RCTs were eligible for analysis. After pooling the data, we found there was no significant effect of albumin-containing fluids on mortality in patients with sepsis of any severity (RR: 0.94, 95% CI: 0.87, 1.02 and RD: –0.01, 95% CI: –0.03, 0.01). The results were robust to subgroup analyses, sensitivity analyses and trial sequential analyses. Conclusion The present meta-analysis did not demonstrate significant advantage of using albumin-containing fluids for resuscitation in patients with sepsis of any severity. Given the cost-effectiveness of using albumin, crystalloids should be the first choice for fluid resuscitation in septic patients.

Role of Transthoracic Lung Ultrasonography in the Diagnosis of Pulmonary Embolism: A Systematic Review and Meta-Analysis.

Background Pulmonary embolism (PE) is a potentially life-threatening condition. Although computed tomography pulmonary angiography (CTPA) is the reference standard for diagnosis, its early diagnosis remains a challenge, and the concerns about the radiation exposures further limit the general use of CTPA. The primary aim of this meta-analysis was to evaluate the overall diagnostic accuracy of transthoracic lung ultrasound (TLS) in the diagnosis of PE. Methods PubMed, Web of science, OvidSP, ProQuest, EBSCO, Cochrane Library and Clinicaltrial.gov were searched systematically. The quality of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. The sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and hierarchical summary receiver operating characteristic (HSROC) curves were used to examine the TS performance. The Bayes analysis was used to calculate the post-test probability of PE. Publication bias was assessed with Deeks funnel plot. Results The results indicated that the sensitivity, specificity, PLR and NLR were 0.85 (95% confidence interval (CI), 0.78 to 0.90), and 0.83 (95% CI, 0.73 to 0.90). And the DOR and HSROC were 28.82 (95% CI, 17.60 to 47.21), 0.91(95% CI, 0.88, 0.93). Conclusions The present meta-analysis suggested that transthoracic lung ultrasonography is helpful in diagnosing pulmonary embolism. Although the application of transthoracic lung ultrasound may change some patients’ diagnostic processes, it is inappropriate to generally use transthoracic ultrasonography in diagnosing pulmonary embolism currently.

Can mean platelet volume predict the prognosis of patients with acute kidney injury requiring continuous renal replacement therapy

To the Editor: IreadthearticlepublishedbyHanetal[1]withagreatinterest. They evaluated the relationship between mean platelet volume (MPV) and 28-day mortality in patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT). They found that MPV was significantly higher in the nonsurvivor group, and MPV was an independent predictor of 28-day mortality in patients with AKI requiring CRRT. We would like to thank the authors for this welldesigned and well-written study. However, I have some minor criticisms about this study. First, the authors have reported that red cell distribution width (RDW) at CRRT initiation was an independent predictor for 28-day all-cause mortality after adjusting for age, sex, mean arterial pressure, hemoglobin level, albumin, total cholesterol, C-reactive protein, and sequential organ failure assessment score in a previous study [2], and in the present study, MPV was an independent predictor for 28-day mortality after adjustment of age, age-adjusted Charlson Comorbidity Index, cause of AKI, platelet count, Acute Physiology and Chronic Health Evaluation (APACHE) II score, presence of malignancy, albumin, and C-reactive protein [1]. We wonder why RDW is not adjusted in the present study. Second, MPV may act through thrombosis and inflammation, and this process is affected by many factors, such as diabetes mellitus, prediabetes, obesity, coronary heart disease, hypercholesterolemia, smoking, metabolic syndrome, hypertension, statins, antihypertensive drug use, and atrial fibrillation [3] .I n addition, ad ecreased MPVhas been reported in patients with ulcerative colitis, rheumatoid arthritis, and ankylosing spondylitis and acute appendicitis [4-7], whereas it also has been

Development of the science of mass casualty incident management: reflection on the medical response to the Wenchuan earthquake and Hangzhou bus fire *

ObjectiveIn this paper, we review the previous classic research paradigms of a mass casualty incident (MCI) systematically and reflect the medical response to the Wenchuan earthquake and Hangzhou bus fire, in order to outline and develop an improved research paradigm for MCI management.MethodsWe searched PubMed, EMBASE, China Wanfang, and China Biology Medicine (CBM) databases for relevant studies. The following key words and medical subject headings were used: ‘mass casualty incident’, ‘MCI’, ‘research method’, ‘Wenchuan’, ‘earthquake’, ‘research paradigm’, ‘science of surge’, ‘surge’, ‘surge capacity’, and ‘vulnerability’. Searches were performed without year or language restriction. After searching the four literature databases using the above listed key words and medical subject headings, related articles containing research paradigms of MCI, 2008 Wenchuan earthquake, July 5 bus fire, and science of surge and vulnerability were independently included by two authors.ResultsThe current progresses on MCI management include new golden hour, damage control philosophy, chain of survival, and three links theory. In addition, there are three evaluation methods (medical severity index (MSI), potential injury creating event (PICE) classification, and disaster severity scale (DSS)), which can dynamically assess the MCI situations and decisions for MCI responses and can be made based on the results of such evaluations. However, the three methods only offer a retrospective evaluation of MCI and thus fail to develop a real-time assessment of MCI responses. Therefore, they cannot be used as practical guidance for decision-making during MCI. Although the theory of surge science has made great improvements, we found that a very important factor has been ignored—vulnerability, based on reflecting on the MCI response to the 2008 Wenchuan earthquake and July 5 bus fire in Hangzhou.ConclusionsThis new paradigm breaks through the limitation of traditional research paradigms and will contribute to the development of a methodology for disaster research.概要研究目的系统回顾大规模伤亡事件(MCI)经典研究范式, 结合2008年汶川地震和2014年杭州7·5公交车起火事件, 优化MCI应对的研究范式。创新要点需求激增理论是MCI应对实时评估的显著进步, 结合2008年汶川地震和2014年杭州7·5公交车起火事件, 我们发现MCI应对评估中一个非常重要的脆弱性因素被忽略。研究方法采用关键词和医学主题词(大规模伤亡事件、 MCI、 研究方法、 汶川、 地震、 研究范式、 激增科学、 激增、 激增应对能力和脆弱性等), 通过检索数据库PubMed、 EMBASE、 中国万方及中国生物医学(CBM)的相关研究资料库, 进行理论的回顾性分析和结合实际案例的分析。重要结论除需求激增理论中的激增和激增应对能力这二个基本维度外, 应引入第三个维度脆弱性, 形成更为全面和客观的三个互为关联维度构建MCI的新研究范式, 突破MCI传统研究范式的局限性。

The predictive value of bedside ultrasound to restore spontaneous circulation in patients with pulseless electrical activity: A systematic review and meta-analysis

Background The prognosis of pulseless electrical activity is dismal. However, it is still challengable to decide when to terminate or continue resuscitation efforts. The aim of this study was to determine whether the use of bedside ultrasound (US) could predict the restoration of spontaneous circulation (ROSC) in patients with pulseless electrical activity (PEA) through the identification of cardiac activity. Methods This was a systematic review and meta-analysis of studies that used US to predict ROSC. A search of electronic databases (Cochrane Central, MEDLINE, EMBASE) was conducted up to June 2017, and the assessment of study quality was performed with the Newcastle-Ottawa Scale. Statistical analysis was performed with Review Manager 5.3 and Stata 12. Results Eleven studies that enrolled a total of 777 PEA patients were included. A total of 230 patients experienced ROSC. Of these, 188 had sonographically identified cardiac activity (pseudo-PEA). A meta-analysis showed that PEA patients with cardiac activity on US were more likely to obtain ROSC compared to those with cardiac standstill: risk ratio (RR) = 4.35 (95% confidence interval [CI], 2.20–8.63; p<0,00001) with significant statistical heterogeneity (I2 = 60%). Subgroup analyses were conducted: US evaluation using only on the subxiphoid view: RR = 1.99 (95% CI, 0.79–5.02; p = 0.15); evaluation using various views: RR = 4.09 (95% CI,2.70–6.02; p<0.00001). Conclusions In cardiac arrest patients who present with PEA, bedside US has an important role in predicting ROSC. The presence of cardiac activity in PEA patients may encourage more aggressive resuscitation.

Can Red Cell Distribution Width Predict Acute Mesenteric Ischemia

To the Editor, We read with great interest the article by Kisaoglu et al. [1] who studied the association between red cell distribution width (RDW) and acute mesenteric ischemia (AMI). The authors concluded that RDW on admission was of marginal help to diagnose AMI among patients with abdominal pain. RDW is a simple, accessible, and cheap parameter which is a measure of erythrocyte size variability [2]. Although promising, it has raised more questions than it has answered. First, any incidence that induces the release of reticulocytes into the circulation will result in an increase in RDW, such as anemia, renal/hepatic dysfunction, thyroid disease, transfusion, acute or chronic inflammation, neurohumoural activation, malnutrition (i.e., iron, vitamin B12, and folic acid), ethnicity, bone marrow depression, and use of some medications (i.e., erythropoietin use and antibiotic use) [2]. AMI is an illness that mostly happens in elderly patients who may develop multiple comorbidities, which may significantly affect RDW level [1]. In the present study, the authors did not describe the above-mentioned influencing factors in a detailed way which would mask the real relationship between RDW and AMI. Second, it would be better if the authors defined the time elapsed between blood sampling and RDW measuring since the RDW level may be altered after a delay [2]. Third, only 159 patients were included in this study, thus there was no enough statistical power to discriminate all included covariates listed in Table 1 [1, 3]. Meanwhile in the Result section, the authors did not report the odds ratio of RDW for AMI in multivariate logistic regression analyses. We used Bayes’ theorem to calculate the probability of AMI, conditioned by the likelihood ratio as a function of the pretest probability (49/159) [4]. The results showed that when RDW [15.04 %, the post-test probability of AMI was 49 %; and when RDW\15.04 %, the post-test probability of AMI was 0.25 %. However, it has been reported that a confirmation strategy can be accurate enough to diagnose a disease when the post-test probability was above 85 %, and that for an exclusion strategy, it was below 5 % [5]. Therefore, RDW seems to be useless for the accurate diagnosis of AMI. Fourth, in the present study, the authors found there was no relation between RDW and mortality/size of lesion which is inconsistent with the results of another study by Bilgic et al [6]. It would be better if the authors explained the reason for these inconsistent results. Finally, there was no comparison of RDW and other prediction models (SAPS) made in this study. Moreover, whether addition of RDW in the previous prediction models or the combination of RDW with other parameters may improve diagnostic accuracy was unknown. However, as subjected to its purpose, further investigations may help to answer the questions raised herein. Although RDW seems to be a promising parameter for the diagnosis of AMI, further researches are needed to determine its clinical value. L. Jiang Y. Ma M. Zhang (&) Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine and Institute of Emergency Medicine, Zhejiang University, Jiefang road 88, Hangzhou, China e-mail: zmhz@hotmail.com

Ideal target arterial pressure after control of bleeding in a rabbit model of severe traumatic hemorrhagic shock: results from volume loading-based fluid resuscitation

BACKGROUND Previously reported ideal target mean arterial pressure (MAP) after control of bleeding in traumatic hemorrhagic shock (THS) requires further verification in more clinically related models. The authors explored this issue via gradient volume loading without vasopressor therapy. As certain volume loading can induce secretion of atrial natriuretic peptide (ANP), which has been shown to be protective, the authors also observed its potential role. MATERIALS AND METHODS Fifty male New Zealand rabbits were submitted to 1.5 h of uncontrolled THS (with another eight rabbits assigned to the sham group). After bleeding control, treated rabbits were randomly (n = 10, respectively) resuscitated with blood and Ringer lactate (1:2) to achieve target MAP of 50, 60, 70, 80, and 90 mm Hg within 1 h. During the following 2 h, they were resuscitated toward baseline MAP. Rabbits were observed until 7 h. RESULTS After resuscitation, infused fluid was lower and oxidative stress injury was milder in the 70 mm Hg group. Fluid volume loaded during the initial hour after hemostasis was negatively correlated with pH, oxygen saturation, and base excess at the end of resuscitation. It also correlated positively with proinflammatory responses in bronchoalveolar lavage fluid at 7 h and 7-h mortality. Moreover, after volume loading, the 80 mm Hg group showed significantly increased serum ANP level, which correlated with the expression of Akt protein in the jejunum at 7 h. CONCLUSIONS In rabbits the ideal target MAP during the initial resuscitation of severe THS after hemostasis was 70 mm Hg. ANP may have a critical role in gut protection.

Review article: Very serious and non-ignorable problem: crisis in emergency medical response in catastrophic event

The crisis of medical response caused by catastrophic events might significantly affect emergency response, and might even initiate more serious social crisis. Therefore, early identification and timely blocking the formation of crisis in the early phase after a major disaster will improve the efficiency of medical response in a major disaster and avoid serious consequences. In the present paper, we described the emergency strategy to crisis management of medical response after a major disaster. Major catastrophic events often lead to various crises, including excess demand, the crisis of response in barrier and the structural crisis in response. The corresponding emergency response strategies include: (i) shunt of catastrophic medical surge; (ii) scalability of medical surge capacity; (iii) matching of the structural elements of response; (iv) maintaining the functions of support system for medical response and maximising the operation of the integrated response system; and (v) selection of appropriate care ‘standard’ in extreme situations of overload of disaster medical surge. In conclusion, under the impact of a major catastrophic event, medical response is often complex and the medical surge beyond the conventional response capacity and it is easy to be in crisis. In addition to the current consensus of disaster response, three additional aspects should be considered. First, all relevant society forces led by the government and military should be linkages. Second, a powerful medical response system must be based on a strong support system. Third, countermeasures of medical surge should be applied flexibly to the special and specific disaster environment, to promote the effective medical response force.

Ultrasound-Guided Subclavian Vein Catheterization: A Systematic Review and Meta-Analysis: Several Facts Need To Be Noticed.

e474 www.ccmjournal.org October 2015 • Volume 43 • Number 10 catheterization to decrease cannulation attempts and potential complications resulting from posterior wall penetrations. With regards to the comments by Drs. Mishra and Azim (1) regarding cannulation of the axillary vein, we are aware that the border between the axillary and the subclavian vein is at the first rib. The technique we use is to place the ultrasound transducer inferior to the clavicle while angling the needle to cannulate the subclavian vessel. A similar approach is used in the landmarkguided placement of a subclavian catheter, with the needle introduced at the medial aspect of the clavicle and the needle angled to facilitate catheter insertion into the subclavian vessel (3). The goal of the inferior approach to the clavicle using ultrasound is cannulation of the subclavian vessel for central access. The authors suggest that the experience of the resident physicians for the subclavian short axis is limited when compared with the internal jugular, and that the inexperience could have resulted in more posterior wall penetrations. The resident experience level was similar for shortand long-axis ultrasound-guided central venous catheterization at the subclavian site. Therefore, if posterior wall penetrations occurred at the subclavian site due to inexperience with ultrasound-guided catheterization, it is anticipated that they would have occurred in both the shortand long-axis views. However, our study findings support fewer posterior wall penetrations in the long-axis view at the subclavian site. The authors suggest that the definition of successful cannulation by aspiration of red fluid is faulty because the difficulties associated with central venous catheter placement are related to inserting the guide wire. Our study was conducted on a human torso mannequin (Blue Phantom, Kirkland, WA), and therefore placement of the guide wire was not feasible in this study design. Additional investigations into ultrasound-guided placement of central venous catheters in live models in which the entire central venous catheterization procedure, including placement of the guide wire, is evaluated are indicated. The authors suggest that use of long axis to cannulate the internal jugular is difficult and that our finding of less time to cannulation in the long axis is not a practical funding. However, we and other investigators have found that the long-axis approach to cannulation of the vessel offers multiple advantages including continuous visualization of the needle and tip, visualization of the anatomy of the target vessel, and the theoretical advantage of not having inadvertent posterior wall penetration and resultant damage to the structures posterior to the target vessel (4–6). Our study findings indicate that physicians in training are facile with the long-axis approach to ultrasound-guided central venous catheterization with fewer posterior wall penetrations at the subclavian site. The authors suggest that the observers were not blinded to the study objectives, which may result in bias. As indicated in the Discussion section of our article, the “lack of blinding may have led to unconscious bias in reporting the results of the two view types at the internal jugular and subclavian sites, thereby affecting the results of our study” (3). Finally, the authors suggest that they do not believe the longaxis approach, which will result in decreased time to cannulation because the target area is small and the view is technically Ultrasound-Guided Subclavian Vein Catheterization: A Systematic Review and Meta-Analysis: Several Facts Need To Be Noticed