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ObjectiveTo investigate the association between serum 25-hydroxy vitamin D [25(OH)D] and the occurrence and outcome of stroke-associated pneumonia (SAP) in patients with acute ischemic stroke (AIS) in emergency ward. MethodsThe clinical data of 256 patients with AIS from January, 2019 to December, 2021 were collected in the emergency department of Beijing Bo'ai Hospital. Blood routine, biochemical indicators and serum concentration of 25(OH)D were detected within 24 hours after enrollment; meanwhile, National Institute of Health Stroke Scale (NIHSS) and A2DS2 score were evaluated. The patients were divided into non-SAP group (n = 164) and SAP group (n = 92) according to whether pneumonia occurred during hospitalization. Multivariable logistic regression model was used to analyze the influencing factors of SAP. The predictive ability of serum 25(OH)D and A2DS2 for SAP were evaluated by receiver operating characteristic (ROC) curves. The 28-day survival of patients with SAP was followed up. Multivariable Cox proportional hazard regression model was used to investigate the association between vitamin D nutritional status and 28-day all-cause mortality. ResultsSerum 25(OH)D was significantly lower in the SAP group than that in the non-SAP group (Z = 6.896, P < 0.001). After adjusting age, sex, infarct volume, A2DS2 score and other factors, lower serum 25(OH)D level (OR = 0.934, 95%CI 0.884 to 0.986, P = 0.014) was an independent risk factor for SAP. The areas under curve (95%CI) of serum 25(OH)D, A2DS2 score and their combined model for predicting SAP were 0.774 (0.718 to 0.824), 0.832 (0.781 to 0.876) and 0.851 (0.802 to 0.893) (P < 0.001), respectively; and the optimum cut-off values were 25(OH)D < 10.2 ng/mL, A2DS2 score > 5 points, combined prediction > 0.207, and the Youden index were 0.493, 0.662 and 0.616, respectively. A2DS2 score could improve the prediction efficiency of serum 25(OH)D (Z = 2.106, P = 0.035). After adjusting age, sex, infarct volume and NIHSS score, vitamin D deficiency was an independent risk factor for all-cause mortality after 28 days of SAP (HR = 2.871, 95%CI 1.004 to 8.208, P = 0.049) . ConclusionSerum 25(OH)D is independently associated with the occurrence and outcome of SAP in patients with AIS in emergency ward, which could serve as an independent predictor for SAP.
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Objective:To establish a prediction model for major adverse cardiovascular and cerebrovascular events (MACCE) in elderly patients with emergency acute coronary syndrome (ACS) within 1 year, and to evaluate its prediction efficiency.Methods:This was a prospective cohort study. Elderly ACS patients who were admitted to the Cardiovascular Care Unit (CCU) or the Emergency Intensive Care Unit (EICU) in Beijing Bo'Ai Hospital through emergency department from January 2019 to December 2021 were successively enrolled. General data of the patients were collected within 24 h after admission, the incidence of malignant arrhythmia, complete revascularization and acute kidney injury (AKI) during hospitalization were recorded. Within 24 h, laboratory indexes such as serum creatinine (Scr), albumin (Alb), hypersensitive C-reactive protein (hs-CRP), creatine kinase isoenzyme MB (CK-MB), D-dimer, cardiac troponin I (cTnI) and N-terminal pro-brain natriuretic peptide (NT-pro-BNP) were measured. In addition, transthoracic echocardiography and the Frailty Screening Questionnaire (FSQ) were performed. Patients were followed up for the occurrence of MACCE within 1 year. The influencing factors of MACCE were screened by univariable and multivariable logistic regression analysis. The cut-off values of continuous variables were determined by receiver operating characteristic (ROC) curve and discretization was carried out with reference to clinical practice. Corresponding scores were set up according to the β regression coefficient of each variable to establish a clinical prediction score scale of MACCE. Finally, ROC curve was used to evaluate its prediction efficiency.Results:The study enrolled 322 elderly ACS patients, and the incidence of MACCE within 1 year was 24.5%. After preliminary screening of independent variables by univariable logistic regression analysis, the influencing factors of MACCE ( P<0.2) were as follows: ① Continuous indicators: age, body mass index (BMI), Alb, hs-CRP, D-dimer, NT-pro-BNP, ejection fraction (EF), Killip grade and FSQ score; ② Discrete indicators: ≥3 comorbidities, incomplete revascularization, and AKI. Multivariable logistic regression analysis after discretization of continuous indicators showed that age ≥84 years old [odds ratio ( OR)=4.351, 95% confidence interval (95% CI): 1.635-11.576, P=0.003], incomplete revascularization ( OR=6.580, 95% CI: 2.397-18.060, P < 0.001), combined with AKI ( OR=2.647, 95% CI: 1.085-6.457, P=0.032), EF ≤50% ( OR=2.742, 95% CI: 1.062-7.084, P=0.037), and FSQ≥3 points ( OR=9.345, 95% CI: 3.156-27.671, P < 0.001) were independent risk factors for MACCE. The total score of the clinical prediction system for MACCE was 8 points, including age ≥84 years old (2 points), incomplete revascularization (2 points), FSQ ≥3 points (2 points), EF ≤50% (1 point), and combined with AKI (1 point). The area under ROC curve (AUC) of the scoring system for predicting MACCE was 0.891, (95% CI: 0.844-0.938, P < 0.001). The optimal cut-off value was >3 points, and the sensitivity and specificity were 0.825 and 0.792, respectively. Conclusions:The prediction score scale of MACCE has a good diagnostic efficacy and has certain guiding value for clinicians to judge the prognosis of elderly ACS patients.
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Objective:To explore the predictive value and prognosis effect of calprotectin on acute kidney injury (AKI) in patients with sepsis.Methods:A prospective observational study was conducted. From December 2018 to November 2020, patients with sepsis admitted to the Emergency Department of China Rehabilitation Research Center were enrolled. General clinical data of patients were collected continuously, and the acute physiology and chronic health evaluationⅡ (APACHEⅡ) score, sequential organ failure assessment (SOFA) score and calprotectin were evaluated in 24 h after admission. The patients were divided into the AKI group and non-AKI group according to the occurrence of AKI within 7 days after admission. Calprotectin level and other clinical data were compared between the two groups. Logistic regression was used to analyze the risk factors for AKI in patients with sepsis, and receiver operating characteristic (ROC) curve was plotted to evaluate the predictive value of calprotectin for AKI in patients with sepsis. The patients with AKI were further divided into the survival group and death group according to the 28-day outcome, and the calprotectin levels between the two groups were compared.Results:A total of 207 patients with sepsis were enrolled, and the incidence of AKI was 68.12% (141/207). The level of calprotectin in patients with AKI was higher than that in patients without AKI [4.65 (3.25, 5.61) μg/mL vs. 3.42 (2.29, 4.09) μg/mL, P < 0.001]. Multivariable Logistic regression analysis showed that APACHEⅡ score ( OR=1.090, 95% CI: 1.043-1.139), C-reactive protein ( OR=1.004, 95% CI: 1.001-1.008) and calprotectin ( OR=1.590, 95% CI: 1.269-1.991) were independent risk factors for AKI in patients with sepsis. The area under ROC curve (AUC) of calprotectin for predicting AKI was 0.716 (95% CI: 0.643-0.788). The cutoff value of prediction was 4.63 μg/mL with the Yoden index of 0.405, which yielded a sensitivity of 0.511 and a specificity of 0.894. When calprotectin was combined with APACHE II score and SOFA score respectively, the predictive ability was significantly improved with the AUC of 0.768 (95% CI: 0.701-0.834) and 0.769 (95% CI: 0.701-0.837), respectively. We further divided patients with AKI into the survival group and non-survival group according to the 28-day outcome and there was no significant difference in calprotectin between the two groups [4.80 (3.40, 5.76) μg/mL vs. 4.19 (2.89, 5.29) μg/mL, P < 0.05]. Conclusions:The level of calprotectin in the AKI group is higher than that in the non-AKI group. Calprotectin can be regarded as an effective predictor of AKI in patients with sepsis, and the combination with APACHEⅡ score or SOFA score will improve its predictive efficacy. However, there is no significant difference in the concentration of calprotectin for patients with sepsis associated AKI with different prognosis.
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Objective:To observe the changes of serum histone H4 level and its predictive value in patients with septic cardiomyopathy.Methods:A prospective study was conducted. A total of 147 patients with sepsis and septic shock were collected in emergency department. The general data were recorded. Transthoracic echocardiography and plasma histone H4 were conducted within 24 hours and 7 days after admission.The scores of sequential organ failure assessment(SOFA), acute physiology and chronic health evaluationⅡ(APACHEⅡ), and nutritional risk screening 2002 (NRS2002) were evaluated within 24 hours. According to whether septic cardiomyopathy occurred, the patients were divided into two groups, and dynamic changes of histone H4 on the first and seventh day of the two groups were observed. The factors influencing the occurrence of septic cardiomyopathy were analyzed by multivariate logistic regression. The prediction ability of serum histone H4 on septic cardiomyopathy was evaluated by receiver operating curve (ROC).Results:The incidence of septic cardiomyopathy was 28.6% (42 / 147). The level of histone H4 in septic cardiomyopathy group was higher than that in non septic cardiomyopathy group ( Z = 4.449, P < 0.001), and dynamic detection showed that the level of histone H4 on the seventh day was lower than that on admission ( Z=3.057, P=0.002). Multivariate logistic regression showed that the high serum histone H4 level [Odd Ratio( OR)=1.337, 95% confidence interval (95% CI) was 1.173-1.522, P < 0.001], SOFA ( OR= 1.474, 95% CI 1.227-1.769, P < 0.001), older age ( OR = 1.074, 95% CI 1.019-1.132, P = 0.008) were independent risk factors for septic cardiomyopathy. The area of ROC curve for serum histone H4 to predict septic cardiomyopathy was 0.729 ( P < 0.001), the predictive cut-off value was 10.81 ng/ml, which yielded a sensitivity 0.524 and a specificity of 0.914. Conclusions:The level of histone H4 showed dynamic change in septic cardiomyopathy, and high serum histone H4 level has a good predictive value for the occurrence of septic cardiomyopathy.
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Objective:To explore the clinical value of arterial partial pressure of carbon dioxide (PaCO 2) combined with Wells score in predicting acute pulmonary embolism (PE). Methods:Patients with suspected acute PE admitted to Emergency Department of Beijing Chaoyang Hospital, Capital Medical University from January 1, 2016 to August 31, 2021 were screened. Patients with positive computed tomography pulmonary angiography (CTPA) results were classified as the PE group, and those with negative CTPA results were classified as the non-PE group. Demographic characteristics, symptoms, vital signs, underlying diseases, risk factors for venous thrombosis, arterial blood gas analysis and Wells scores were statistically analyzed and compared between the two groups, and the clinical efficacy of PaCO 2 combined with Wells score in predicting acute PE was evaluated. Results:A total of 1 869 patients with suspected acute PE were screened, and 1 492 patients were finally selected. There were 537 cases in the PE group and 955 cases in the non-PE group. The frequency of chest pain, dyspnea, unilateral lower limb edema, history of PE or deep venous thrombosis, history of surgery or immobilization within 3 months, history of fracture within 3 months, active malignant tumor, elevated Wells score and reduced PaCO 2 in the PE group was significantly higher than that in the non-PE group (all P< 0.05). The area under receiver operating characteristic (ROC) curve (AUC) of Wells score was 0.784 (95% CI: 0.758-0.810), and the sensitivity and specificity of predicting acute pulmonary embolism were 61.64% and 88.48%, respectively. The AUC of reduced PaCO 2 was 0.679 (95% CI: 0.651-0.707), and the sensitivity and specificity of predicting acute pulmonary embolism were 79.89% and 55.92%, respectively. The AUC of reduced PaCO 2 combined with Wells score was 0.837 (95% CI: 0.816-0.858), and the sensitivity and specificity of predicting acute pulmonary embolism were 74.12% and 77.07%, respectively. The AUC of reduced PaCO 2 combined with Wells score was significantly greater than the AUC of Wells score ( P<0.001) and the AUC of reduced PaCO 2 ( P<0.001). Conclusions:The efficacy of PaCO 2 reduction combined with Wells score in predicting acute PE was superior to that of either of them alone. This was a beneficial supplement to the screening of patients with acute PE, and would also help reduce the abuse of CTPA in the emergency department.
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Objective:To investigate the correlation between the level of serum 25-hydroxyvitamin D [25(OH)D] and infarction volume in patients with acute ischemic stroke (AIS) with internal carotid artery system (anterior circulation).Methods:A prospective cohort study was conducted. Patients with AIS admitted to the department of emergency of Beijing Boai Hospital from October 2017 to September 2019 were enrolled. Nutritional risk screening 2002 (NRS 2002) were assessed in all cases within 24 hours after enrollment. Fasting venous blood was collected for biochemical analysis, including albumin (ALB), homocysteine (HCY), uric acid (UA), hypersensitive C-reactive protein (hs-CRP), etc. Serum 25(OH)D level was detected by electrochemiluminescence immunoassay. Magnetic resonance imaging (MRI) was performed to calculate the volume of cerebral infarction. According to the volume of cerebral infarction, the patients were divided into small volume (≤ 1 cm 3) group, medium volume (1 cm 3 < infarct volume < 20 cm 3) group and large volume (≥20 cm 3) group. The differences of serum 25(OH)D and other indicators in each group were compared; the influencing factors of infarct volume were analyzed by Logistic regression; and the goodness of fit of regression model was tested by Hosmer-Lemeshow (HL). Results:A total of 224 patients with AIS were enrolled, 92 in small volume group, 90 in medium volume group and 42 in large volume group, and there was no significant difference in serum 25(OH)D level among small, medium and large volume groups [μg/L: 13.21 (7.47, 19.33), 11.20 (7.00, 15.07), 9.19 (6.30, 17.10), H = 4.994, P = 0.082]. There were 124 patients with AIS in anterior circulation, 45, 56 and 23 patients in the small, medium and large volume groups, respectively, with the increase of the cerebral infarction volume, the serum 25(OH)D level in small, medium and large volume groups decreased gradually, and the difference was statistically significant [μg/L: 13.22 (9.00, 19.65), 10.41 (6.72, 14.92), 8.30 (4.70, 11.30), H = 11.068, P = 0.004]. In addition, with the increase of the cerebral infarction volume, the older the patients with AIS in anterior circulation [years old: 63.0 (54.0, 75.5), 76.0 (63.0, 84.0), 82.0 (67.5, 85.0), H = 14.981, P = 0.001], the higher the nutritional risk ratio (35.6%, 53.6%, 73.9%, χ2 = 9.271, P = 0.010), the higher the serum hs-CRP level [mg/L: 1.91 (0.92, 3.40), 4.10 (1.73, 22.42), 19.74 (4.02, 68.81), H = 21.477, P < 0.001], and the lower the ALB level (g/L: 42.30±12, 38.11±5.06, 35.14±5.49, F = 19.347, P < 0.001). After adjusting for age, gender, atrial fibrillation, nutritional risk, hs-CRP and other confounding factors, serum 25(OH)D was an independent protective factor for the infarct volume of AIS in anterior circulation [odds ratio ( OR) = 0.962, P = 0.040], For every 10 μg/L decrease of 25(OH)D, the risk of one grade increase in infarction volume was increased by 47.7% respectively (goodness of fit: χ2 = 5.357, P = 0.719). Conclusion:The low serum 25(OH)D level was associated with the increase of infarct volume in the anterior circulation cerebral infarction, and early detection of serum 25(OH)D level can help risk stratification of AIS patients.
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Objective:To explore a medical big data algorithm to screen the core indicators in clinical database that can be used to evaluate the prognosis of elderly patients with pneumonia.Methods:Based on the clinical database of a Beijing Chaoyang Hospital Consortium Chaoyang Emergency Ward in Beijing Chaoyang Hospital, Capital Medical University, patients with pulmonary infection were selected through the big data retrieval technology. According to the prognosis at the time of discharge, they were divided into death group and survival group. The general data of patients were collected, including gender, age, blood gas and laboratory indices. A computer language called Python was used to make batch calculations of key indicators that affect mortality in elderly patients with pneumonia. Logistic regression analysis was used to analyze the relationship between laboratory indicators and patients' prognosis. Receiver operating characteristic curve (ROC curve) was drawn to analyze the predictive value of screening method for patients' prognosis.Results:A total of 265 patients were included in the study, 64 died and 201 survived. The data of the first detection indexes of each patient after admission were collected, and 23 key indicators with significant differences were selected from 472 indicators: blood routine indicators ( n = 7), blood gas indicators ( n = 3), tumor markers indicators ( n = 3),coagulation related indicators ( n = 4), and nutrition and organ function indicators ( n = 6). ① The key indicators of blood gas in patients died of pneumonia: Cl - was 97-111 mmol/L in 51.6% (33 cases) of patients, lactic acid (Lac) was 0.5-2.5 mmol/L in 81.2% (52 cases) of patients, and H + was 0-46 mmol/L in 87.5% (56 cases) of patients. ② The key indicators of blood routine of patients died of pneumonia: hemoglobin count (Hb) of 46.9% (30 cases) patients was 80-109 g/L, the eosinophils proportions (EOS%) in 67.2% (43 cases) patients was 0.000-0.009, the lymphocytes proportions (LYM%) in 51.6% (33 cases) patients was 0.00-0.09, the red blood cell count (RBC) in 50.0% (32 cases) patients was (3.0-3.9)×10 12/L, the white blood cell count (WBC) in 54.7% (35 cases) patients was (0.0-9.9)×10 9/L, and the red blood cell volume distribution width coefficientof variability (RDW-CV) in 48.4% (31 cases) patients was 10.0%-14.9%, serum C-reactive protein (CRP) was 0.0-49.9 mg/L in 48.4% (31 cases) patients. ③ The key indicators of tumor markers in patients died of pneumonia: 76.6% (49 cases) of patients had negative free prostate specific antigen/total prostate specific antigen (FPSA/TPSA, the ratio was 0), 92.2% (59 cases) had cytokeratin 19 fragment (CYFRA21-1) between 0.0-11.0 μg/L, and 75.0% (48 cases) had carbohydrate antigen 125 (CA125) between 0-104 kU/L.④ The key coagulation indexes of patients died of pneumonia: 68.8% (44 cases) of patients had activated partial thromboplastin time (APTT) of 57-96 s, 73.4% (47 cases) of patients had D-dimer of 0-6 mg/L, 93.8% (60 cases) of patients had thrombin time (TT) of 14-22 s, and 89.1% (57 cases) of patients had adenosine diphosphate (ADP) inhibition rate of 0%-53%. ⑤ Nutrition and organ function key indicatorsin patients died of pneumonia: 92.2% (59 cases) of brain natriuretic peptide (BNP) in patients with 0, 46.9% (30 cases) of patients had prealbumin (PA) of 71-140 mg/L, 90.6% (58 cases) of the patients with uric acid (UA) for 21-41 μmol/L, 75.0% (48 cases) of the patients with albumin (Alb) to 10-20 g/L, 93.5% (60 cases) of patients had albumin/globulin ratio (A/G ratio) of 0-0.9, 84.4% (54 cases) of the patients with lactate dehydrogenase (LDH) from 0-6.68 μmol/L·s -1·L -1. ⑥ Logistic regression analysis and ROC curve analysis: Logistic regression analysis showed that PA and Lac were the prognostic factors. PA could reduce the risk of death by 0.9%, Lac could increase the risk of death by 69.4%; the area under ROC curve (AUC) between laboratory indicators and the prediction effect of death prediction model for patients' prognosis was 0.80, which showed that the classification effect was better, and this study model could better predict the prognosis of elderly patients with pneumonia. Conclusion:By using big data technology, 23 core indicators for evaluating the prognosis of elderly patients with pneumonia can be screened from the clinical database of emergency ward, which provides a new perspective and method for clinical evaluation of the prognosis of elderly patients with pneumonia.
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Objective:To explore the differences between emergency healthcare-associated pneumonia (HCAP) and community-acquired pneumonia (CAP), to analyze whether HCAP is a relatively independent type pneumonia in the emergency department in China.Methods:Clinical data of HCAP and CAP patients admitted to the emergency department of Beijing Tiantan Hospital, Beijing Chaoyang Hospital of Capital Medical University and Huilongguan Hospital from September 2018 to May 2019 were retrospectively analyzed. General information of the patients, types of basic diseases, laboratory examination within 24 h of admission, etiological examination results, empirical anti-infection treatment plan, mechanical ventilation and clinical outcome were collected. The pneumonia severity index (PSI) was used to assess the pneumonia severity. The measurement data were expressed as mean ± standard deviation for t test, and the counting data were performed by χ 2 test. A P<0.05 indicated statistical difference. Results:One hundred and five HCAP patients and 105 CAP patients were collected. The number of HCAP combined with two or more basic diseases was higher than that of the CAP group. There were statistically significant differences between the two groups in white blood cell count, mean hemoglobin and blood lactic acid level.The PSI score of the HCAP group was higher than that of the CAP group (134.0±26.3 vs 113.0±16.34). The PSI score grade IV of the HCAP group was lower than that of the CAP group, while the PSI score grade V of the HCAP group was higher than that of the CAP group, with statistically significant differences ( P<0.05). In the HCAP group, 73 strains (69.52%) and 55 strains (52.38%) of multi-drug resistant strains were isolated. Acinetobacter baumannii and Streptococcus pneumoniae, Klebsiella pneumoniae and Escherichia coli in the HCAP group were more than those in the CAP group. The drug resistance rate of pseudomonas aeruginosa to imipenem in the HCAP group was higher than that in the CAP group (22.2% vs 10.0%); the drug resistance rate of Acinetobacter baumannii to cefoperazone/sulbactam was lower than that in the CAP group (27.3% vs 54.5%); the drug resistance rate of Pseudomonas aeruginosa to Meropenem was lower than that in the CAP group (45.5% vs 72.7%). The proportion of carbapenems in the initial empirical anti-infection treatment in the HCAP group was higher than that in the CAP group (21.00% vs 10.48%), and the difference was statistically significant. The ratio of invasive mechanical ventilation and the fatality rate in the HCAP group were higher than those in the CAP group (21.00% vs 7.62%, 21.00% vs 8.57%; both P<0.05). Conclusions:HCAP patients in emergency department are complicated with a variety of basic diseases, high drug resistance rate of pathogenic bacteria, and more advanced drugs are required for initial empirical anti-infection treatment, high proportion of mechanical ventilation, and high fatality rate. HCAP is a relatively independent category of pneumonia in emergency in China.
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Objective:To analyze the clinical characteristics of acute drug poisoning, and provide better management for poisoned patients in Emergency Department.Methods:We retrospectively enrolled 197 patients diagnosed as acute drug poisoning in Emergency Department of Beijing Chaoyang Hospital from January 1, 2019 to December 31, 2019. Medical records included age, gender, baseline diseases, medication time, visit time, kinds of drugs, drug concentrations, accompanying symptom, hospitalization duration, treatment, fluid resuscitation and outcomes. The inclusion criteria were as follows: age≥ 14 years old, and met the criteria of acute poisoning. The exclusion criteria were as follows: age<14 years old; incomplete clinical data; pesticide poisoning; toxic gas poisoning; and other non-drug poisoning. All patients were divided into the survival group and death group according to their outcomes at the discharge. Clinical characteristics, laboratory parameters and treatments were compared using the Student’s t test, Mann-Whitney U test, as appropriate. Results:The mean age of all the patients was 38.9±20.4 years. The majority were young patients, accounting for 134 cases (68.0%). The accompanying symptoms included consciousness disturbance (106 cases), dizziness (56 cases), fatigue (38 cases), and nausea and/or vomiting (42 cases). The duration of medication-to-visit time was 0.5-96 h, with an average of 7.17±0.89 h. The types of drugs included 105 (53.2%) sedatives and hypnotics, 73 antipsychotics (37.1%), 17 antibiotics (8.6%), and 20 antipyretic analgesics (10.2%). The Glasgow comascale (GCS) score of patients in the survival group was higher than that of the death group (12.47±3.05 vs 7.60±4.43, P<0.01). In the death group, the alanine aminotransferase, urea nitrogen, creatinine, cardiac troponin I, prothrombin time, activated partial thromboplastin time, plasma fibrinogen and D-dimer were higher than those of the survival group (all P<0.05). One hundred and eighty-seven patients were cured, while 10 patients died. One hundred and fifty-nine patients were treated with gastric lavage, and 23 patients were treated with blood purification. The concentrations of toxic drugs before and after treatment in 134 poisoned patients were compared. The concentration of drugs after treatment was significantly lower than that before treatment. Conclusions:Acute non-pesticide poisoning in Emergency Department is mainly caused by sedatives, hypnotics, antipsychotics, and antipyretics and analgesics. It is important to conduct laboratory examinations for toxic medications to provide better management for poisoned patients. It is necessary to establish a standardized monitoring system and management path for acute drug poisoning.
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Objective:To establish a clinical diagnostic scoring system for septic cardiomyopathy (SCM) and evaluate its diagnostic efficacy.Methods:A prospective cohort study was performed. Patients with sepsis and septic shock admitted to the department of emergency of China Rehabilitation Research Center were enrolled from January 2019 to December 2020. The baseline information, medical history, heart rate (HR), mean arterial pressure (MAP), body temperature and respiratory rate (RR) on admission were recorded. Laboratory indexes such as white blood cell count (WBC), hypersensitivity C-reactive protein (hs-CRP), N-terminal pro-brain natriuretic peptide (NT-proBNP), and blood lactic acid (Lac) were measured. Transthoracic echocardiography was conducted within 24 hours and on the 7th after admission. Sequential organ failure assessment (SOFA) score, acute physiology and chronic health evaluationⅡ(APACHEⅡ), and nutritional risk screening 2002 scale (NRS2002) were also assessed. The patients were divided into two groups according to whether SCM occurred or not. The risk factors of SCM were screened by univariate and multivariate Logistic regression. The cut-off value of continuous index was determined by receiver operator characteristic curve (ROC curve) and discretized concerning clinical data. The regression coefficient β was used to establish the corresponding score, and the clinical diagnostic score system of SCM was established. The diagnostic value of the model was evaluated by ROC curve.Results:In total, 147 patients were enrolled in the study and the incidence of SCM was 28.6% (42/147). Univariate Logistic regression analysis showed the risk factors of SCM included: ① continuous indicators: age, NT-proBNP, RR, MAP, Lac, NRS2002, SOFA, APACHEⅡ; ② discrete indicators: shock, use of vasoactive drugs, history of coronary heart disease, acute kidney injury (AKI). Multivariate Logistic regression analysis after discretization of above continuous index showed that age≥87 years old, NT-proBNP≥3 000 ng/L, RR≥30 times/min, Lac≥3 mmol/L and SOFA≥10 points were independent risk factors for SCM [age ≥87 years: odds ratio ( OR) = 3.491, 95% confidence interval (95% CI) was 1.371-8.893, P = 0.009; NT-proBNP≥3 000 ng/L: OR = 2.708, 95% CI was 1.093-6.711, P = 0.031; RR≥30 times/min: OR = 3.404, 95% CI was 1.356-8.541, P = 0.009; Lac≥3 mmol/L: OR = 3.572, 95% CI was 1.460-8.739, P = 0.005; SOFA≥10 points: OR = 8.693, 95% CI was 2.541-29.742, P = 0.001]. The clinical diagnostic score system of SCM was established successfully, which was composed of age≥87 years old (1 point), NT-proBNP ≥ 3 000 ng/L(1 point), RR≥30 times/min (1 point), Lac≥3.0 mmol/L (1 point), SOFA≥10 points (2 points), and the total score was 6 points. ROC curve analysis showed the cut-off value of the scoring system for diagnosing SCM was 3 points, the area under ROC curve (AUC) was 0.833, 95% CI was 0.755-0.910, P < 0.001, with the sensitivity of 71.4%, and specificity of 86.7%. Conclusion:The clinical diagnostic scoring system has good diagnostic efficacy for SCM and contributes to early identification of SCM for clinicians.
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Objective:To explore the predictive value of red blood cell count (RBC), fibrinogen (FBG) combined with platelet count (PLT)for risk stratification of acute pulmonary embolism (PE).Methods:Patients admitted to Beijing Chaoyang Hospital from January 2013 to October 2019 and diagnosed with acute PE were retrospectively collected. According to the risk stratification criteria for PE, the patients were divided into the high/medium risk group and low risk group. The demographic characteristics, previous medical history, parameters of RBC and PLT, and FBG of the two groups were compared.Results:Totally 696 patients were selected in the study, of them, 193 patients were in the high/medium risk group and 503 in the low risk group. RBC and hematocrit (HCT) in the high/medium risk group were significantly higher than those in the low risk group, but FBG and PLT in the high/medium risk group were significantly lower than those in the low risk group (all P<0.05). There was no significant difference in age, gender, previous medical history, hemoglobin (HGB), HCT, mean corpuscular volume (MCV), mean corpuscular hemogloin (MCHC), red blood cell distribution width (RDW), platelet distribution width (PDW), mean platelet volume (MPV), and platelet large cell rate (P-LCR) between the two groups. Logistic regression analysis showed that RBC, PLT and FBG were independent influencing factors for risk stratification of acute PE. RBC was positively correlated with risk stratification, while PLT and FBG were negatively correlated. The area under the ROC curve (AUC) of RBC, PLT and FBG were 0.552 (95% CI: 0.514-0.589), 0.591 (95% CI: 0.554-0.628), and 0.565 (95% CI: 0.527-0.602), with the cut-off value of 4.57 ×10 12/L,182 ×10 9/L and 322.8 mg/dL, respectively. Conclusions:RBC, FBG combined with PLT have clinical predictive value for risk stratification of acute PE.
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Objective To investigate the failure factors of no-invasive ventilation (NIV) as an initial ventilation mode for the treatment of community acquired pneumonia (CAP).Methods Totally 237 cases of CAP patients with NIV as initial ventilation were analyzed retrospectively in the emergency department of Beijing Chaoyang Hospital.According to the failure of NIV,patients were divided into two groups.General clinical data and acute physiological and chronic health score (APACHE Ⅱ),physiological parameters,pulmonary infection and the prognosis of the patients were recorded,and were compared between the two groups.The risk factors of NIV 1 hour and 3 hours later were analyzed by multivariate logistic regression.Results Compared with the NIV failure group,the mortality of the patients in the NIV successful group (17.6 and 35.6,P＜ 0.01) was significantly lower.The risk factors for the NIV1 hour failure of the patients included the APACHE Ⅱ score(OR=l.352,95％CI:l.132-3.015,P=0.035),the hemodynamic support (OR=9.826,95％CI:2.525-86.377,P=0.002) and the severity of the pulmonary infection,and the risk factors for the physiological index of the failure of NIV3 hours included hemodynamic support(OR=6.365,95％CI:2.552-28.316,P=0.004),respiratory frequency and pH value.Conclusions Hemodynamic support is the most important risk factor for the failure of NIV in CAP patients.During the NIV treatment,the patients' respiratory frequency,oH and blood pressure should be closely monitored to ensure the success and safety of the treatment.
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To investigate the assessment values of procalcitonin (PCT), lactic acid (LAC), sequential organ failure assessment (SOFA) score and acute physiology and chronic health evaluationⅡ (APACHEⅡ) score in patients with sepsis. Methods 140 patients with suspicious bacterial infection admitted to emergency department of Beijing Chaoyang Hospital of the Capital Medical University from August 2017 to June 2018 were enrolled. They were divided into three groups according to diagnostic criteria of Sepsis-3: non-sepsis group (n = 58), sepsis group (n = 66) and septic shock group (n = 16). The PCT, LAC, SOFA score, APACHEⅡscore, 28-day prognosis, and positive detection rate of PCT and LAC were compared among three groups. Independent predictors of 28-day mortality were analyzed by Logistic regression; predictive values of PCT, LAC, SOFA score and APACHEⅡscore for 28-day mortality in sepsis patients were analyzed by receiver operating characteristic (ROC) curve. Results PCT, LAC, SOFA score, APACHEⅡscore at admission, and 28-day mortality in sepsis group and septic shock group were significantly higher than those in non-sepsis group, and PCT, LAC, APACHEⅡ score, and 28-day mortality in sepsis shock group were further higher than those in sepsis group [PCT (μg/L): 38.1±12.6 vs. 4.6±2.3, LAC (mmol/L):3.3±2.1 vs. 2.4±2.1, APACHEⅡ score: 14.9±2.4 vs. 9.5±4.3, 28-day mortality: 75.0% vs. 24.2%, all P < 0.05]. The positive detection rate of PCT and LAC in sepsis group and septic shock group were higher than those in non-sepsis group (positive detection rate of PCT: 56.1%, 81.3% vs. 32.8%; positive detection rate of LAC: 42.4%, 62.5% vs. 13.7%; all P < 0.01). Logistic regression analysis showed that PCT, LAC, SOFA score and APACHEⅡ score were independent predictors of 28-day mortality [PCT: odds ratio (OR) = 0.933, 95% confidence interval (95%CI) = 0.878-0.991; LAC:OR = 0.539, 95%CI = 0.347-0.838; SOFA score: OR = 0.291, 95%CI = 0.514-0.741; APACHEⅡ score: OR = 0.808, 95%CI = 0.669-0.976; all P < 0.05]. ROC curve analysis showed that the area under ROC curve (AUC) of PCT, LAC, SOFA score and APACHEⅡ score predicting 28-day mortality was 0.76, 0.86, 0.81 and 0.87, respectively. The assessment values of APACHEⅡscore and LAC were higher than PCT in predicting 28-day mortality (Z1 = 2.56, Z2 = 2.45, both P < 0.01), and the performance of SOFA score was similar to PCT. Conclusions PCT, LAC, SOFA score and APACHEⅡscore were reliable indexes to evaluate disease severity for patients diagnosed with infection. The assessment values of APACHEⅡscore and LAC in 28-day mortality were superior to SOFA score and PCT.
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Objective To analyze retrospectively the cardioversion for paroxysmal supraventricular tachycardia (PSVT) in emergency department in order to explore rational guidance for the diagnosis and treatment for PSVT.Methods A retrospective analysis of PSVT patients in the emergency department admitted from June 2015 to December 2015 was carried out.First,all the patients were divided into two groups according to the cardioversion achieved by Valsalva's maneuvre or not.Forty patients were enrolled in study.There were 11 patients got cardioversion successfully achieved by the Valsalva's maneuvre and 29 patients failed to get cardioversion.Then,comparisons of demographics,vital sign,serum CTNI,potassium and NTproBNP level were carried out between these groups of patients using statistical analysis.The categorical variable was expressed in percentage and the continuous variable was described by mean±standard deviation and the comparisons of parameters were conducted by group t-test and chi-square test.Results The success rate of PSVT maneuvre cardioversion was 27.5％.In addition,there were no significant differences in demographics vital sign,TNI and NTproBNP between the two groups while there were significant differences in serum potassium level between the two groups [(3.8±0.4)mmol/L vs.(3.5±0.35)mmol/L P＜0.05].There was no significant difference in successful rate of cardioversion between the standard Valsalva's maneuvre(n=6) the modified Valsalva's maneuvre(n=5).The second-line treatment mainly included propafenone,adenosine,electroversion,verapamil and amiodarone.The propafenone was the most common second-line agent used for PSVT cardioversion accounting for 58.6％.Conclusions The success rate of Valsalva's maneuver cardioversion was low.Keeping properly a higher level of serum potassium could increase the success rate of cardioversion by Valsalva's maneuvre.
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Objective To investigate the perioperative complications and therapeutic effects of balloon-assisted coiling (BAC) and stent-assisted coiling (SAC) in patients with ruptured intracranial aneurysms in the acute phase. Methods Totally 91 patients with 91 intracranial ruptured aneurysms were treated with BAC or SAC in our hospital between January 2014 and December 2016. Among them, 37 patients were treated with BAC and 54 patients with SAC respectively. Of the two groups, the position distribution and shape of aneurysms, and the complications after procedures and the therapeutic effects were summarized and evaluated retrospectively using chi-square test. Results The width of the aneurysm neck was narrower in the BAC-treated group compared to the SAC-treated group (3.31±1.63 mm vs. 4.35±2.10 mm, P=0.01). The aneurysm body/neck ratio (B/N) was lower in the BAC-treated group than in the SAC-treated group (1.64 ± 0.46 vs. 1.35±0.66, P=0.025). The recurrence rate was higher in the BAC-treated group than that in the SAC-treated group (18.9％ vs. 0.9％, P=0.005). There was no statistical difference in perioperative complication in both the BAC-treated group and SAC-treated group. However, 2 patients died due to the relative postoperative intracranial bleeding in the SAC-treated group. Better outcomes (Modified Rankin Score, mRS, 0-2) were achieved in the BAC-treated group compared to the SAC-treated group (94.6％ vs. 88.9％, P=0.028) at the follow-up visit. Conclusions These findings suggested that there is no difference between the BAC-treated group and the SAC-treated group in the risk of complication. BAC can achieve a better prognosis,but it is more prone to relapse. The SAC method was more appropriate for wider neck aneurysms. It was also an option to coiling the aneurysm in BAC in acute phase firstly, followed by additional treatment in SAC during the follow-up period.
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Objective To investigate the accuracy of sequential organ failure assessment (SOFA) scoring in emergency physicians in Beijing. Methods Emergency physicians from 8 hospitals in Beijing in January 2018 were demanded to complete a SOFA questionnaire which was developed on ''wenjuanxing'' website and submit via cell phone. All participants were divided into urban center group (UC group) and no-urban center group (NUC group) based on the hospital's location. The accuracy rate of components and total score of SOFA along with the mistakes were evaluated, and the results of the two groups were compared. Results ① The questionnaire was sent to 217 emergency physicians of the 8 hospitals, and 197 qualified questionnaires were received with 109 of NUC group and 88 of UC group, respectively, the total response rate was 90.8%. Compared with those from NUC group, UC physicians had older ages [years:37 (32, 42) vs. 34 (29, 40), Z = -2.554, P = 0.011] and higher education level [postgraduate degree 76.1% (67/88) vs. 40.4% (44/109), χ2= 25.327, P < 0.001], and more of them experienced SOFA scoring [62.5% (55/88) vs. 45.9% (50/109), χ2= 5.409, P = 0.020]. Other baseline characteristics such as gender, working years, professional title and training experience were not different between the two groups. ② The accuracy rate of total SOFA score was 62.4% (123/197) in the whole cohort, and UC group was lower than that of NUC group, but the difference was not significant [56.8% (50/88) vs. 67.0% (73/109), χ2= 2.141, P = 0.143]. While comparing the accuracy of individual variable/system of SOFA, the accuracy rate of norepinephrine of UC group was much higher than NUC group [80.7% (71/88) vs. 66.1% (72/109), χ2= 5.235, P = 0.022], but the accuracy of Glasgow coma scale (GCS) was much lower in NUC group [38.6% (27/70) vs. 81.6% (71/87), χ2= 30.629, P < 0.001]. Other variables of SOFA were not different between the two groups. ③Based upon the results of all submitted questionnaires, 566 mistakes were identified. It was indicated that the mistakes per capital was 2.9 in the whole cohort and in the two groups. The first type mistakes which caused by carelessness (including calculating error, filling error, choosing error) were 233 times. The calculating error in norepinephrine from NUC physicians was higher than the UC group [33.9% (37/109) vs. 19.3% (17/88), χ2= 5.235, P =0.022], there was no significant difference in any other first type mistakes between the two groups. The total second type mistakes caused by misunderstanding of SOFA (including using wrong variables, not using the worst value within 24 hours, and incorrect GCS score) were 333 times in the whole cohort. GCS error [61.8% (42/88) vs. 16.9% (14/109), χ2=32.292, P<0.001], and using urine output per hour instead of urine output per 24 hours [15.9% (14/88) vs. 4.6% (5/109), χ2= 7.162, P = 0.007] were much higher in UC group than NUC group. Conclusions The total accuracy of SOFA scoring in the investigated emergency physicians of 8 hospitals in Beijing was not good. Mistakes causing by carelessness or misunderstanding of score rules were similar. It is necessary to apply strict training in SOFA scoring.
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Objective To determine whether left ventricular Tei Index evaluate the cardiac function and prognosis of patients with sepsis-induced cardiomyopathy (SIC).Methods A total of 86 patients with septic shock combined with SIC in the emergency department of Beijing Chaoyang Hospital affiliated to Capital Medical University from July 2014 to June 2016 were recruited and divided into non-survival group (n=35) and survival group (n=51) according to 28-day follow-up.Left ventricular Tei Index, BNP, cTNI and left ventricular ejection fraction within the first 24 h after admisson were detected and compared between the two groups.The correlations of left ventricular Tei Index to BNP, cTNI and ejection fraction were analyzed.The receiver operating characteristic curves (ROC) were constructed to analysize the value of Tei Index in evaluating the cardiac function and prognosis.Results The patientsin the non-survival group had a higher Tei Index compared with that in the survival group [(0.75±0.13) vs.(0.51±0.09), P<0.05].The Tei Index of SIC patients was significantly positively correlated with BNP and cTNI (both P<0.05), and significantly negatively correlated with ejection fraction (P<0.05).The AUC of Tei Index for predicting 28-day mortality in SIC patients was high comapred with that of BNP, cTNI and ejection fraction.Conclusion The left ventricular Tei Index has a reliable value in evaluating the cardiac function and prognosis of patients with SIC.
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Sepsis is one of the most common causes of mortality in the intensive care units (ICUs) with high mortality rates which may be related to the lack of thoroughly understanding of the specific pathophysiological mechanisms.Improved treatment protocols have resulted in most patients got out of the initial hyperinflammatory phase and entered into a protracted immune suppressed phase.Deaths in this immunosuppressive phase are typically due to failure to control the primary infection or the secondary nosocomial infections often with opportunistic pathogens.As the complexity in multiple systems and varied mechanisms involved in the development of disease,the disorder of immune system and inflammation reaction may be one of the main mechanisms,which were mainly characterized by inflammation cytokines storm and immune dysfunction.The mechanism in the later course of disease may include apoptosis and depletion of immune cells,increased suppression of T regulatory cell and increased myeloid-derived suppressor cell,and cellular exhaustion.In this review we focus on the pathophysiologic mechanism of sepsis with immune compromized,monitoring the immune response,the cellular immunoadjuvant therapy,and improving the recognition of sepsis immunosuppression.
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Objective To explore the correlations between renal artery resistance index (RRI) and renal function in patients with thrombotic microangiopathy (TMA) so as to provide the clinical basis for predictable diagnosis and treatment in patients with acute kidney injury (AKI).Methods Patients diagnosed with thrombotic microangiopathy admitted to department of emergency of Peking Union Medical College Hospital between August 1st,2014 and March 31th,2015 were enrolled.Intrarenal arteries resistive index of right kidney was detected in all cases on admission by color Doppler flow image.The serum creatinine (SCR) and glomerular fihration rate (GFR) were measured at the same time.According to the diagnostic criteria of the guideline of Kidney Disease:Improving Global Outcomes 2012 (KDIGO-AKI 2012),patients were divided into non-AKI group and AKI group.The intergroup difference was compared and the correlation between RRI and SCR as well as between RRI and GFR were assessed.RRI,SCR and GFR were measured again at the most severe stage of kidney injury.The above index were marked as RRI*,SCR and GFRmin.At the same time,△RRI (RRI*-RRI),△SCR (SCRmax-SCR) and △GFR (GFR-GFRmin) were calculated.According to the stage classification of KDIGO-AKI 2012,36 patients diagnosed with AKI during their hospitalization were divided into KDIGO-1 group (n =10),KDIGO-2 group (n =10) or KDIGO-3 group (n =16).The intergroup difference of RRI* was compared and the correlation between △RRI and △SCR as well as between △RRI and △GFR were assessed.Results When RRI ＞ 0.7 was used as the diagnostic threshold for AKI,the sensitivity was 92.3％ and the specificity was 80.1％.RRI was positively correlated with SCR (r1 =-0.728,P＜0.01;r2=-0.709,P＜0.01) and negatively correlated with GFR (r1 =-0.728,P＜0.01;r2 =-0.709,P ＜0.01) in all patients at the time of admission and the most severe stage of kidney injury.While there was a significant difference in the RRI* among KDIGO-1,KDIGO-2 and KDIGO-3 groups (F =37.979,P =0.Q01),and there was no significant difference in △RRI (F =0.634,P =0.537).The △RRI was not correlated with △GFR or △SCR.Conclusions RRI can be used as a marker for diagnosis of AKI and the evaluation of renal function in patients with TMA,but it is not helpful to reflect the trends of renal injury especially for the critically ill patients.
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<p><b>OBJECTIVE</b>To study the accuracy of pulse contour cardiac output (PCCO) during blood volume change.</p><p><b>METHODS</b>Hemorrhagic shock model was made in twenty dogs followed by volume resuscitation. Two PiCCO catheters were placed into each model to monitor the cardiac output (CO). One of catheters was used to calibrate CO by transpulmonary thermodilution technique (COTP) (calibration group), and the other one was used to calibrate PCCO (none-calibration group). In the hemorrhage phase, calibration was carried out each time when the blood volume dropped by 5 percents in the calibration group until the hemorrhage volume reached to 40 percent of the basic blood volume. Continuous monitor was done in the none-calibration group.Volume resuscitation phase started after re-calibration in the two groups. Calibration was carried out each time when the blood equivalent rose by 5 percents in calibration group until the percentage of blood equivalent volume returned back to 100. Continuous monitor was done in none-calibration group. COTP, PCCO, mean arterial pressure (MAP), systemic circulation resistance (SVR), global enddiastolic volume (GEDV) were recorded respectively in each time point.</p><p><b>RESULTS</b>(1) At the baseline, COTP in calibration group showed no statistic difference compared with PCCO in none-calibration group (P >0.05). (2) In the hemorrhage phase, COTP and GEDV in calibration group decreased gradually, and reached to the minimum value (1.06 ± 0.57) L/min, (238 ± 93) ml respectively at TH8. SVR in calibration group increased gradually, and reached to the maximum value (5 074 ± 2 342) dyn · s · cm⁻⁵ at TH6. However, PCCO and SVR in none-calibration group decreased in a fluctuating manner, and reached to the minimum value (2.42 ± 1.37) L/min, (2 285 ± 1 033) dyn · s · cm⁻⁵ respectively at TH8. COTP in the calibration group showed a significant statistic difference compared with PCCO in the none-calibration group at each time point (At TH1-8, t values were respectively -5.218, -5.495, -4.639, -6.588, -6.029, -5.510, -5.763 and -5.755, all P < 0.01). From TH1 to TH8, the difference in percentage increased gradually. There were statistic differences in SVR at each time point between the two groups (At TH1 and TH4, t values were respectively 2.866 and 2.429, both P < 0.05, at TH2 - TH3 and TH5 - TH8, t values were respectively 3.073, 3.590, 6.847, 8.425, 6.910 and 8.799, all P < 0.01). There was no statistic difference in MAP between the two groups (P > 0.05). (3) In the volume resuscitation phase, COTP and GEDV in the calibration group increased gradually. GEDV reached to the maximum value ((394±133) ml) at TR7, and COTP reached to the maximum value (3.15 ± 1.42) L/min at TR8. SVR in the calibration group decreased gradually, and reached to the minimum value (3 284 ± 1 271) dyn · s · cm⁻⁵ at TR8. However, PCCO and SVR in the none-calibration group increased in a fluctuating manner. SVR reached to the maximum value (8 589 ± 4 771) dyn · s · cm⁻⁵ at TR7, and PCCO reached to the maximum value (1.35 ± 0.70) L/min at TR8. COTP in the calibration group showed a significant statistic difference compared with PCCO in the none-calibration group at each time point (At TR1-8, t values were respectively 8.195, 8.703, 7.903, 8.266, 9.600, 8.340, 8.938, 8.332, all P < 0.01). From TR1 to TR8, the difference in percentage increased gradually. There were statistic differences in SVR at each time point between the two groups (At TR1, t value was -2.810, P < 0.05, at TR2-8, t values were respectively -6.026, -6.026, -5.375, -6.008, -5.406, -5.613 and -5.609, all P < 0.05). There was no statistic difference in MAP between the two groups (P > 0.05).</p><p><b>CONCLUSION</b>PCCO could not reflect the real CO in case of rapid blood volume change, which resulting in the misjudgment of patient's condition. In clinical practice, more frequent calibrations should be done to maintain the accuracy of PCCO in rapid blood volume change cases.</p>