ABCD2-I Score Predicts Unplanned Emergency Department Revisits within 72 Hours Due to Recurrent Acute Ischemic Stroke.

BACKGROUND: the ABCD2 score is valuable for predicting early stroke recurrence after a transient ischemic attack (TIA), and Doppler ultrasound can aid in expediting stroke triage. The study aimed to investigate whether combining the ABCD2 score with carotid duplex results can enhance the identification of early acute ischemic stroke after TIA. METHODS: we employed a retrospective cohort design for this study, enrolling patients diagnosed with TIA who were discharged from the emergency department (ED). The modified ABCD2-I (c50) score, which incorporates a Doppler ultrasound assessment of internal carotid artery stenosis > 50%, was used to evaluate the risk of acute ischemic stroke within 72 h. Patients were categorized into three risk groups: low risk (with ABCD2 and ABCD2-I scores = 0-4), moderate risk (ABCD2 score = 4-5 and ABCD2-I score = 5-7), and high risk (ABCD2 score = 6-7 and ABCD2-I score = 8-9). RESULTS: between 1 January 2014, and 31 December 2019, 1124 patients with new neurological deficits were screened, with 151 TIA patients discharged from the ED and included in the analysis. Cox proportional hazards analysis showed that patients in the high-risk group, as per the ABCD2-I (c50) score, were significantly associated with revisiting the ED within 72 h due to acute ischemic stroke (HR: 3.12, 95% CI: 1.31-7.41, p = 0.0102), while the ABCD2 alone did not show significant association (HR: 1.12, 95% CI: 0.57-2.22, p = 0.7427). CONCLUSION: ABCD2-I (c50) scores effectively predict early acute ischemic stroke presentations to the ED within 72 h after TIA.

Early Identification of Sepsis-Induced Acute Kidney Injury by Using Monocyte Distribution Width, Red-Blood-Cell Distribution, and Neutrophil-to-Lymphocyte Ratio.

Sepsis-induced acute kidney injury (AKI) is a common complication in patients with severe illness and leads to increased risks of mortality and chronic kidney disease. We investigated the association between monocyte distribution width (MDW), red-blood-cell volume distribution width (RDW), neutrophil-to-lymphocyte ratio (NLR), sepsis-related organ-failure assessment (SOFA) score, mean arterial pressure (MAP), and other risk factors and sepsis-induced AKI in patients presenting to the emergency department (ED). This retrospective study, spanning 1 January 2020, to 30 November 2020, was conducted at a university-affiliated teaching hospital. Patients meeting the Sepsis-2 consensus criteria upon presentation to our ED were categorized into sepsis-induced AKI and non-AKI groups. Clinical parameters (i.e., initial SOFA score and MAP) and laboratory markers (i.e., MDW, RDW, and NLR) were measured upon ED admission. A logistic regression model was developed, with sepsis-induced AKI as the dependent variable and laboratory parameters as independent variables. Three multivariable logistic regression models were constructed. In Model 1, MDW, initial SOFA score, and MAP exhibited significant associations with sepsis-induced AKI (area under the curve [AUC]: 0.728, 95% confidence interval [CI]: 0.668-0.789). In Model 2, RDW, initial SOFA score, and MAP were significantly correlated with sepsis-induced AKI (AUC: 0.712, 95% CI: 0.651-0.774). In Model 3, NLR, initial SOFA score, and MAP were significantly correlated with sepsis-induced AKI (AUC: 0.719, 95% CI: 0.658-0.780). Our novel models, integrating MDW, RDW, and NLR with initial SOFA score and MAP, can assist with the identification of sepsis-induced AKI among patients with sepsis presenting to the ED.

Efficacy and safety of tirofiban in patients with acute ischemic stroke treated with endovascular thrombectomy: A frequentist and Bayesian meta-analysis.

BACKGROUND: Tirofiban is an antiplatelet treatment approved for acute coronary syndrome, but it has not been rigorously evaluated for efficacy and safety in patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT). METHODS: Electronic databases were systematically searched for studies conducted from January 1, 2015, to July 31, 2021, that evaluated tirofiban administration for patients with AIS treated with EVT in comparison with control. Risk ratios (RRs) and confidence intervals (CIs) were estimated for favorable functional outcomes (FFOs), mortality, and symptomatic intracranial hemorrhage (SICH), each 90 days after AIS. Bayesian hierarchical modeling was performed to obtain posterior RR and its 95% highest posterior density (HPD) for validation. RESULTS: Compared with controls, tirofiban users exhibited increased FFOs (RR, 1.18; 95% CI, 1.08-1.30), decreased mortality (RR, 0.77; 95% CI, 0.64-0.92), and no difference in SICH (RR, 0.97; 95% CI, 0.77-1.23). Tirofiban users in the postbolus infusion subgroup exhibited increased FFOs (RR, 1.20; 95% CI, 1.07-1.35), decreased mortality (RR, 0.71; 95% CI, 0.58-0.88), and no increase in SICH (RR, 0.97; 95% CI, 0.72-1.29). The bolus-only subgroup showed no differences in FFO, mortality, or SICH between the tirofiban and control groups. Consistent results were obtained for posterior density of FFO (posterior RR, 1.20; 95% HPD, 1.06-1.34), mortality (posterior RR, 0.77; 95% HPD, 0.63-0.92), and SICH (posterior RR, 0.98; 95% HPD, 0.71-1.26). CONCLUSION: For patients with AIS treated with EVT, tirofiban improved FFOs, decreased mortality, and did not increase SICH compared with controls; postbolus infusion for administering tirofiban was more favored than the bolus-only regimen.

Thromboembolic Presentations among Patients Hospitalized to the Intensive Care Unit for Coronavirus Disease 2019 (COVID-19) - A Northern Taiwan Single Center Experience.

Coronavirus Disease 2019 (COVID-19) has been associated with a high thromboembolic risk among patients in intensive care units. Asian populations may share a similar thromboembolic risk, but with a higher prevalence of arterial thromboembolism than venous thromboembolism. To clarify this risk in Taiwan, this single-center retrospective study collected 27 consecutive intensive care unit patients with COVID-19 confirmed by polymerase chain reaction, with a median age of 67.6 years (male 81.5%). Twenty-three patients received prophylactic anticoagulation (85.2%), and there were four bleeding events (14.8%). Nine patients had thromboembolism (33.3%), including three with deep vein thrombosis, two with peripheral artery thromboembolism, and four with ischemic stroke. There were no significant clinical differences between the patients with or without thromboembolism. Initial serum ferritin [adjusted odds ratio (OR): 13.19, 95% confidence interval (CI): 1.01-172.07] and peak serum procalcitonin (adjusted OR: 18.93, 95% CI: 1.08-330.91) were associated with a higher risk of thromboembolism. Furthermore, prophylactic anticoagulation (adjusted OR: 0.01, 95% CI: < 0.001-0.55) was associated with a lower risk of thromboembolism. All cases of deep vein thrombosis and one peripheral artery thromboembolism occurred at intravascular catheter locations. No association between thromboembolism and survival was found (age-adjusted hazard ratio: 0.55, 95% CI: 0.10-2.95). In conclusion, the prevalence of COVID-19 thromboembolism among Taiwanese patients in intensive care units was high, even with prophylactic anticoagulation. Serum ferritin and procalcitonin may identify high-risk populations. Prophylactic anticoagulation may reduce the risk of thromboembolism with a manageable bleeding risk. Larger prospective studies are needed to clarify the risk of COVID-19 thromboembolism and its risk factors in the post-Omicron era.

Effects of morphine and P2Y inhibitor amongst patients with acute coronary syndrome: A meta-analysis of comparative studies.

BACKGROUND: P2Y inhibitor and morphine are widely used in caring for patients with the acute coronary syndrome (ACS), but there are some concerns about the combination use due to interaction in metabolism. Therefore, this study aimed to examine whether using morphine with antiplatelets in patients with ACS affects the clinical outcomes based on currently available evidence. METHODS: Three databases were searched for comparative studies on this topic by using relevant keywords of ACS and morphine. Two authors independently extracted study information, mortality, major adverse cardiac event (MACE), major bleeding, and length of hospital stay. Then, they evaluated the quality of evidence independently. Meta-analysis was planned to be conducted in random-effects model. Risk ratio (RR) was used for most outcomes except hospital stay, and Peto odds ratio (POR) was used if there were any zero cells. Pooled estimate was presented with 95% confidence interval (CI). RESULTS: Fourteen studies (n = 73,033) met eligibility criteria, and there was non-significant difference in mortality between antiplatelet with and without morphine (RR = 1.13, 95%CI: 0.78 to 1.64). Antiplatelet therapy without morphine significantly reduced the risk of MACE (RR = 0.78, 95%CI: 0.67 to 0.89; I-square = 0%), but increased the odds of major bleeding (POR = 1.87, 95%CI: 1.04 to 3.35; I-square = 0%) as compared with the combined use of antiplatelet therapy and morphine. CONCLUSION: In conclusion, there is no statistically significant difference in mortality in patients with ACS using morphine or not, but clinicians ought to make a trade-off between a lower risk of MACE and a higher risk of major bleeding before adding morphine to antiplatelet therapy.

A novel scoring system combining Modified Early Warning Score with biomarkers of monocyte distribution width, white blood cell counts, and neutrophil-to-lymphocyte ratio to improve early sepsis prediction in older adults.

OBJECTIVES: This study aims to investigate whether combining scoring systems with monocyte distribution width (MDW) improves early sepsis detection in older adults in the emergency department (ED). METHODS: In this prospective observational study, we enrolled older adults aged ≥60 years who presented with confirmed infectious diseases to the ED. Three scoring systems-namely quick sepsis-related organ failure assessment (qSOFA), Modified Early Warning Score (MEWS), and National Early Warning Score (NEWS), and biomarkers including MDW, neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP), were assessed in the ED. Logistic regression models were used to construct sepsis prediction models. RESULTS: After propensity score matching, we included 522 and 2088 patients with and without sepsis in our analysis from January 1, 2020, to September 30, 2021. NEWS ≥5 and MEWS ≥3 exhibited a moderate-to-high sensitivity and a low specificity for sepsis, whereas qSOFA score ≥2 demonstrated a low sensitivity and a high specificity. When combined with biomarkers, the NEWS-based, the MEWS-based, and the qSOFA-based models exhibited improved diagnostic accuracy for sepsis detection without CRP inclusion (c-statistics=0.842, 0.842, and 0.826, respectively). Of the three models, MEWS ≥3 with white blood cell (WBC) count ≥11 × 109/L, NLR ≥8, and MDW ≥20 demonstrated the highest diagnostic accuracy in all age subgroups (c-statistics=0.886, 0.825, and 0.822 in patients aged 60-74, 75-89, and 90-109 years, respectively). CONCLUSIONS: Our novel scoring system combining MEWS with WBC, NLR, and MDW effectively detected sepsis in older adults.

Effect of ultramarathon running on iron metabolism.

BACKGROUND: Iron is a vital trace element for energy production and oxygen transportation; importantly, it is essential to athletic performance. Maintaining iron balance is tightly controlled at systemic and cellular levels. This study aimed to determine serum iron tests, hepcidin levels, and cellular iron import and export activities in peripheral blood mononuclear cells (PBMCs) in ultramarathon runners to elucidate the association of systemic inflammation response and iron metabolism. METHODS: Sixteen amateur runners were enrolled. Blood samples were taken 1 week before, immediately, and 24 h after the run. Plasma hepcidin levels were measured by enzyme-linked immunosorbent assay. The expression levels of divalent metal iron transporter 1 (DMT1), ZRT/IRT-like protein 14 (ZIP14), transferrin receptor 1 (TfR1), and ferroportin (FPN) in PBMCs were measured using real-time quantitative reverse transcription-polymerase chain reaction. RESULTS: Serum iron concentrations and transferrin saturation significantly decreased immediately after the race and dramatically recovered 24 h post-race. Serum ferritin levels had a statistically significant rise immediately after the race and remained high 24 h after the completion of the race. Ultramarathons were associated with increased plasma interleukin-6 concentrations corresponding to the state of severe systemic inflammation and therefore boosted plasma hepcidin levels. The expression levels of DMT1 and FPN mRNA were markedly decreased immediately and 24 h after the race. The ZIP14 and TfR1 mRNA expression in PBMCs significantly decreased immediately after the race and returned to the baseline level at 24 h post-race. Positive significant correlations were observed between plasma hepcidin and ferritin levels. CONCLUSION: Iron homeostasis and systemic inflammatory response are closely interconnected. Cellular iron import and export mRNA activities in PBMCs were acutely inhibited during an ultramarathon.

Split-hand index for amyotrophic lateral sclerosis diagnosis: A frequentist and Bayesian meta-analysis.

OBJECTIVE: Preferential wasting of the thenar muscles, the split-hand sign, may be used for early diagnosis of amyotrophic lateral sclerosis (ALS). METHODS: Electronic databases were searched for studies assessing the split-hand index (SHI) and the compound muscle action potential (CMAP) amplitudes of abductor pollicis brevis (APB), first dorsal interosseous (FDI), and abductor digiti minimi (ADM). The SHI was obtained by multiplying CMAP amplitudes of APB and FDI and dividing the product by the CMAP amplitude of ADM. The Bayesian analysis was used for validation. RESULTS: In total, 17 studies and 1635 patients were included. Our meta-analysis revealed that ALS patients had significantly decreased SHI (standardized mean difference [SMD], -1.60, P < 0.001), CMAP of the APB (SMD, -1.67, P < 0.001), FDI (SMD, -1.12, P < 0.001), and ADM (SMD, -1.09, P < 0.001). The binormal receiver operating characteristic curve analysis showed a threshold of < 7.4 for SHI, and cutoff values of < 6.4 mV for APB and < 8.4 mV for FDI, respectively. The Bayesian analysis validated decreased SHI in ALS patients (posterior mean difference of - 5.91). CONCLUSIONS: An SHI of < 7.4 can be used facilitating earlier diagnosis of ALS. SIGNIFICANCE: SHI can be used as a standard neurophysiological biomarker for early diagnosis.

Should We Use Hyperbaric Oxygen for Carbon Monoxide Poisoning Management? A Network Meta-Analysis of Randomized Controlled Trials.

Carbon monoxide (CO) poisoning is a public health issue in numerous countries. Oxygen supplementation is the standard and initial management for acute CO poisoning. Normobaric oxygen (NBO) and hyperbaric oxygen (HBO) therapies for CO poisoning have been discussed for several decades. NBO, one-session HBO, two-session HBO, and three-session HBO have not been clearly compared, although there are some syntheses. Therefore, this study aimed to provide an overview of various HBO therapies for CO poisoning. We searched online databases for randomized controlled trials (RCTs) on this topic, and two authors individually extracted data on characteristics, mortality, headache recovery, general fatigue, memory impairment, and difficulty concentrating. Outcomes were pooled using network meta-analysis. We included eight RCTs (n = 1785) that met our eligibility criteria. Pooled estimates showed that HBO had no better outcomes than NBO. Moreover, two-session HBO seemed to have a higher general fatigue rate than NBO, and compared with one-session HBO therapy, it had a higher fatigue rate (risk ratio (RR): 1.29, 95% confidence interval (CI): 1.03-1.62), memory impairment rate (RR = 1.80, 95% CI: 1.01-3.19), and concentration impairment rate (RR = 1.85, 95% CI: 1.19-2.89). HBO may be ineffective for patients with CO poisoning. Therefore, clinicians should consider the available treatment options carefully before recommending HBO to patients.

Effects of acetaminophen and ibuprofen monotherapy in febrile children: a meta-analysis of randomized controlled trials.

Introduction: When a child presents with fever in the clinical encounter, parents are usually concerned about alleviating the fever. However, the indications for selecting an appropriate drug from the most commonly used antipyretic drugs, acetaminophen and ibuprofen, remain unclear. The purpose of this study was to assess the efficacy and safety of acetaminophen and ibuprofen in febrile children through a systematic review with meta-analysis of randomized controlled trials (RCTs). Material and methods: Cochrane, Embase, and PubMed databases were searched for the relevant RCTs. Two authors individually extracted information on trial design, demography, rate of fever resolution, body temperature, and overall adverse events. Data were pooled mainly using a random-effects model; however, because of some sparse data, Peto odds ratios (PORs) were used for outcomes of fever resolution and adverse event. 95% confidence intervals (CIs) were also presented. Results: In total, 26 RCTs (n = 4137) fulfilled eligibility criteria. Pooled estimates demonstrated that acetaminophen led to significantly lower fever resolution rates than ibuprofen did (POR = 0.91, 95% CI: 0.84-0.98; I 2 = 0%) in the subgroup of trials with a mean age of < 2 years. However, the treatment-time interaction model for body temperature demonstrated that the fever resolution effect was mainly from the time factor based on the available data (effect size = -0.20; 95% CI: -0.30 to -0.11; I 2 = 6.9%). Acetaminophen demonstrated lower overall adverse event rates than ibuprofen (POR = 0.71; 95% CI: 0.58-0.87; I 2 = 0%). Conclusions: The effects of ibuprofen are similar to acetaminophen even in children with mean age of approximately 5 years. Nevertheless, acetaminophen is safer than ibuprofen, particularly in children approximately 5 years old.

Monocyte Distribution Width in Children With Systemic Inflammatory Response: Retrospective Cohort Examining Association With Early Sepsis.

OBJECTIVES: To investigate the association between increased monocyte distribution width (MDW) and pediatric sepsis in the emergency department (ED). DESIGN: Retrospective cohort study. SETTING: A single academic hospital study. PATIENTS: Patients from birth to the age of 18 years who presented at the ED of an academic hospital with systemic inflammatory response syndrome (SIRS) were consecutively enrolled. Sepsis was diagnosed using the International Pediatric Surviving Sepsis Campaign criteria. INTERVENTIONS: Antibiotic treatment was administrated once infection was suspected. MEASUREMENTS AND MAIN RESULTS: Routine complete blood cell count, neutrophil-to-lymphocyte ratio (NLR), and MDW, a new inflammatory biomarker, were evaluated in the ED. Logistic regression models were used to explore associations with early pediatric sepsis. We included 201 patients with sepsis and 1,050 without sepsis. In the multivariable model, MDW greater than 23 U (odds ratio [OR], 4.97; 95% CI, 3.42-7.22; p < 0.0001), NLR greater than 6 (OR, 2.06; 95% CI, 1.43-2.94; p = 0.0001), WBC greater than 11,000 cells/µL (OR, 6.52; 95% CI, 4.45-9.53; p < 0.0001), and the SIRS score (OR, 3.42; 95% CI, 2.57-4.55; p < 0.0001) were associated with pediatric sepsis. In subgroup analysis, MDW greater than 23 U remained significantly associated with sepsis for children 6-12 years old (OR, 6.76; 95% CI, 2.60-17.57; p = 0.0001) and 13-18 years (OR, 17.49; 95% CI, 7.69-39.76; p = 0.0001) with an area under the receiver operating curve of 0.8-0.9. CONCLUSIONS: MDW greater than 23 U at presentation is associated with the early diagnosis of sepsis in children greater than or equal to 6 years old. This parameter should be considered as a stratification variable in studies of pediatric sepsis.

Determining Carina and Clavicular Distance-Dependent Positioning of Endotracheal Tube in Critically Ill Patients: An Artificial Intelligence-Based Approach.

Early and accurate prediction of endotracheal tube (ETT) location is pivotal for critically ill patients. Automatic and timely detection of faulty ETT locations from chest X-ray images may avert patients' morbidity and mortality. Therefore, we designed convolutional neural network (CNN)-based algorithms to evaluate ETT position appropriateness relative to four detected key points, including tracheal tube end, carina, and left/right clavicular heads on chest radiographs. We estimated distances from the tube end to tracheal carina and the midpoint of clavicular heads. A DenseNet121 encoder transformed images into embedding features, and a CNN-based decoder generated the probability distributions. Based on four sets of tube-to-carina distance-dependent parameters (i.e., (i) 30-70 mm, (ii) 30-60 mm, (iii) 20-60 mm, and (iv) 20-55 mm), corresponding models were generated, and their accuracy was evaluated through the predicted L1 distance to ground-truth coordinates. Based on tube-to-carina and tube-to-clavicle distances, the highest sensitivity, and specificity of 92.85% and 84.62% respectively, were revealed for 20-55 mm. This implies that tube-to-carina distance between 20 and 55 mm is optimal for an AI-based key point appropriateness detection system and is empirically comparable to physicians' consensus.

Fever, Tachypnea, and Monocyte Distribution Width Predicts Length of Stay for Patients with COVID-19: A Pioneer Study.

(1) Background: Our study investigated whether monocyte distribution width (MDW) could be used in emergency department (ED) settings as a predictor of prolonged length of stay (LOS) for patients with COVID-19. (2) Methods: A retrospective cohort study was conducted; patients presenting to the ED of an academic hospital with confirmed COVID-19 were enrolled. Multivariable logistic regression models were used to obtain the odds ratios (ORs) for predictors of an LOS of >14 days. A validation study for the association between MDW and cycle of threshold (Ct) value was performed. (3) Results: Fever > 38 °C (OR: 2.82, 95% CI, 1.13−7.02, p = 0.0259), tachypnea (OR: 4.76, 95% CI, 1.67−13.55, p = 0.0034), and MDW ≥ 21 (OR: 5.67, 95% CI, 1.19−27.10, p = 0.0269) were robust significant predictors of an LOS of >14 days. We developed a new scoring system in which patients were assigned 1 point for fever > 38 °C, 2 points for tachypnea > 20 breath/min, and 3 points for MDW ≥ 21. The optimal cutoff was a score of ≥2. MDW was negatively associated with Ct value (ß: −0.32 per day, standard error = 0.12, p = 0.0099). (4) Conclusions: Elevated MDW was associated with a prolonged LOS.

Diagnostic test accuracy of pretreatment collateral score in predicting stroke outcomes after intra-arterial endovascular thrombectomy: a meta-analysis in DSA and CTA.

OBJECTIVES: This study compared the diagnostic accuracy of pretreatment circulation collateral scoring (CS) system using digital subtraction angiography (DSA) and computed tomography angiography (CTA) in predicting favorable functional outcome (FFO) after intra-arterial endovascular thrombectomy (IA-EVT). Subgroup analysis characterizing scoring systems within each category was additionally conducted. MATERIALS AND METHODS: We performed a diagnostic meta-analysis to assess the sensitivity and specificity of each CS system by using DSA and CTA, respectively. The hierarchical summary receiver operating characteristic curve (HSROC) models were used to estimate the diagnostic odds ratio (DOR) and area under the curve (AUC). The Bayes theorem was employed to determine posttest probability (PTP). RESULTS: In total, 14 and 21 studies were assessed with DSA and CTA, respectively. In DSA, the pooled sensitivity and specificity were 0.72 (95% CI, 0.63-0.79) and 0.61 (0.53-0.68), respectively, and in the HSROC model, the DOR was 3.94 (2.71-5.73), and the AUC was 0.71 (90.67-0.75). CTA revealed a pooled sensitivity and specificity of 0.74 (0.64-0.82) and 0.53 (0.44-0.62), respectively, and in the HSROC model, the DOR was 3.17 (2.34-4.50), and the AUC was 0.67 (0.63-0.71). With a pretest probability of 26.3%, the CS in DSA and CTA exhibited limited increase of PTPs of 39% and 36%, respectively, in detecting the FFO on day 90. CONCLUSION: DSA and CTA have comparable accuracy and are limited in predicting the functional outcome. The collateral score systems assessed with DSA and CTA were more suitable for screening than diagnosis for patients before IA-EVT. KEY POINTS: • Our study revealed the differences of various scoring systems for assessing collateral status. • DSA and CTA have comparable accuracy, but both imaging modalities played relatively limited roles in predicting functional outcome on day 90. • The collateral score systems assessed with DSA and CTA were more suitable for screening than diagnosis for patients before IA-EVT.

Monocyte Distribution Width, Neutrophil-to-Lymphocyte Ratio, and Platelet-to-Lymphocyte Ratio Improves Early Prediction for Sepsis at the Emergency.

(1) Background: Sepsis is a life-threatening condition, and most patients with sepsis first present to the emergency department (ED) where early identification of sepsis is challenging due to the unavailability of an effective diagnostic model. (2) Methods: In this retrospective study, patients aged ≥20 years who presented to the ED of an academic hospital with systemic inflammatory response syndrome (SIRS) were included. The SIRS, sequential organ failure assessment (SOFA), and quick SOFA (qSOFA) scores were obtained for all patients. Routine complete blood cell testing in conjugation with the examination of new inflammatory biomarkers, namely monocyte distribution width (MDW), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR), was performed at the ED. Propensity score matching was performed between patients with and without sepsis. Logistic regression was used for constructing models for early sepsis prediction. (3) Results: We included 296 patients with sepsis and 1184 without sepsis. A SIRS score of >2, a SOFA score of >2, and a qSOFA score of >1 showed low sensitivity, moderate specificity, and limited diagnostic accuracy for predicting early sepsis infection (c-statistics of 0.660, 0.576, and 0.536, respectively). MDW > 20, PLR > 9, and PLR > 210 showed higher sensitivity and moderate specificity. When we combined these biomarkers and scoring systems, we observed a significant improvement in diagnostic performance (c-statistics of 0.796 for a SIRS score of >2, 0.761 for a SOFA score of >2, and 0.757 for a qSOFA score of >1); (4) Conclusions: The new biomarkers MDW, NLR, and PLR can be used for the early detection of sepsis in the current sepsis scoring systems.

Expression of ABC transporter and scavenger receptor mRNAs in PBMCs in 100-km ultramarathon runners.

BACKGROUND: Cholesterol metabolism is tightly regulated at the cellular level. This study was to measure the expression levels of ATP-binding cassette transporter A1 (ABCA1) and G1 (ABCG1), scavenger receptor class B type I (SR-BI) and class A (SRA), and CD36 mRNAs in peripheral blood mononuclear cells (PBMCs) in response to 100-km ultramarathon event and determine any correlation between these ABC transporters/scavenger receptor expression levels and plasma cholesterol homeostasis. MATERIALS AND METHODS: Twenty-six participants were enrolled. Blood was drawn from each individual 1 week prior, immediately after, and 24 hours after the race. The expression levels of ABCA1, ABCG1, SR-BI, SRA and CD36 in PBMCs were measured by using real-time quantitative reverse transcription polymerase chain reaction. RESULTS: Plasma triglyceride levels were significantly increased immediately after the race and dropped at 24-hour post-race compared with pre-race values. The 100-km ultramarathon boosted high-density lipoprotein cholesterol (HDL-C) levels and decreased low-density lipoprotein cholesterol (LDL-C) levels 24-hour post-race. The expression levels of ABCA1, ABCG1 and SR-BI were markedly decreased, whereas that of CD36 was slightly but significantly upregulated in runners' PBMCs immediately after the race. Ultramarathon resulted in immediate large-scale stimulation of inflammatory cytokines with increased plasma interleukin-6 and tumour necrosis factor-alpha levels. Moreover, by using in vitro models with human monocytic cell lines, incubation of runners' plasma immediately after the race significantly downregulated ABCA1 and ABCG1, and upregulated CD36 expression in these cells. CONCLUSIONS: ABCA1, ABCG1 and CD36 gene expressions in PBMCS might be associated with endurance exercise-induced plasma cholesterol homeostasis and systemic inflammatory response.

Tranexamic acid for gastrointestinal bleeding: A systematic review with meta-analysis of randomized clinical trials.

BACKGROUND: Acute gastrointestinal bleeding is a common life-threatening emergent condition. Immediate tranexamic acid is useful for reducing hemorrhage following operation and bleeding trauma, but evidence on the effects of tranexamic acid in patients with gastrointestinal bleeding is limited or highly heterogeneous. It is still unclear about using tranexamic acid in the emergent condition of gastrointestinal bleeding. This study, therefore, aimed to determine whether or not tranexamic acid should be used in gastrointestinal bleeding management through systematic review and meta-analysis. METHODS: We searched three biomedical databases for relevant randomized controlled trials on this topic. Two authors independently selected studies and extracted data for bias assessment and meta-analysis of bleeding, further intervention, mortality, transfusion, and intensive care unit admission. Available data were pooled using a random-effects model, and the results were presented as risk ratios (RRs) with 95% confidence intervals (CIs). Heterogeneity and small study effects were also assessed. RESULTS: Thirteen randomized controlled trials (n = 2271) were included in the present synthesis. Our meta-analysis revealed that tranexamic acid significantly reduced the rates of continued bleeding (RR = 0.60; 95%CI, 0.43-0.84), urgent endoscopic intervention (RR = 0.35; 95%CI, 0.24-0.50), and mortality (RR = 0.60; 95%CI, 0.45-0.80) compared with the placebo. CONCLUSION: According to the available evidence, the present synthesis confirms that tranexamic acid is an effective medication for patients with upper gastrointestinal bleeding. Early administration of tranexamic acid may be worth to be recommended for treating upper gastrointestinal bleeding in the emergency department. However, the effects of tranexamic acid on lower gastrointestinal bleeding warrant further clarification.

Efficacy of gabexate mesilate in preventing post endoscopic retrograde cholangiopancreatography pancreatitis: A meta-analysis of randomized clinical trials.

BACKGROUND/PURPOSE: The evidence provided by syntheses of the preventative effects of gabexate mesilate against pancreatitis among patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) is limited and highly heterogeneous. To enhance the understanding of this topic, this study aimed to provide overview of gabexate mesilate on preventing post ERCP pancreatitis (PEP) by synthesizing all relevant randomized controlled trials (RCTs). METHODS: We searched three databases for relevant RCTs. Two authors independently extracted data of pancreatitis incidence after ERCP, abdominal pain within 48 hours, and hyperamylasemia for quality assessment and meta-analysis. RESULTS: Thirteen RCTs with 3718 patients undergoing ERCP met the eligibility criteria and were included. The results revealed that the use of gabexate mesilate led to lower PEP (Peto odds ratio: 0.66, 95% confidence interval [CI]: 0.49 to 0.89), especially in the subgroup of gabexate mesilate infusion starting more than 30 min (Risk ratio: 0.45, 95% CI: 0.29 to 0.72). CONCLUSION: The present synthesis found that gabexate mesilate could be an option of prophylactic treatment of pancreatitis for patients undergoing ERCP, and reveals that it is favorable to administer it starting 30 min before the ERCP. This evidence may improve the clinical prevention of PEP.

Clinical impact of monocyte distribution width and neutrophil-to-lymphocyte ratio for distinguishing COVID-19 and influenza from other upper respiratory tract infections: A pilot study.

The coronavirus disease 2019 (COVID-19) has become a pandemic. Rapidly distinguishing COVID-19 from other respiratory infections is a challenge for first-line health care providers. This retrospective study was conducted at the Taipei Medical University Hospital, Taiwan. Patients who visited the outdoor epidemic prevention screening station for respiratory infection from February 19 to April 30, 2020, were evaluated for blood biomarkers to distinguish COVID-19 from other respiratory infections. Monocyte distribution width (MDW) ≥ 20 (odds ratio [OR]: 8.39, p = 0.0110, area under curve [AUC]: 0.703) and neutrophil-to-lymphocyte ratio (NLR) < 3.2 (OR: 4.23, p = 0.0494, AUC: 0.673) could independently distinguish COVID-19 from common upper respiratory tract infections (URIs). Combining MDW ≥ 20 and NLR < 3.2 was more efficient in identifying COVID-19 (AUC: 0.840). Moreover, MDW ≥ 20 and NLR > 5 effectively identified influenza infection (AUC: 0.7055). Thus, MDW and NLR can distinguish COVID-19 from influenza and URIs.

Measurement of resilience potential - development of a resilience assessment grid for emergency departments.

BACKGROUND: Resilience engineering has been advocated as an alternative to the management of safety over the last decade in many domains. However, to facilitate metrics for measuring and helping analyze the resilience potential for emergency departments (EDs) remains a significant challenge. The study aims to redesign the Hollnagel's resilience assessment grid (RAG) into a custom-made RAG (ED-RAG) to support resilience management in EDs. METHODS: The study approach had three parts: 1) translation of Hollnagel's RAG into Chinese version, followed by generation of a tailored set of ED-RAG questions adapted to EDs; 2) testing and revising the tailored sets until to achieve satisfactory validity for application; 3) design of a new rating scale and scoring method. The test criteria of the ED-RAG questionnaire adopted the modified three-level scoring criteria proposed by Bloom and Fischer. The study setting of the field test is a private regional hospital. RESULTS: The fifth version of ED-RAG was acceptable after a field test. It has three sets of open structured questions for the potentials to respond, monitor, and anticipate, and a set of structured questions for the potential to learn. It contained 38 questions corresponding to 32 foci. A new 4-level rating scale along with a novel scaling method can improve the scores conversion validity and communication between team members and across investigations. This final version is set to complete an interview for around 2 hours. CONCLUSIONS: The ED-RAG represents a snapshot of EDs'resilience under specific conditions. It might be performed multiple times by a single hospital to monitor the directions and contents of improvement that can supplement conventional safety management toward resilience. Some considerations are required to be successful when hospitals use it. Future studies to overcome the potential methodological weaknesses of the ED-RAG are needed.