Yuefeng Ma

The analysis of risk factors of impacting mortality rate in severe multiple trauma patients with posttraumatic acute respiratory distress syndrome

OBJECTIVE We hypothesize that not all of the traditional risk factors of impacting mortality rate in commonly traumatic populations with posttraumatic acute respiratory distress syndrome (ARDS) are independently associated with those patient populations identified with severe multiple trauma. Rather, we postulate that there may exist significantly different impacting degrees of specific risk factors in stratified patients (surviving beyond 24 and 96 hours)--more severe multiple trauma with higher injury score and long-term mechanical ventilation as well. METHODS This is a retrospective cohort study regarding trauma as a single cause for emergency intensive care unit admission. Twenty-two items of potential risk factors of impacting mortality rate were calculated by univariate and multivariate logistic analyses to find distinctive items in these severe multiple trauma patients. RESULTS The unadjusted odds ratio and 95% confidence intervals of mortality rate were found to be associated with 6 (out of 22) risk factors, namely, (1) Acute Physiology and Chronic Health Evaluation II score, (2) duration of trauma factor, (3) aspiration of gastric contents, (4) sepsis, (5) pulmonary contusion, and (6) duration of mechanical ventilation. Significant results also appeared in stratified patients. CONCLUSIONS Impact of pulmonary contusion and Acute Physiology and Chronic Health Evaluation II score contributing to prediction of mortality may exist in the early phase after trauma. Sepsis is still a vital risk factor referring to systemic inflammatory response syndrome, infection, secondary multiple organ dysfunction, etc. Discharging trauma factors as early as possible becomes the critical therapeutic measure. Aspiration of gastric contents in emergency intensive care unit admission could lead to incremental mortality rate due to aspiration pneumonia. Long-standing mechanical ventilation should be constrained because it is likely to cause severe refractory complications.

The Correlation between Plasma Fibrinogen Levels and the Clinical Features of Patients with Ovarian Carcinoma

Pre-operative plasma levels of fibrinogen, plasma prothrombin time, activated partial thromboplastin time and thrombin time (TT) were retrospectively examined in 105 patients with ovarian carcinoma and 21 control patients with benign ovarian tumour. Plasma cancer antigen 125 (CA-125) levels, pathological type, age, body mass index and blood group were evaluated. The TTs of patients with stage III and stage IV ovarian carcinoma were significantly shorter than in controls. Levels of plasma fibrinogen in patients with stage III and IV ovarian carcinoma were higher than those in patients with stage I and II ovarian carcinoma and the controls. There was a positive relationship between levels of plasma CA-125 and plasma fibrinogen in patients with stage II malignancy. There were no significant differences between plasma fibrinogen levels in patients of different age, BMI, blood group and pathological type. Shorter TT was an indication of advanced stage ovarian carcinoma, and fibrinogen was associated with the peritoneal carcinomatosis of ovarian carcinoma.

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.

The Impact of Clinical Risk Factors in the Conversion from Acute Lung Injury to Acute Respiratory Distress Syndrome in Severe Multiple Trauma Patients

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are different stages of the same disease, the aggravated stage of ALI leading to ARDS. Patients with ARDS have higher hospital mortality rates and reduced long-term pulmonary function and quality of life. It is, therefore, important to prevent ALI converting to ARDS. This study evaluated 17 risk factors potentially associated with the conversion from ALI to ARDS in severe multiple trauma. The results indicate that the impact of pulmonary contusion, APACHE II score, gastrointestinal haemorrhage and disseminated intravascular coagulation may help to predict conversion from ALI to ARDS in the early phase after multiple-trauma injury. Trauma duration, in particular, strongly impacted the short- and long-term development of ALI. Being elderly (aged ≥ 65 years) and undergoing multiple blood transfusions in the early phase were independent risk factors correlated with secondary sepsis, deterioration of pulmonary function and transfusion-related acute lung injury due to early multiple fluid resuscitation.

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。

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

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.

Real-time continuous glucose monitoring versus conventional glucose monitoring in critically ill patients: a systematic review study protocol.

Introduction Stress-induced hyperglycaemia, which has been shown to be associated with an unfavourable prognosis, is common among critically ill patients. Additionally, it has been reported that hypoglycaemia and high glucose variabilities are also associated with adverse outcomes. Thus, continuous glucose monitoring (CGM) may be the optimal method to detect severe hypoglycaemia, hyperglycaemia and decrease glucose excursion. However, the overall accuracy and reliability of CGM systems and the effects of CGM systems on glucose control and prognosis in critically ill patients remain inconclusive. Therefore, we will conduct a systematic review and meta-analysis to clarify the associations between CGM systems and clinical outcome. Methods and analysis We will search PubMed, EMBASE and the Cochrane Library from inception to October 2014. Studies comparing CGM systems with any other glucose monitoring methods in critically ill patients will be eligible for our meta-analysis. The primary endpoints include the incidence of hypoglycaemia and hyperglycaemia, mean glucose level, and percentage of time within the target range. The second endpoints include intensive care unit (ICU) mortality, hospital mortality, duration of mechanical ventilation, length of ICU and hospital stay, and the Pearson correlation coefficient and the results of error grid analysis. In addition, we will record all complications (eg, acquired infections) in control and intervention groups and local adverse events in intervention groups (eg, bleeding or infections). Ethics and dissemination Ethics approval is not required as this is a protocol for a systematic review. The findings will be disseminated in a peer-reviewed journal and presented at a relevant conference. Trial registration number PROSPERO registration number: CRD42014013488.

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.