Cognition and Ability of Emergency Physicians for Palliative Care in Tertiary Hospitals / 中国医学科学院学报

Objective To understand the cognition and related abilities of emergency physicians for palliative care in China. Methods A total of 115 emergency physicians were selected by convenient sampling to conduct a questionnaire survey.The questionnaire included the physicians' basic information,feelings and attitudes towards end-stage patients and their families,cognition of palliative care,and personal ability for palliative care. Results 25.2%,59.1%,and 15.7% of the emergency physicians considered they had "no understanding","partial understanding",and "full understanding" of palliative care,respectively.32(27.8%)physicians participated in palliative care-related lectures and they showed higher self-rated cognition levels(

A survey of ventilation strategies during cardiopulmonary resuscitation / 世界急诊医学杂志（英文）

BACKGROUND@# Many controversies still exist regarding ventilator parameters during cardiopulmonary resuscitation (CPR). This study aimed to investigate the CPR ventilation strategies currently being used among physicians in Chinese tertiary hospitals.@*METHODS@# A survey was conducted among the cardiac arrest team physicians of 500 tertiary hospitals in China in August, 2018. Surveyed data included physician and hospital information, and preferred ventilation strategy during CPR.@*RESULTS@# A total of 438 (88%) hospitals completed the survey, including hospitals from all 31 Chinese mainland provinces. About 41.1% of respondents chose delayed or no ventilation during CPR, with delayed ventilations all starting within 12 minutes. Of all the respondents who provided ventilation, 83.0% chose to strictly follow the 30:2 strategy, while 17.0% chose ventilations concurrently with uninterrupted compressions. Only 38.3% respondents chose to intubate after initiating CPR, while 61.7% chose to intubate immediately when resuscitation began. During bag- valve-mask ventilation, only 51.4% of respondents delivered a frequency of 10 breaths per minute. In terms of ventilator settings, the majority of respondents chose volume control (VC) mode (75.2%), tidal volume of 6–7 mL/kg (72.1%), PEEP of 0–5 cmH2O (69.9%), and an FiO2 of 100% (66.9%). However, 62.0% of respondents had mistriggers after setting the ventilator, and 51.8% had high pressure alarms.@*CONCLUSION@#There is a great amount of variability in CPR ventilation strategies among cardiac arrest team physicians in Chinese tertiary hospitals. Guidelines are needed with specific recommendations on ventilation during CPR.

Venous thromboembolism in the emergency department: A survey of current best practice awareness in physicians and nurses in China / 世界急诊医学杂志（英文）

BACKGROUND@# For emergency department (ED) patients, risk assessment, prophylaxis, early diagnosis and appropriate treatment of venous thromboembolism (VTE) are essential for preventing morbidity and mortality. This study aimes to investigate knowledge amongst emergency medical staff in the management of VTE.@*METHODS@# We designed a questionnaire based on multiple scales. The questionnaire was distributed to the medical and nursing clinical staff in the large urban ED of a medical center in Northern China. Data was described with percentages and the Kruskal-Wallis test was used to compare ranked data between different groups. The statistical analysis was done using the SPSS 22.0 software.@*RESULTS@# In this survey, 180 questionnaires were distributed and 174 valid responses (response rate of 96.67%) were collected and analyzed. In scores of VTE knowledge, no significant differences were found with respect to job (doctor vs. nurse), the number of years working in clinical medicine, education level, and current position, previous hospital experience and nurses' current work location within the ED. However, in pair wise comparison, we found participants who worked in ED for more than 5 years (n=83) scored significantly higher on the questionnaire than those under 5 years (n=91) (95.75 vs. 79.97, P=0.039). There was a significant difference in some questions based on gender, age, job, and nurse work location, number of working years, education level, and different ED working lifetime.@*CONCLUSION@# Our survey has shown deficiencies among ED medical staff in knowledge and awareness of the management of VTE. We recommend several changes be considered, such as the introduction of an interdisciplinary workshop for medical staff; the introduction of a standardized VTE protocol; a mandatory study module on VTE for new physicians and nurses; the introduction of a mandatory reporting system for adverse events (including VTE).

Utility and Safety of Intrathecal Methotrexate Treatment in Severe Anti-N-methyl-D-aspartate Receptor Encephalitis: A Pilot Study / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a treatable autoimmune neurologic syndrome that occurs with or without tumor association. However, some severe cases are refractory to systemic immunotherapy. This pilot study aimed to evaluate the utility and safety of intrathecal methotrexate injection for severe patients with anti-NMDAR encephalitis who did not respond to first-line immunotherapy.</p><p><b>METHODS</b>Intrathecal injections with methotrexate and dexamethasone were performed weekly in four legible patients within consecutive 4 weeks. Cerebrospinal fluid (CSF) was collected at baseline and each time of intrathecal injection for identification of anti-NMDAR antibody titers.</p><p><b>RESULTS</b>Significant clinical improvement was observed in three patients associated with a stepwise decrease of CSF anti-NMDAR antibody titers (maximum: 1/320 to minimum: 1/10). After 2 months of follow-up, they were able to follow simple commands and had appropriate interactions with people (modified Rankin scale [mRS] of 0-2). At 12 months of follow-up, they all had returned to most activities of daily life (mRS of 0), and no relapses were reported. One patient showed no clinical improvement and died of neurologic complications.</p><p><b>CONCLUSIONS</b>Intrathecal treatment may be a potentially useful supplementary therapy in severely affected patients with anti-NMDAR encephalitis. Further large cohort study and animal experiment may help us elaborate the utility of intrathecal injection of methotrexate and its mechanism of action.</p>

Application of simulation training for central venous catherteriazation in emergency department / 基础医学与临床

Objective To compare the simulaion training with traditional training on central venous cathertrization(CVC). Methods Forty emergency residents from a teaching hospital were selected from May 2016 to May2017, and they were randomly assigned into two groups: simulation group (SG) and traditional group(TG). After the training they must completed one CVC and filled in a questionaire. The success rate, puncture time, trail time and complication rate between the two groups were compared. Results There were 18 students on tradional group(TG) and 19 students on simulation group(SG) who completed the whole procedure(complete the procedure in-dependently and filled in the questionaire). The success rate of SG and TG were 73.7％ and 33.3％ respectively (P＜0.05).the lengthen of procedure was (21.3±4.0) min on SG and (31.3±5.9) min on TG, The trail times were (2.1±1.0) on SG and (4.5±1.0) on TG, the complication rate was 16％±37％ on SG and 38％±50％ on TG, compared with TG, the lengthen of procedure on SG was significantly shortened (P＜0.05), the trail times on SG were significantly reduced (P < 0.05) and the complication rate significantly decreased (P <0.05). Conclusions The simulation training significantly improved the success rate of CVC, shortened the lengthen of procedure, decreased the trail times and complication rate. It deserved teaching hospitals to popularize-ing on standardized training for resident physicians.

Sympathetic excitation and dendritic cell activation aggravates myocardial injury in LPS-induced rats / 基础医学与临床

Objective To investigate the effects of sympathetic excitation and dendritic cell activation on myocar-dial injury in LPS-induced rats. Methods The rats were randomly divided into four groups:control group, LPS group ( intraperitoneal injection of LPS 10 mg/kg) ,intervention group ( given beta receptor blocker Ate 5 mg/kg after LPS administration) and DC inhibitor VAG539 intervention group ( VAG539 30 mg/kg gavage twice a day for 2 days after LPS administration) respectively . The powerlab system was used to record the hemodynamic and sympathetic data. The concentration of norepinephrine ( NE) in plasma was measured by high performance liquid chromatography ( HPLC) , and the expression and positive cells of TNF-α and DCs in myocardium were detected by immunohistochemistry. Results Compared with the control group, the plasma NE level significantly increased ( P＜0.05) ;The expression of TNF-α and DCs in heart tissue significantly increased ( P＜0.05) ;the renal sym-pathetic nerve activity (SNA) significantly increased in the three groups after LPS administration for 24 hours. Compared with the LPS group, the plasma NE level significantly decreased ( P＜0.05 ) ; The expression of TNF-α and DCs in heart tissue significantly decreased ( P＜0.05) ;the renal SNA significantly decreased after Ate and VAG539 administration(P＜0.05).Conclusions Excessive activation of sympathetic nervous system and activation of DC aggravate myocardial injury in LPS-induced rats.

Effect of Paroxysmal Atrial Fibrillation on Parameters Monitored by Transpulmonary Thermodilution Method / 中国医学科学院学报

<p><b>OBJECTIVE</b>To investigate the effect of atrial fibrillation on the accuracy of parameters monitored by transpulmonary thermodilution method.</p><p><b>METHODS</b>Totally 12 patients from emergency intensive care unit with paroxysmal atrial fibrillation were enrolled. The hemodynamic parameters such as heart rate, mean arterial pressure, cardiac index, systemic vascular resistance index, intrathoracic blood volume index, and extravascular lung water index were monitored by transpulmonary thermodilution method before paroxysmal atrial fibrillation and during atrial fibrillation, the number of B-lines was detected by lung ultrasonography before and during paroxysmal atrial fibrillation. The changes of all the parameters were analyzed.</p><p><b>RESULTS</b>When the paroxysmal atrial fibrillation happened, the heart rate increased significantly [(123.3±20.0) beat/min vs. (98.9±12.3) beat/min, P=0.006]; the mean arterial pressure [(86.9±10.2) mmHg vs. (93.0±12.5) mmHg, P=0.058], cardiac index [(2.82±0.62) L/(min·m(2)) vs. (3.31±1.02) L/(min·m(2)), P=0.058] and systemic vascular resistance index [(2254±947) dyn·s·cm(-5)·m(2) vs. (2302±828) dyn·s·cm(-5)·m(2), P=0.351] had no obvious change; however, the intrathoracic blood volume index significantly increased [(1333±90) ml/m(2) vs. (937±111) ml/m(2), P<0.001]; extravascular lung water index also increased significantly [(16.1±1.1) ml/kg vs. (6.5±1.9) ml/kg, P<0.001]. No significant difference was found in the number of B-lines detected by lung ultrasonography before and during atrial fibrillation (10.0±4.2 vs. 9.4±4.4, P=0.180).</p><p><b>CONCLUSION</b>Both intrathoracic blood volume and extravascular lung water monitored by transpulmonary thermodilution method were overvalued during paroxysmal atrial fibrillation, which may mislead the clinical judgment and decision-making.</p>

Modified shock index and mortality rate of emergency patients / 世界急诊医学杂志（英文）

BACKGROUND: This study aimed to determine whether modified shock index (MSI) is associated with mortality that is superior to heart rate, blood pressure, or the shock index (SI) in emergency patients.METHODS: A retrospective database review was performed on 22161 patients who presented to Peking Union Medical College Hospital Emergency Department and received intravenous fluids from January 1 to December 31, 2009. We gathered data of the patients on age, gender, vital signs, levels of consciousness, presenting complaints, and SI and MSI were calculated for all patients.RESULTS: Multivariate regression analysis was performed to determine the correlation between risk factors and outcome. There is a significant correlation between emergency patient mortality rate and patient's vital signs obtained at the triage desk (HR>120 beats/min, systolic BP<90 mmHg, diastolic BP<60 mmHg). MSI is a stronger predictor of emergency patient mortality compared to heart rate and blood pressure alone, whereas SI does not have a significant correlation with emergency patient mortality rate.CONCLUSION: MSI is a clinically significant predictor of mortality in emergency patients. It may be better than using heart rate and blood pressure alone. SI is not significantly correlated with the mortality rate of the emergency patient.

Evaluation and treatment of altered mental status patients in the emergency department: Life in the fast lane / 世界急诊医学杂志（英文）

BACKGROUND: Altered mental status (AMS) is a very common emergency case, but the exact etiology of many AMS patients is unknown. Patients often manifest vague symptoms, thus, AMS diagnosis and treatment are highly challenging for emergency physicians. The aim of this study is to provide a framework for the assessment of AMS patients. This assessment should allow providers to better understand the etiology of mental status changes and therefore improve diagnostic skills and management. METHODS: This is a prospective cohort observational study. We recruited all adult patients with undifferentiated AMS at a single center tertiary care academic emergency department over 24 months (June 2009 to June 2011). Demographic characteristics, clinical manifestations, assessment approaches, causative factors, emergency treatments and outcomes were collected prospectively. RESULTS: In 1934 patients with AMS recruited, accounting for 0.93％ of all emergency department (ED) patients, 1026 (53.1％) were male, and 908 (46.9％) female. Their average age was 51.95±15.71 years. Etiologic factors were neurological (n=641; 35.0％), pharmacological and toxicological (n=421; 23.0％), systemic and organic (n=266; 14.5％), infectious (n=167; 9.1％), endocrine/metabolic (n=145; 7.9％), psychiatric (n=71; 3.9％), traumatic (n=38; 2.1％), and gynecologic and obstetric (n=35; 1.9％). Total mortality rate was 8.1％ (n=156). The death rate was higher in elderly patients (≥60) than in younger patients (10.8％ vs. 6.9％,P=0.003). CONCLUSIONS: Patients with AMS pose a challenge for ED physicians. The most frequently encountered diagnostic categories causing AMS were primary CNS disorders, intoxication, organ system dysfunction, and endocrine/metabolic diseases. AMS has a high fatality rate in the ED. AMS is an important warning signal for ED patients because of its potentially fatal and reversible effects. Prompt evaluation and treatment are essential to decreasing morbidity and mortality associated with AMS.

Effects of methylene blue on refractory hemorrhagic shock / 中国医学科学院学报

<p><b>OBJECTIVE</b>To evaluate the effects of methylene blue (MB) on refractory hemorrhagic shock.</p><p><b>METHODS</b>Totally 24 rabbits subjected to prolonged hemorrhagic shock and resuscitation were randomly divided into hemorrhagic shock group (12 rabbits) and MB group (12 rabbits; MB was administered immediately after resuscitation was performed). The plasma levels of tumor necrosis factor alpha (TNFalpha) , interleukin (IL)-6, IL-8, nitric oxide (NO), lactic acid (LA) , and mean arterial pressure (MAP) were detected before shock, immediately after resuscitation, and 0.5, 2, and 4 hours after resuscitation. The 12-hour survival rates were observed.</p><p><b>RESULTS</b>The plasma levels of TNFalpha, IL-6, IL-8, NO and LA after shock were significantly higher than before shock (P <0.01), and maintained at high levels. Compared with the shock group, higher MAP and lower plasma levels of TNFalpha, IL-6, IL-8, NO, and LA were observed in the MB group after resuscitation (P<0.01). The 12-hour survival rates were not significantly different between shock group and MB group.</p><p><b>CONCLUSION</b>Although MB can not improve the prognosis of refractory hemorrhagic shock, it can increase and maintain the MAP and thus play a beneficial role in the treatment of hemorrhagic shock.</p>

Influence of gastrointestinal decontamination on asymptomatic presentation poisoning patients / 中华急诊医学杂志

Objective To know the influence of gastrointestinal decontamination (including gastric lavage and activated charcoal treatment) on prognosis of asymptomatic presentation poisoning patients.Method six hundred and twenty seven asymptomatic presentation poisoning cases through January 1999 to December 2006 were reviewed retrospectively.Duration of ED stay and intubation requiring rate were compared between the intervention group and control group (patients treated only with supportive care),as well as complications associated with gastrointestinal decontamination intervention.Results Statistic analysis reveals no difference between the intervention group and the control group in rate of intubation (6.5 % vs 5.3 %,P=0.51) and emergency care unit admission (28.1% vs 26.6%,P=0.68).Meanwhile duration of ED stay is prolonged profoundly in prevention group [ (11.2?4.7) vs (8.9?5.0),P