A Clinical Practice Guideline for the Emergency Management of Anaphylaxis (2020).

Background: For anaphylaxis, a life-threatening allergic reaction, the incidence rate was presented to have increased from the beginning of the 21st century. Underdiagnosis and undertreatment of anaphylaxis are public health concerns. Objective: This guideline aimed to provide high-quality and evidence-based recommendations for the emergency management of anaphylaxis. Method: The panel of health professionals from fifteen medical areas selected twenty-five clinical questions and formulated the recommendations with the supervision of four methodologists. We collected evidence by conducting systematic literature retrieval and using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Results: This guideline made twenty-five recommendations that covered the diagnosis, preparation, emergency treatment, and post-emergency management of anaphylaxis. We recommended the use of a set of adapted diagnostic criteria from the American National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network (NIAID/FAAN), and developed a severity grading system that classified anaphylaxis into four grades. We recommended epinephrine as the first-line treatment, with specific doses and routes of administration for different severity of anaphylaxis or different conditions. Proper dosage is critical in the administration of epinephrine, and the monitor is important in the IV administration. Though there was only very low or low-quality evidence supported the use of glucocorticoids and H1 antagonists, we still weakly recommended them as second-line medications. We could not make a well-directed recommendation regarding premedication for preventing anaphylaxis since it is difficult to weigh the concerns and potential effects. Conclusion: For the emergency management of anaphylaxis we conclude that: • NIAID/FAAN diagnostic criteria and the four-tier grading system should be used for the diagnosis • Prompt and proper administration of epinephrine is critical.

Pulse oximetry waveform: A non-invasive physiological predictor for the return of spontaneous circulation in cardiac arrest patients ---- A multicenter, prospective observational study.

OBJECTIVE: This study aimed to investigate the predictive value of pulse oximetry plethysmography (POP) for the return of spontaneous circulation (ROSC) in cardiac arrest (CA) patients. METHODS: This was a multicenter, observational, prospective cohort study of patients hospitalized with cardiac arrest at 14 teaching hospitals cross China from December 2013 through November 2014. The study endpoint was ROSC, defined as the restoration of a palpable pulse and an autonomous cardiac rhythm lasting for at least 20 minutes after the completion or cessation of CPR. RESULTS: 150 out-of-hospital cardiac arrest (OHCA) patients and 291 in-hospital cardiac arrest (IHCA) patients were enrolled prospectively. ROSC was achieved in 20 (13.3%) and 64 (22.0%) patients in these cohorts, respectively. In patients with complete end-tidal carbon dioxide (ETCO2) and POP data, patients with ROSC had significantly higher levels of POP area under the curve (AUCp), wave amplitude (Amp) and ETCO2 level during CPR than those without ROSC (all p < 0.05). Pairwise comparison of receiver operating characteristic (ROC) curve analysis indicated no significant difference was observed between ETCO2 and Amp (p = 0.204) or AUCp (p = 0.588) during the first two minutes of resuscitation. CONCLUSION: POP may be a novel and effective method for predicting ROSC during resuscitation, with a prognostic value similar to ETCO2 at early stage.

Long-term outcomes and independent predictors of mortality in patients presenting to emergency departments with acute heart failure in Beijing: a multicenter cohort study with a 5-year follow-up.

BACKGROUND: Acute heart failure (AHF) is the most common disease in emergency departments (EDs). However, clinical data exploring the outcomes of patients presenting AHF in EDs are limited, especially the long-term outcomes. The purposes of this study were to describe the long-term outcomes of patients with AHF in the EDs and further analyze their prognostic factors. METHODS: This prospective, multicenter, cohort study consecutively enrolled 3335 patients with AHF who were admitted to EDs of 14 hospitals from Beijing between January 1, 2011 and September 23, 2012. Kaplan-Meier and Cox regression analysis were adopted to evaluate 5-year outcomes and associated predictors. RESULTS: The 5-year mortality and cardiovascular death rates were 55.4% and 49.6%, respectively. The median overall survival was 34 months. Independent predictors of 5-year mortality were patient age (hazard ratio [HR]: 1.027, 95 confidence interval [CI]: 1.023-1.030), body mass index (BMI) (HR: 0.971, 95% CI: 0.958-0.983), fatigue (HR: 1.127, 95% CI: 1.009-1.258), ascites (HR: 1.190, 95% CI: 1.057-1.340), hepatic jugular reflux (HR: 1.339, 95% CI: 1.140-1.572), New York Heart Association (NYHA) class III to IV (HR: 1.511, 95% CI: 1.291-1.769), heart rate (HR: 1.003, 95% CI: 1.001-1.005), diastolic blood pressure (DBP) (HR: 0.996, 95% CI: 0.993-0.999), blood urea nitrogen (BUN) (HR: 1.014, 95% CI: 1.008-1.020), B-type natriuretic peptide (BNP)/N-terminal pro-B-type natriuretic peptide (NT-proBNP) level in the third (HR: 1.426, 95% CI: 1.220-1.668) or fourth quartile (HR: 1.437, 95% CI: 1.223-1.690), serum sodium (HR: 0.980, 95% CI: 0.972-0.988), serum albumin (HR: 0.981, 95% CI: 0.971-0.992), ischemic heart diseases (HR: 1.195, 95% CI: 1.073-1.331), primary cardiomyopathy (HR: 1.382, 95% CI: 1.183-1.614), diabetes (HR: 1.118, 95% CI: 1.010-1.237), stroke (HR: 1.252, 95% CI: 1.121-1.397), and the use of diuretics (HR: 0.714, 95% CI: 0.626-0.814), ß-blockers (HR: 0.673, 95% CI: 0.588-0.769), angiotensin-converting enzyme inhibitors (ACEIs) (HR: 0.714, 95% CI: 0.604-0.845), angiotensin-II receptor blockers (ARBs) (HR: 0.790, 95% CI: 0.646-0.965), spironolactone (HR: 0.814, 95% CI: 0.663-0.999), calcium antagonists (HR: 0.624, 95% CI: 0.531-0.733), nitrates (HR: 0.715, 95% CI: 0.631-0.811), and digoxin (HR: 0.579, 95% CI: 0.465-0.721). CONCLUSIONS: The results of our study demonstrate poor 5-year outcomes of patients presenting to EDs with AHF. Age, BMI, fatigue, ascites, hepatic jugular reflux, NYHA class III to IV, heart rate, DBP, BUN, BNP/NT-proBNP level in the third or fourth quartile, serum sodium, serum albumin, ischemic heart diseases, primary cardiomyopathy, diabetes, stroke, and the use of diuretics, ß-blockers, ACEIs, ARBs, spironolactone, calcium antagonists, nitrates, and digoxin were independently associated with 5-year all-cause mortality.

Comparison of intraosseous access and central venous catheterization in Chinese adult emergency patients: A prospective, multicenter, and randomized study.

BACKGROUND: It is challenging to establish peripheral intravenous access in adult critically patients. This study aims to compare the success rate of the first attempt, procedure time, operator satisfaction with the used devices, pain score, and complications between intraosseous (IO) access and central venous catheterization (CVC) in critically ill Chinese patients. METHODS: In this prospective clustered randomized controlled trial, eight hospitals were randomly divided into either the IO group or the CVC group. Patients who needed emergency vascular access were included. From April 1, 2017 to December 31, 2018, each center included 12 patients. We recorded the data mentioned above. RESULTS: A total of 96 patients were enrolled in the study. There were no statistically significant differences between the two groups regarding sex, age, body mass index, or operator satisfaction with the used devices. The success rates of the first attempt and the procedure time were statistically significant between the IO group and the CVC group (91.7% vs. 50.0%, P<0.001; 52.0 seconds vs. 900.0 seconds, P<0.001). During the study, 32 patients were conscious. There was no statistically significant difference between the two groups regarding the pain score associated with insertion. There were statistically significant differences between the two groups regarding the pain score associated with IO or CVC infusion (1.5 vs. 0.0, P=0.044). Complications were not observed in the two groups. CONCLUSIONS: IO access is a safe, rapid, and effective technique for gaining vascular access in critically ill adults with inaccessible peripheral veins in the emergency departments.

Association between anemia and outcome in patients hospitalized for acute heart failure syndromes: findings from Beijing Acute Heart Failure Registry (Beijing AHF Registry).

Whether the anemia increases the risk of mortality in patients with acute heart failure (AHF) remains unclear. This study aims to explore the relationship between anemia and outcomes in patients with AHF including subgroup analysis. This study included 3279 patients with hemoglobin available from the Beijing Acute Heart Failure Registry (Beijing AHF Registry) study. The primary endpoint was all-cause mortality in 1 year, and the secondary endpoint was 1-year all-cause events including all-cause death and readmission. Logistic regression models were applied to describe related variables of anemia in patients with AHF. Multivariate Cox proportional hazards models described associations of anemia with clinical outcomes in the overall cohort and subgroups. 45.4% of the patients were found anemic. They were older and had more comorbidities than non-anemic patients. Variables including older age, female, chronic kidney dysfunction (CKD), lower hematocrit, lower albumin, with loop diuretics applied, without beta-blockers, angiotensin-converting enzyme inhibitors /angiotensin receptor blockers (ACEIs/ARBs) and spironolactone applied in the emergency department (ED) were associated with anemia in AHF patients. Anemic patients had higher 1-year mortality (38.4% vs. 27.2%, p < 0.0001) and 1-year events rates (63.2% vs. 56.7%, p < 0.0001). After adjusted for covariates, anemia was associated with the increase of 1-year mortality (hazard ratio [HR] 1.278; 95% confidence interval [CI] 1.114-1.465; p = 0.0005) and 1-year events (HR 1.136; 95% CI 1.025-1.259; p = 0.0154). The severer anemia patients had higher risks both of 1-year mortality and events. In the subgroup analysis, the independent associations of anemia with 1-year mortality were shown in the subgroups including age < 75 years, male, body mass index < 25 kg/m2 and BMI ≥ 25 kg/m2, New York Heart Association (NYHA) functional class I-II and NYHA functional class III-IV, with and without cardiovascular ischemia, heart rate (HR) < 100 bpm and HR ≥ 100 bpm, systolic blood pressure (SBP) < 120 mmHg and SBP ≥ 120 mmHg, left ventricular ejection fraction (LVEF) < 40% and LVEF ≥ 40%, serum creatinine (Scr) < 133 umol/l, and with diuretics use, with and without beta-blockers use, without ACEIs/ARBs use in the ED. Anemia is associated with older age, female, CKD, volume overload, malnutrition, with loop diuretics, without beta-blockers, ACEIs/ARBs and spironolactone administration, and higher mortality and readmission in AHF. The risk associations are particular significantly obvious in younger, male, overweight, preserved LVEF, lower Scr, with diuretics and beta-blockers, without ACEIs/ARBs administration subgroups.Clinical trial No. ChiCTR-RIC-17014222.

Febrile Hashimoto's encephalopathy associated with Graves' disease and acute pancytopenia: A case report.

RATIONALE: Hashimoto's encephalopathy (HE) is an autoimmune-mediated encephalopathy rarely seen in Graves' disease, with <20 cases reported previously, associated with elevated concentration of circulating serum anti-thyroid antibodies usually responsive to steroid therapy. PATIENT CONCERNS: We present a HE case (25-year-old male) with Graves' disease, complicated by fever and pancytopenia. The patient presented with fever, gait impairment, delirium, agitation and disorientation. DIAGNOSES: Thyroid-related antibodies were elevated and brain magnetic resonance imaging confirmed symmetrical white-matter lesion. There was no evidence of infection or other reasons to explain all of his clinical manifestations. Hashimoto's encephalopathy (HE) is an autoimmune encephalopathy with various manifestations and the characteristic of elevated anti-thyroid antibodies and has no relationship to thyroid function. INTERVENTIONS: The patient had nonspecific clinical manifestations and excellently respond to glucocorticoid therapy.The symptoms and the radiographic abnormalities disappeared after glucocorticoid therapy. OUTCOMES: We followed up with him for 5 years, in which there was no recurrence and his thyroid function continued to be normal. LESSONS: It is important to evaluate thyroid function and related antibodies in patients present with neuropsychological symptoms to avoid delay in diagnosis.

Predictors of survival and neurologic outcome for adults with extracorporeal cardiopulmonary resuscitation: A systemic review and meta-analysis.

BACKGROUND: This systemic review aimed to explore the predictors of discharge and neurologic outcome of adult extracorporeal cardiopulmonary resuscitation (ECPR) to provide references for patient selection. METHODS: Electronically searching of the Pubmed, Embase, Cochrane Library, and manual retrieval were done for clinical trials about predictors for adult ECPR which were published between January 2000 and January 2018 and included predictors for discharge and neurologic outcome. The literature was screened according to inclusion and exclusion criteria, the baseline information and interested outcomes were extracted. Two reviewers assessed the methodologic quality of the included studies and the quality of evidence for summary estimates independently. Pooled mean difference (MD) or odds ratio (OR) and 95% confidence interval (CI) were calculated by Review Manager Software 5.3. At last the quality of evidence for summary estimates was appraised according to Grading of Recommendations Assessment, Development, and Evaluation rating system. RESULTS: In 16 studies, 1162 patients were enrolled. Out-of-hospital cardiac arrest (CA) (OR 0.58, 95% CI 0.36-0.93, P = .02), in-hospital CA (OR 1.73, 95% CI 1.08-2.77, P = .02), witnessed CA (OR 5.2, 95% CI 1.18-22.88, P = .01), bystander cardiopulmonary resuscitation (CPR) (OR 7.35, 95% CI 2.32-23.25, P < .01), initial shockable rhythm (OR 2.29, 95% CI 1.53-3.42, P < .01), 1st recorded nonshockable rhythm (OR 0.44, 95% CI 0.29-0.66, P < .01), CPR duration (MD -13.84 minutes, 95% CI -21 to -6.69, P < .0001), arrest-to-extracorporeal membrane oxygenation (ECMO) (MD -17.88 minutes, 95% CI -23.59 to -12.17, P < .01), PH (MD 0.14, 95% CI 0.08-0.21, P < .01), lactate (MD -3.66 mmol/L, 95% CI -7.15 to -0.17, P = .04), and percutaneous coronary intervention (PCI) (OR 1.63, 95% CI 1.02-2.58, P = .04)were identified as the survival predictors of ECPR. Shockable rhythm (OR 2.33, 95% CI 1.20-4.52, P = .01) and CPR duration (MD -9.85 minutes, 95% CI -15.71 to -3.99, P = .001) were identified as the neurologic outcome predictors of ECPR. CONCLUSION: Current evidence showed that in-hospital CA, witnessed CA, bystander CPR, initial shockable rhythm, shorter CPR duration and arrest-to-ECMO duration, higher baseline PH, lower baseline lactate and PCI were favourable survival predictors of adult ECPR, and shockable rhythm and shorter CPR duration were good neurological outcome predictors of adult ECPR.

Impact of body mass index on survival of medical patients with sepsis: a prospective cohort study in a university hospital in China.

OBJECTIVE: To evaluate the impact of body mass index (BMI) on survival of a Chinese cohort of medical patients with sepsis. DESIGN: A single-centre prospective cohort study conducted from May 2015 to April 2017. SETTING: A tertiary care university hospital in China. PARTICIPANTS: A total of 178 patients with sepsis admitted to the medical intensive care unit (ICU) were included. MAIN OUTCOME MEASURES: The primary outcome was 90-day mortality while the secondary outcomes were in-hospital mortality, length of ICU stay and length of hospital stay. RESULTS: The median age (IQR) was 78 (66-84) years old, and 77.0% patients were older than 65 years. The 90-day mortality was 47.2%. The in-hospital mortality was 41.6%, and the length of ICU stay and hospital stay were 12 (5-22) and 15 (9-28) days, respectively. Cox proportional hazard regression analysis identified that Sequential Organ Failure Assessment score (HR=1.229, p<0.001), Acute Physiology and Chronic Health Evaluation II score (HR=1.050, p<0.001) and BMI (HR=0.940, p=0.029) were all independently associated with the 90-day mortality. Patients were divided into four groups based on BMI (underweight 33 (18.5%), normal 98 (55.1%), overweight 36 (20.2%) and obese 11 (6.2%)). The 90-day mortality (66.7%, 48.0%, 36.1% and 18.2%, p=0.015) and in-hospital mortality (60.6%, 41.8%, 30.6% and 18.2%, p=0.027) were statistically different among the four groups. Differences in survival among the four groups were demonstrated by Kaplan-Meier survival analysis (p=0.008), with the underweight patients showing a lower survival rate. CONCLUSIONS: BMI was an independent factor associated with 90-day survival in a Chinese cohort of medical patients with sepsis, with patients having a lower BMI at a higher risk of death.

Characteristics, Management, and Outcomes of Acute Heart Failure in the Emergency Department: A Multicenter Registry Study with 1-year Follow-up in a Chinese Cohort in Beijing.

BACKGROUND: The emergency department (ED) has a pivotal influence on the management of acute heart failure (AHF), but data concerning current ED management are scarce. This Beijing AHF Registry Study investigated the characteristics, ED management, and short- and long-term clinical outcomes of AHF. METHODS: This prospective, multicenter, observational study consecutively enrolled 3335 AHF patients who visited 14 EDs in Beijing from January 1, 2011, to September 23, 2012. Baseline data on characteristics and management were collected in the EDs. Follow-up data on death and readmissions were collected until November 31, 2013, with a response rate of 92.80%. The data were reported as median (interquartile range) for the continuous variables, or as number (percentage) for the categorical variables. RESULTS: The median age of the enrolled patients was 71 (58-79) years, and 46.84% were women. In patients with AHF, coronary heart disease (43.27%) was the most common etiology, and myocardium ischemia (30.22%) was the main precipitant. Most of the patients in the ED received intravenous treatments, including diuretics (79.28%) and vasodilators (74.90%). Fewer patients in the ED received neurohormonal antagonists, and 25.94%, 31.12%, and 33.73% of patients received angiotensin converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, and spironolactone, respectively. The proportions of patients who were admitted, discharged, left against medical advice, and died were 55.53%, 33.58%, 7.08%, and 3.81%, respectively. All-cause mortalities at 30 days and 1 year were 15.30% and 32.27%, respectively. CONCLUSIONS: Substantial details on characteristics and ED management of AHF were investigated. The clinical outcomes of AHF patients were dismal. Thus, further investigations of ED-based therapeutic approaches for AHF are needed.

Performance of Simplified Acute Physiology Score 3 In Predicting Hospital Mortality In Emergency Intensive Care Unit.

BACKGROUND: Since the 1980s, severity of illness scoring systems has gained increasing popularity in Intensive Care Units (ICUs). Physicians used them for predicting mortality and assessing illness severity in clinical trials. The objective of this study was to assess the performance of Simplified Acute Physiology Score 3 (SAPS 3) and its customized equation for Australasia (Australasia SAPS 3, SAPS 3 [AUS]) in predicting clinical prognosis and hospital mortality in emergency ICU (EICU). METHODS: A retrospective analysis of the EICU including 463 patients was conducted between January 2013 and December 2015 in the EICU of Peking University Third Hospital. The worst physiological data of enrolled patients were collected within 24 h after admission to calculate SAPS 3 score and predicted mortality by regression equation. Discrimination between survivals and deaths was assessed by the area under the receiver operator characteristic curve (AUC). Calibration was evaluated by Hosmer-Lemeshow goodness-of-fit test through calculating the ratio of observed-to-expected numbers of deaths which is known as the standardized mortality ratio (SMR). RESULTS: A total of 463 patients were enrolled in the study, and the observed hospital mortality was 26.1% (121/463). The patients enrolled were divided into survivors and nonsurvivors. Age, SAPS 3 score, Acute Physiology and Chronic Health Evaluation Score II (APACHE II), and predicted mortality were significantly higher in nonsurvivors than survivors (P < 0.05 or P < 0.01). The AUC (95% confidence intervals [CI s]) for SAPS 3 score was 0.836 (0.796-0.876). The maximum of Youden's index, cutoff, sensitivity, and specificity of SAPS 3 score were 0.526%, 70.5 points, 66.9%, and 85.7%, respectively. The Hosmer-Lemeshow goodness-of-fit test for SAPS 3 demonstrated a Chi-square test score of 10.25, P = 0.33, SMR (95% CI) = 0.63 (0.52-0.76). The Hosmer-Lemeshow goodness-of-fit test for SAPS 3 (AUS) demonstrated a Chi-square test score of 9.55, P = 0.38, SMR (95% CI) = 0.68 (0.57-0.81). Univariate and multivariate analyses were conducted for biochemical variables that were probably correlated to prognosis. Eventually, blood urea nitrogen (BUN), albumin,lactate and free triiodothyronine (FT3) were selected as independent risk factors for predicting prognosis. CONCLUSIONS: The SAPS 3 score system exhibited satisfactory performance even superior to APACHE II in discrimination. In predicting hospital mortality, SAPS 3 did not exhibit good calibration and overestimated hospital mortality, which demonstrated that SAPS 3 needs improvement in the future.

[Bacteriology in acute exacerbation in patients hospitalized frequently for acute exacerbation of chronic obstructive pulmonary disease].

OBJECTIVE: To analyze the distribution of pathogens and bacterial drug resistance for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in patients hospitalized frequently for AECOPD versus those with infrequent admissions. METHODS: A total of 172 patients admitted into Peking University Third Hospital for AECOPD from January 2007 to December 2008 were recruited. According to the frequency of AECOPD-related hospitalization during the previous year, they were divided into two groups of frequently hospitalized ( ≥ 2 hospitalizations due to AECOPD during the previous year) and infrequently hospitalized (<2 hospitalizations due to AECOPD during the previous year). The distribution and drug resistance of pathogenic bacteria were compared between two groups. RESULTS: At the time of acute exacerbation, the frequently hospitalized patients had significantly higher rates of non-fermentative gram-negative bacteria (18.8% (9/48) vs 4.8% (6/124), χ² = 6.756, P = 0.009), enterobacteriaceae (18.8% (9/48) vs 7.3% (9/124), χ² = 4.877, P = 0.027) versus those infrequently hospitalized ones. The frequently hospitalized patients had more multidrug resistant bacteria isolated from sputum versus those infrequently hospitalized ones (25.0% (12/48) than 8.1% (10/124), χ² = 8.898, P = 0.003). CONCLUSION: The distribution and drug resistance of pathogenic bacteria are associated with the frequency of AECOPD-related hospitalization during the previous year.

Normal blood D-dimer concentrations: do they exclude pulmonary embolism?

BACKGROUND: Although pulmonary embolism (PE) with normal blood D-dimer (DD) concentrations is considered rare, in practice the incidence may be greater than is generally believed. Overlooking PE is potentially dangerous. The aim of this study was to explore the incidence and clinical features of PE with normal DD concentrations. METHODS: We retrospectively analyzed the records of 29 patients with PE and normal DD concentrations from the past seven years. We here compare relevant clinical characteristics of these patients with those of patients with PE and abnormal DD concentrations. We evaluated the probabilities of differences by computing pretest probability scores (Wells score and revised Geneva score). RESULTS: The frequency of normal DD concentrations in patients with PE was 4%. Previous episode(s) of PE were more common in patients with normal DD concentrations than in those with abnormal DD concentrations (P = 0.001). Fever, tachycardia, and tachypnea occurred less frequently in the former group (P < 0.05) and time between onset of symptoms and DD testing was longer (P = 0.001). The diagnosis of PE was delayed in 22 of the 29 cases. Nineteen and seven cases with normal DD concentrations were classified according to pretest scores as intermediate and low risk, respectively. CONCLUSIONS: PE with normal DD concentrations is uncommon. Although most diagnoses of PE are ruled out by normal DD values, a small number of cases with PE are missed. A combination of pretest probability score and normal DD concentration increases the probability of making the correct diagnosis, but cannot completely exclude patients with suspected PE. When the clinical manifestations cannot be otherwise explained, clinicians should be alert to the possibility of PE with normal DD concentrations in patients with previous episode(s) of PE or a long interval between onset of symptoms and DD testing.

[The value of D-dimer for etiological diagnosis of mortal chest pain: an analysis of 438 cases].

OBJECTIVE: To investigate the role of plasma D-dimer in differentiating fatal chest pain due either to acute myocardial infarction (AMI), acute pulmonary embolism (APE) or acute aortic dissection (AAD) in emergency department. METHODS: The data of a total of 445 consecutive patients complaining chest (back) pain and/or dyspnea who visited emergency department of Peking University Third Hospital from January 2011 to January 2012 were retrospectively analyzed. All cases were either diagnosed as AMI, APE or AAD finally. D-dimer concentrations were assessed and compared among different groups. The receiver operating characteristic curve (ROC curve) was established. The potency of D-dimer in distinguishing AMI, non-ST-segment elevation myocardial infarction (NSTEMI) by difference in values was assessed. RESULTS: Finally, 438 cases were enrolled, including 327 AMI [253 ST-segment elevation myocardial infarction (STEMI) and 74 NSTEMI], 76 APE and 35 AAD cases. The D-dimer concentrations in AMI group [0.21(0.15, 0.33) mg/L] were significantly lower than those in APE group [1.06 (0.86, 3.01) mg/L, Z=-11.416, P<0.001], AAD group [1.79 (0.83, 3.37) mg/L, Z=-8.715, P<0.001], APE/AAD group [1.15 (0.85, 3.13) mg/L, Z=-13.509, P<0.001]. The D-dimer concentrations in STEMI group were significantly lower than those in NSTEMI group [mg/L: 0.20 (0.15, 0.30) vs. 0.24 (0.17, 0.54), Z=-3.248, P=0.001]. The area under ROC curve (AUC) to discriminate AMI from APE/AAD was 0.929±0.015, and optimal value was 0.535 mg/L. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), negative likelihood ratio (NLR) with cut-off value of 0.535 mg/L were 86.2%, 93.7%, 97.6%, 69.8%,13.68, 0.15, while sensitivity, specificity, PPV, NPV, PLR, NLR with cut-off value of 0.5 mg/L were 84.4%, 93.7%, 97.5%, 67.1%, 13.40, 0.17. The AUC to discriminate NSTEMI from APE/AAD was 0.881±0.028. Sensitivity, specificity, PPV, NPV with cut-off value of 0.535 mg/L were 75.7%, 93.7%, 88.9%, 85.2%, while sensitivity, specificity, PPV, NPV with cut-off value of 0.5 mg/L were 70.3%, 93.7%, 88.1%, 82.5%, respectively. CONCLUSIONS: D-dimer is a better index in differentiating AMI from APE/AAD in emergency setting, guiding further examination and therapy, and increasing diagnosis efficiency.

Common underlying diseases do not contribute in determining the causes of sudden unexplained death.

BACKGROUND: Underlying diseases have a statistically significant positive correlation to sudden death. However, sudden unexplained death (SUD) is different from sudden death, as there is no clinical evidence to support the sudden death due to the original underlying disease, nor a lethal pathological basis to be found during autopsy. In addition, SUD are more common in young, previously healthy individuals, usually without any signs of disease, with no positive lesions found after autopsy. Therefore, a causal relationship between SUD and the underlying disease needs to be further explored. This study aimed to explore the role that common underlying diseases play in patients with SUD and to reveal the correlation between them. METHODS: The medical records, history and case information of 208 patients with SUD were collected for the survey. All these SUD occurred in the emergency room of Peking University Third Hospital from January 2006 to December 2009. The patients were stratified by with and without common underlying diseases. To examine possible associations between the underlying diseases and the cause of unexplained sudden death, the chi-squared and Fisher's exact tests were used. RESULTS: Among the 208 patients, 65 were diagnosed with common underlying diseases while 143 were not. Within these two groups, there were 45 patients for whom the clear cause of death was determined. However, there were no statistically significant differences or strong associations (χ(2) = 1.238, P > 0.05) between the 11 patients with (16.90%) and 34 without (23.78%) common underlying disease among these 45 patients. We also found that occurrence of the common underlying diseases, such as neurological system, cardiovascular and pulmonary system diseases, are not statistically significant (P > 0.05) in the diagnosis of the SUD. CONCLUSION: Common underlying diseases make no obvious contributions to SUD and are not useful in diagnosing the underlying reasons for death.

[Relationship between daily mean temperature and emergency department visits for respiratory diseases: a time-series analysis].

OBJECTIVE: To quantitatively evaluate the influences of daily mean air temperature (DMT) on Emergency Department Visits (EDVs) for the respiratory diseases. METHODS: The EDV data from medical records for respiratory diseases in Peking University Third Hospital between January 2004 and June 2009 were collected. The data of the air pollutants (SO(2), NO(2) and PM(10)) and meteorological factors at the same time periods were also collected from the local authorities of Beijing. Time-series analysis and generalized additive models (GAM) were used to explore the exposurrre-response relationship between DMT and EDVs for respiratory diseases. RESULTS: A total of 35 073 patients [males 14 707(41.93%,14 707/35 073), females 19 122(54.52%,19 122/35 073) and gender missing 1 244(3.55%, 1 244/35 073)] EDVs for respiratory diseases were included. The relationship between DMT and EDVs for the respiratory diseases was mainly of "V" shape, the optimum temperature(OT) was about 4 °C and the effect of DMT was significant with a 0-3 day lag structure for most of the models. When DMT≤OT, each 1°C decrease in DMT corresponded to 3.75% (95% CI of RR: 0.938 3-0.965 3), 3.10% (95% CI of RR:0.949 2-0.989 1), 4.09% (95% CI of RR:0.940 7-0.977 8) increase of EDVs for the overall, male, and female, respectively. When DMT>OT, the value caused by each increase in 1°C in DMT was 1.54% (95% CI of RR:1.006 6-1.024 3), 1.80% (95% CI of RR:1.005 3-1.030 9), and 1.51 (95% CI of RR:1.003 2- 1.027 2), respectively. The effect was statistically significant within the 0-3 day lag. When DMT≤OT, the effect was stronger for the older people, while the effect was strongest for the 45-59 years old people. CONCLUSION: The relationship between DMT and EDVs for respiratory diseases is mainly of "V" type, with an optimum temperature of 4 °C.Both DMT decrease when DMT≤OT and increase when DMT>OT correspond to different increase of EDVs for respiratory diseases. Low DMT has stronger effect than high DMT. Different age group and gender have different effects.

Pulmonary embolism in adolescents.

BACKGROUND: Pulmonary embolism (PE) is rare and seldom considered in adolescent patients; however it occurs with a greater frequency than is generally recognized, and it is a potentially fatal condition. The aim of the current study was to understand its epidemiology, clinical features and the cause of delay of its diagnosis in adolescents. METHODS: A retrospective analysis of nine adolescents with acute PE admitted to the Peking University Third Hospital over the past 16-year period was performed. The epidemiology, clinical features and risk factors of the adolescents were described and compared with those of adults and elderly patients. The time to diagnosis and misdiagnosed diseases were analyzed. Pretest probability of PE was assessed retrospectively by the Wells score and revised Geneva score. RESULTS: The incidence of PE was 43.6 per 100 000 hospitalized adolescents in our hospital. The incidence of PE in adolescents was much lower than that in adults and PE is diagnosed in about 1/50 of elderly people. The clinical features in adolescents were similar to those in adults. But fever and chest pain were more common in adolescents (P < 0.05). The major risk factors included surgery, systemic lupus erythematosus (SLE), thrombocytopenia, long-term oral glucocorticoids and trauma. The mean diagnostic time was (7.8 ± 8.4) days. Six cases had a delayed diagnosis. The mean delay time from symptom onset to diagnosis was (11.0 ± 8.8) days. The time of presentation to diagnosis in patients initially admitted to the emergency department was less than one day, and was much shorter than the time in outpatients, (9.4 ± 7.5) days. Most of the patients were initially misdiagnosed with a respiratory tract infection. Most patients' values of Wells score or revised Geneva score were in the moderate or high clinical probability categories; 88% by Well score vs. 100% by revised Geneva score. CONCLUSIONS: PE was seldom considered in the adolescent patients by physicians, especially outpatient physicians, so the diagnosis was often delayed. If adolescent patients complain of dyspnea or chest pain or syncope with/without fever, and they had risk factors such as surgery, thrombocytopenia and trauma, PE should be considered and included in the differential diagnosis.

[The endoscopic and clinical features of Indigo Naturalis-associated ischemic lesions of colonic mucosa].

OBJECTIVE: By analysing the clinical features of Indigo Naturalis-associated ischemic lesion of colon mucosa to improve the precautionary and therapeutic level of the disease. METHODS: Thirteen patients diagnosed as Indigo Naturalis-associated ischemic lesion of colon mucosa in Peking University Third Hospital from 2005 to 2010 were reviewed. The endoscopic and clinical features were analysed. RESULTS: The 13 patients with an average age of (60.6 ± 14.1) years old were prescribed Chinese traditional medicine containing Indigo Naturalis for psoriasis or idiopathic thrombocytopenic purpura (ITP). The ratio of males to females was 1:1.6. The typical manifestations were abdominal pain and bloody stool with watering diarrhea before bloody stool in 61.5% patients. Endoscopic and pathological characteristics were coincident with ischemic lesion and more like a chronic index. Vasodilatic medicine was effective and the average hemostatic time was (1.7 ± 0.8) days. The prognosis was well and no recurrence was found during 3 months follow-up. CONCLUSIONS: Patients having psoriasis or ITP treated with Chinese traditional medicine containing Indigo Naturalis have an inclination to colon mucosa lesions, even ischemic lesion. Careful assessment and observation before prescribing are necessary in these patients.

[Analysis of etiological and related factors responsible for acute gastrointestinal hemorrhage].

OBJECTIVE: To investigate the etiology, related factors and endoscopic characteristics of acute gastrointestinal hemorrhage. METHODS: The data including age, gender, medical and medication history, and endoscopic characteristics of patients receiving emergency treatment for acute gastrointestinal hemorrhage between February 2006 and February 2010 were collected to analyze the etiological profiles of this disorder. RESULTS: (1) A total of 1415 patients with a 2: 1 male-to-female ratio visited our hospital for acute gastrointestinal hemorrhage in the past 4 years. There was a higher mean age of disease onset in men than in women [(51 +/- 20) years old vs (61 +/- 17) years old, P = 0.000]. The numbers of patients were 399, 361, 242 and 413 for 4 respective quarters in order of sequence. (2) And 1030 patients received endoscopy. Among them, there were 897 (87.1%) with upper gastrointestinal hemorrhage and 133 (12.9%) with lower gastrointestinal hemorrhage. Significant differences existed in the mean age of two groups [(51 +/- 20) years old vs (57 +/- 18) years old, P = 0.000]. The male-to-female ratio was 656: 241 and 65:68 for these 2 groups respectively (P = 0.000). The percentage of patient with a history of NSAID (non-steroidal anti-inflammatory drug) treatment was 22.1% (n = 198) and 12.0% (n = 16) for these 2 groups respectively (P < 0.01). (3) The most common causative diseases of upper gastrointestinal hemorrhage were peptic ulcer (n = 546, 60.8%), esophageal & gastric varices hemorrhage (n = 130, 14.5%) and gastric cancer (n = 40, 4.6%). When the patients were divided into 5 groups of < 12 h, 12-24 h, 24-48 h, 48-72 h and > or = 72 h per time window of gastroscopy, their percentages with endoscopically active hemorrhage were 24.1% (20/83), 14.9% (24/161), 9.6% (16/166), 7.5% (8/106) and 7.6% (29/381) for these groups respectively with statistically significant differences. When peptic ulcer was examined by the Forrest classification, the ratio of grade I a- II c decreased gradually while the ratio of grade III increased gradually among 5 groups (chi2 = 80.414, P = 0.040). (4) The most common causative diseases of lower gastrointestinal hemorrhage were ischemic colitis (n = 44, 33.1%), small intestinal hemorrhage (n = 26, 19.5%) and colonic polyps (n = 18, 13.5%). (5) When the patients were divided into > 65 years old group (n = 277) and < or = 65 years old group (n = 620), the ratio of gastric ulcer and cancer in upper gastrointestinal hemorrhage was higher in the former than in the latter [23.5% (n = 65) vs 8.9% (n = 55) & 9.7% (n = 27) vs 2.1% (n = 13), P < 0.01)]. While the ratio of duodenal ulcer was lower in the former than in the latter [22.4% (n = 62) vs 49.7% (n = 308), P < 0.01]. The ratio of small intestinal hemorrhage in lower gastrointestinal hemorrhage was higher in the former than in the latter (all P < 0.01). CONCLUSION: At the lowest in the third quarter, the incidence rate of acute gastrointestinal hemorrhage is higher in males than that in females at a lower age of onset. More common than lower gastrointestinal hemorrhage, upper gastrointestinal hemorrhage has a lower mean age of onset. Peptic ulcer is the most common disorder in upper gastrointestinal hemorrhage. Ischemic colitis is the most common disorder in lower gastrointestinal hemorrhage. The rate of gastric ulcer and gastric cancer in the old age group is higher than that in the young group. Emergency gastroscopy is recommended.