Xuezhong Yu

Severe Community-Acquired Pneumonia Caused by Human Adenovirus in Immunocompetent Adults: A Multicenter Case Series

Background Severe community-acquired pneumonia (CAP) caused by human adenovirus (HAdV), especially HAdV type 55 (HAdV-55) in immunocompetent adults has raised increasing concerns. Clinical knowledge of severe CAP and acute respiratory distress syndrome induced by HAdV-55 is still limited, though the pathogen has been fully characterized by whole-genome sequencing. Methods We conducted a multicentre retrospective review of all consecutive patients with severe CAP caused by HAdV in immunocompetent adults admitted to the Emergency Department Intensive Care Unit of two hospitals in Northern China between February 2012 and April 2014. Clinical, laboratory, radiological characteristics, treatments and outcomes of these patients were collected and analyzed. Results A total of 15 consecutive severe CAP patients with laboratory-confirmed adenovirus infections were included. The median age was 30 years and all cases were identified during the winter and spring seasons. HAdV-55 was the most frequently (11/15) detected HAdV type. Persistent high fever, cough and rapid progression of dyspnea were typically reported in these patients. Significantly increased pneumonia severity index (PSI), respiratory rate, and lower PaO2/FiO2, hypersensitive CRP were reported in non-survivors compared to survivors (P = 0.013, 0.022, 0.019 and 0.026, respectively). The rapid development of bilateral consolidations within 10 days after illness onset were the most common radiographic finding, usually accompanied by adjacent ground glass opacities and pleural effusions. Total mortality was 26.7% in this study. Corticosteroids were prescribed to 14 patients in this report, but the utilization rate between survivors and non-survivors was not significant. Conclusions HAdV and the HAdV-55 sub-type play an important role among viral pneumonia pathogens in hospitalized immunocompetent adults in Northern China. HAdV should be tested in severe CAP patients with negative bacterial cultures and a lack of response to antibiotic treatment, even if radiologic imaging and clinical presentation initially suggest bacterial pneumonia.

Emergency Department Characteristics and Capabilities in Beijing, China

BACKGROUND Emergency Departments (EDs) are a critical, yet heterogeneous, part of international emergency care. OBJECTIVES We sought to describe the characteristics, resources, capabilities, and capacity of EDs in Beijing, China. METHODS Beijing EDs accessible to the general public 24 h per day/7 days per week were surveyed using the National ED Inventories survey instrument (www.emnet-nedi.org). ED staff were asked about ED characteristics during the calendar year 2008. RESULTS Thirty-six EDs participated (88% response rate). All were located in hospitals and were independent hospital departments. Participating EDs saw a median of 80,000 patients (interquartile range 40,000-118,508). The vast majority (91%; 95% confidence interval [CI] 78-98%) had a contiguous layout, with medical and surgical care provided in one area. Most EDs (55%) saw only adults; 39% saw both adults and children, and 6% saw only children. Availability of technological and consultant resource in EDs was high. The typical ED length of stay was between 1 and 6 h in 49% of EDs (95% CI 32-67%), whereas in the other half, patients reportedly remained for over 6 h; 36% (95% CI 21-54%) of respondents considered their ED over capacity. CONCLUSIONS Beijing EDs have high volume, long length of stay, and frequent reports of EDs being over capacity. To meet its rapidly growing health needs in urban areas, China should consider improving urban ED capacity and training more Emergency Medicine specialists capable of efficiently staffing its crowded EDs.

Severe adenovirus community-acquired pneumonia in immunocompetent adults: chest radiographic and CT findings

BACKGROUND Severe adenovirus pneumonia and its associated imaging features are well-described in immunocompromised patients but are rare and poorly understood in immunocompetent adults. We sought to describe the radiographic and CT findings of severe adenovirus community-acquired pneumonia (CAP) in eight immunocompetent adults. METHODS We reviewed systematically chest imaging manifestations of laboratory-confirmed severe adenovirus pneumonia in eight immunocompetent adults from April 2012 to April 2014. RESULTS All patients showed abnormal results on initial chest radiograph and CT, with the exception of one normal initial chest radiograph. The abnormalities of the initial chest radiographs were unilateral (n=4) or bilateral (n=3), including consolidation (n=4), dense patchy opacity (n=3), ground glass opacity (GGO) (n=1), and pleural effusion (n=1). The initial CT findings consisted of unilateral (n=5) and bilateral (n=3) abnormalities, including consolidation (n=8), GGO (n=2), pleural effusion (n=3) and small nodules (n=1). Focal consolidation was the predominant finding in six patients whose initial CT scans were examined within one week after illness onset. Follow-up radiologic findings showed rapid development of bilateral consolidation within ten days after illness onset, usually accompanied by adjacent ground-glass opacity and pleural effusion. The parenchymal abnormalities began to absorb around two weeks after illness onset, with no appearances of fibrosis. CONCLUSIONS Severe adenovirus CAP in immunocompetent adults mainly appears as focal consolidation followed by rapid progression to bilateral consolidation, usually accompanied by adjacent GGO and pleural effusion, which may resemble bacterial pneumonia. Adenovirus should be considered in severe pneumonia cases with negative cultures and failure to respond to antibiotics.

Why do not we use finger pulse oximeter plethysmograph waveform to monitor the effectiveness of cardiopulmonary resuscitation

Both the European Resuscitation Council (ERC) and the Amerian Heart Association (AHA) 2010 guidelines for cardiopulmonary esuscitation (CPR) once again emphasize the need for high quality PR, including a compression rate of at least 100 min−1.1 Quanitative waveform capnography is recommended as a physiologic onitor of the effectiveness of chest compressions in the new uidelines. Quantitative waveform capnography is not available in most PR situations and it has to be calibrated, which is time-consuming. ulse oximetry is much more commonly available. Recent studies how the pulse oximeter plethysmographic waveform can be used s an early indication of changes in the circulation.2 Why do not we se a finger pulse oximeter plethysmograph waveform to monitor ffectiveness of resuscitation efforts during CPR? The pulse oximeter provides a rapid, noninvasive, and continous measurement of arterial oxygen saturation that has become uniform standard for patient monitoring throughout medicine. ulse oximeters often show the pulsatile change in absorbance n a graphical form – the plethysmograph. The plethysmograph aveform is similar in appearance to an arterial blood presure waveform. Although the plethysmograph is not a direct nalogue of arterial pressure or cardiac output, its waveform is elated to general haemodynamic status and peripheral tissue erfusion, so it can provide useful information about the cariovascular system. Because the pulse oximeter is noninvasive nd ubiquitous in hospitals, it is logical to seek circulatory inforation from the plethysmograph waveform. The extraction of irculatory information from the plethysmographic waveform has een well researched. The plethysmograph waveform may provide nformation related to hypotension, hypovolaemia, low cardiac utput, vasoconstriction and other circulatory conditions.2,3 During PR time is limited; it is difficult to establish invasive haemodyamic monitoring to assess the quality of CPR. The pulse oximetry lethysmograph waveform can be used to monitor adequacy of nterventions. In our clinical practice, high quality chest compresions often produce excellent pulse oximetry tracings in patients ith a lack of spontaneous circulation. During CPR, the plethysograph may indicate the presence or absence of measurable erfusion with each chest compression. Since the plethysmograph isplays a pulsatile waveform, it can used also to monitor chest

Effects of Shenfu Injection in the Treatment of Septic Shock Patients: A Multicenter, Controlled, Randomized, Open-Label Trial

The effect of Shenfu on biochemical parameters and survival during resuscitation in patients with septic shock was examined. This was a multicenter, controlled, randomized, open-label trial carried out in 210 patients with septic shock from seven medical centers in China. They were randomized to Shenfu or saline. The primary outcome was lactate clearance. The secondary outcomes were shock index normalization, dose of vasopressors, ICU stay, hospital stay, and mortality. A total of 199 patients completed the trial. Blood pressure, heart rate, and other routine lab tests showed no difference between the groups. Lactate levels and lactate clearance were similar between the two groups. Hospital and ICU stay were similar between the two groups. When considering all patients, the 7- and 28-day mortality were similar between the two groups, but when considering only patients with lactate levels ≥4.5 mmol/L, the Shenfu group showed a better 7-day survival than the control group (7 days: 83.3% versus 54.5%, P = 0.034; 28 days: 72.7% versus 47.6%, P = 0.092). Shenfu may improve the 7-day survival in patients with impaired lactate clearance (≥4.5 mmol/L), but the mechanism for this effect is unclear. Additional studies are necessary to characterize the hemodynamic changes after Shenfu infusion. This trial is registered with ChiCTR-TRC-11001369.

LEFT ATRIAL MYOXMA PRESENTING AS HEADACHE IN THE PEDIATRIC PATIENT

BACKGROUND Cardiac myxomas rarely occur in children or adolescents. In addition, it is even more rare for the adolescent patient to present with neurological symptoms only. Early diagnosis is difficult because the symptoms of left atrial myxoma are frequently nonspecific. If delayed or left undiagnosed, severe and fatal complications, such as systemic embolism, heart failure, and pulmonary hypertension, may occur. CASE REPORT A 13-year-old girl was admitted to our resuscitation room because of loss of consciousness for the preceding 2 h; she had a longstanding history of headache and dizziness for the previous 18 months. Repeated investigations at her local hospital did not reveal any abnormalities. During this admission, routine chest x-ray study found an abnormal bulge of a segment of the pulmonary artery and elevated cardiac enzymes. Emergency bedside echocardiography was performed and revealed a myxoma in the left atria. Subsequent computed tomography head revealed cardiogenic cerebral embolism. When her condition was stable, the patient was taken to the operating room, where a tumorectomy was performed successfully. The patient was then treated with oral anticoagulants and an uneventful recovery was made. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In order to avoid delayed diagnosis and treatment of its potentially fatal complications, it is important for the emergency clinician to have a high level of suspicion for a cardiac myxoma when attending to young patients that present with syncope. We therefore recommend that, as routine practice, bedside echocardiography to be carried in the emergency department for young patients that present with syncope.

Comparison of different inspiratory triggering settings in automated ventilators during cardiopulmonary resuscitation in a porcine model

Background Mechanical ventilation via automated in-hospital ventilators is quite common during cardiopulmonary resuscitation. It is not known whether different inspiratory triggering sensitivity settings of ordinary ventilators have different effects on actual ventilation, gas exchange and hemodynamics during resuscitation. Methods 18 pigs enrolled in this study were anaesthetized and intubated. Continuous chest compressions and mechanical ventilation (volume-controlled mode, 100% O2, respiratory rate 10/min, and tidal volumes 10ml/kg) were performed after 3 minutes of ventricular fibrillation. Group trig-4, trig-10 and trig-20 (six pigs each) were characterized by triggering sensitivities of 4, 10 and 20 (cmH2O for pressure-triggering and L/min for flow-triggering), respectively. Additionally, each pig in each group was mechanically ventilated using three types of inspiratory triggering (pressure-triggering, flow-triggering and turned-off triggering) of 5 minutes duration each, and each animal matched with one of six random assortments of the three different triggering settings. Blood gas samples, respiratory and hemodynamic parameters for each period were all collected and analyzed. Results In each group, significantly lower actual respiratory rate, minute ventilation volume, mean airway pressure, arterial pH, PaO2, and higher end-tidal carbon dioxide, aortic blood pressure, coronary perfusion pressure, PaCO2 and venous oxygen saturation were observed in the ventilation periods with a turned-off triggering setting compared to those with pressure- or flow- triggering (all P<0.05), except when compared with pressure-triggering of 20 cmH2O (respiratory rate 10.5[10/11.3]/min vs 12.5[10.8/13.3]/min, P = 0.07; coronary perfusion pressure 30.3[24.5/31.6] mmHg vs 27.4[23.7/29] mmHg, P = 0.173; venous oxygen saturation 46.5[32/56.8]% vs 41.5[33.5/48.5]%, P = 0.575). Conclusions Ventilation with pressure- or flow-triggering tends to induce hyperventilation and deteriorating gas exchange and hemodynamics during CPR. A turned-off patient triggering or a pressure-triggering of 20 cmH2O is preferred for ventilation when an ordinary inpatient hospital ventilator is used during resuscitation.

Efficacy of non-invasive ventilation and oxygen therapy on immunocompromised patients with acute hypoxaemic respiratory failure: protocol for a systematic review and meta-analysis of randomised controlled trials

Background The number of immunocompromised patients has increased in recent years. Acute respiratory failure is a common complication leading to intensive care unit (ICU) admission and high mortality among such patients. The use of non-invasive ventilation (NIV) or oxygen therapy among these patients remains controversial, according to the inconsistent results of several randomised clinical trials (RCTs). This meta-analysis aims to evaluate whether NIV or oxygen therapy is the more appropriate initial oxygenation strategy for the immunocompromised patients with acute respiratory failure. Method We will search all the RCTs that compared the efficacy of NIV and oxygen therapy on immunocompromised adult patients with acute hypoxaemic respiratory failure on the major databases (Cochrane Library, MEDLINE, EMBASE, Web of Science and others), conference proceedings and grey literature. Eligible RCTs will be included in accordance with the pre-specified eligibility criteria. The risk of bias will be assessed using the Cochrane Collaboration criteria and the quality of evidence will be assessed with the Grading of Recommendations Assessment, Development and Evaluation system. Data will be extracted with a standardised form and analysed using RevMan V.5.3 analyses software. Heterogeneity will be assessed using I2 statistic and the source of which will be investigated. Publication bias will be identified with the funnel plot. Ethics and dissemination Ethical approval is not required since it is not carried out in humans. The systematic review will be published in peer-reviewed journals and disseminated extensively through conferences.

Influence of Chest Compressions on Circulation during the Peri-Cardiac Arrest Period in Porcine Models.

Objective Starting chest compressions immediately after a defibrillation shock might be harmful, if the victim already had a return of spontaneous circulation (ROSC) and yet was still being subjected to external compressions at the same time. The objective of this study was to study the influence of chest compressions on circulation during the peri-cardiac arrest period. Design Prospective, randomized controlled study. Setting Animal experimental center in Peking Union Medical Collage Hospital, Beijing, China. Subjects Healthy 3-month-old male domestic pigs. Interventions 44 pigs (28±2 kg) were randomly assigned to three groups: Group I (non-arrested with compressions) (n = 12); Group II (arrested with compressions only) (n = 12); Group III (ROSC after compressions and defibrillation) (n = 20). In Groups I and II, compressions were performed to a depth of 5cm (Ia and IIa, n = 6) or a depth of 3cm (Ib and IIb, n = 6) respectively, while in Group III, the animals which had just achieved ROSC (n = 18) were compressed to a depth of 5cm (IIIa, n = 6), a depth of 3cm (IIIb, n = 6), or had no compressions (IIIc, n = 6). Hemodynamic parameters were collected and analyzed. Measurements and Findings Hemodynamics were statistically different between Groups Ia and Ib when different depths of compressions were performed (p < 0.05). In Group II, compressions were beneficial and hemodynamics correlated with the depth of compressions (p < 0.05). In Group III, compressions that continued after ROSC produced a reduction in arterial pressure (p < 0.05). Conclusions Chest compressions might be detrimental to hemodynamics in the early post-ROSC stage. The deeper the compressions were, the better the effect on hemodynamics during cardiac arrest, but the worse the effect on hemodynamics after ROSC.

Transesophageal echocardiography to assess mitral valve movement and flow during long term cardiopulmonary resuscitation: How cardiac effects fade with time

BACKGROUND Although the cardiac pump and the thoracic pump are the two main theories, the actual mechanisms of blood flow during Cardiopulmonary Resuscitation (CPR) in humans are still unclear. The aim of this study was to explore the relationship between the pump mechanism and time after cardiac arrest. METHODS AND RESULTS 20 patients with non-traumatic cardiac arrest were enrolled in this study. Transesophageal two-dimensional and pulse-doppler echocardiography were used during CPR. The duration of CPR was 60-80min if there was no return of spontaneous circulation (ROSC). We found: (1) The mechanisms of blood flow during CPR varied with time: the thoracic pump took the place of the cardiac pump after prolonged CPR in the same patient. (2) Peak transmitral flow (TMF) decreased (p<0.05) after prolonged CPR in patients with mitral valve closure during chest compressions. (3) Longer elapsed time from collapse to CPR and TEE was correlated to lower peak TMF in CPR (Both p<0.05). (4) Peak TMF(p<0.01), mitral valve time-velocity integrals(p<0.05), left ventricular stroke volume (p<0.05) and end-tidal carbon dioxide tension (p<0.05) is higher in the group of patients with mitral valve closure during chest compressions. This group of patients had a shorter time from collapse to CPR (p<0.01), shorter time from collapse to TEE (p<0.01) and had overall better outcomes. CONCLUSIONS The pump mechanism changes over the course of prolonged CPR. Cardiac effect is an essential part of the pump at the beginning of cardiac arrest, but it faded with time, making the thoracic pump the dominate mechanism after prolonged CPR.