Clinical and Experimental Emergency Medicine最新文献

Objective: The Objective of this systematic review and meta-analysis is to evaluate the efficacy, safety, time to international normalized ratio (INR) reversal, and total volume of four-factor prothrombin complex concentrate (4-PCC) administered using fixed-dose versus weight-based dosing strategies in patients requiring urgent warfarin reversal, with specific focus on clinical outcomes of hemostatic efficacy, thromboembolic events, and mortality rates.

Methods: A comprehensive systematic review was conducted using the PubMed, Embase, and Cochrane databases from inception through October 2023. We searched for randomized clinical trials or observational studies that compared efficacy or safety outcomes of fixed versus variable 4-PCC dose in adult patients.

Results: In the 14 included studies, the overall use of fixed-dose 4-PCC was associated with a lower likelihood of reaching the INR goal (risk ratio [RR], 0.84; 95% confidence interval [CI], 0.80-0.89) compared to the variable-dose group. In addition, a significantly larger proportion of patients (169 of 651, 26%) required an additional dose of 4-PCC. The rates of mortality (RR, 0.85; 95% CI, 0.70-1.03) and thromboembolic events (RR, 1.27; 95% CI, 0.65-2.45) were similar between the two treatment groups.

Conclusion: This systematic review and meta-analysis showed that variable dosing of 4-PCC more successfully achieves the target INR for warfarin reversal compared to fixed dosing. However, the dosing strategies have similar mortality and thromboembolic rates. While fixed dosing offers a simpler approach, it may require additional administration. Future studies should focus on optimizing dosing strategies to balance efficacy, safety, and practicality in various clinical scenarios.

Objective: The study explores the long-term impacts of traumatic brain injury (TBI) on neuroinflammation and neuronal apoptosis in pediatric and adult mice, focusing on how age at injury influences these processes.

Methods: Controlled cortical impacts were used to induce TBI in pediatric (21-25 days old) and adult (8-12 weeks old) C57BL/6 male mice. Neuroinflammation was evaluated by measuring immunoreactivity for allograft inflammatory factor 1 (AIF-1)/ionized calcium-binding adaptor molecule 1 (Iba-1) and glial fibrillary acidic protein (GFAP), while apoptosis was assessed using markers such as B-cell lymphoma 2 (Bcl-2)-associated X protein (Bax), Bcl-2, and procaspase-3. Additionally, heat shock protein 70 (HSP70) expression was measured to understand the stress response.

Results: Following controlled cortical impacts, pediatric mice exhibited a significant reduction in expression of neuronal nuclei (P<0.001), and significant increases in expression of GFAP (P<0.01) and AIF-1/Iba-1 (P<0.05) at 3 days post-injury (DPI) compared with sham controls. In contrast, adult mice exhibited no significant change in AIF-1/Iba-1 expression and a less pronounced increase in GFAP (P<0.05) at 3 DPI compared with sham controls. A more significant increase in Bax/Bcl-2 ratio at 7 DPI (P<0.01) was seen in pediatric mice, while a weak but significant increase in Bax/Bcl-2 ratio at 7 DPI (P<0.05) was evident in adults. Both age groups showed a significant but transient increase in HSP70 levels at 7 DPI, which normalized by 90 DPI.

Conclusion: Pediatric and adult mice exhibited significant time-dependent differences in neuroinflammation and apoptosis following TBI, with pediatric mice showing more intense early responses indicative of age-specific vulnerabilities in post-injury outcomes. Both age groups showed a significant but transient increase in HSP70 expression, suggesting an acute response to stress post-injury.

Objective: Acute cardiogenic pulmonary edema (ACPE) is a frequently encountered medical emergency associated with high early mortality rates, but existing tools to predict short-term outcomes for risk stratification have several limitations. Our aim was to derive and validate a simple clinical scoring system using baseline vital signs, clinical and presenting characteristics, and readily available laboratory tests for accurate prediction of short-term mortality in individuals experiencing ACPE.

Methods: This retrospective cohort study comprised 1,088 patients with ACPE from six health centers. Subjects were randomly allocated into derivation and validation cohorts at a 4:3 ratio for comprehensive examination and validation of the prognostic model. Independent predictors of mortality (P<0.05) from the multivariable model were included in the risk score. Discriminant ability of the model was tested by receiver operating characteristic analysis.

Results: In the derivation cohort (623 patients), age, blood urea nitrogen, heart rate, intubation, anemia, and systolic blood pressure were identified as independent predictors of mortality in multivariable analysis. These variables were used to develop a risk score ranging from 0 to 6 by scoring each of these factors as 0 or 1. The SABIHA (systolic blood pressure, age, blood urea nitrogen, invasive mechanical ventilation requirement, heart rate, and anemia) score provided good calibration with a concordance index of 0.879 (95% confidence interval, 0.821-0.937). While the probability of short-term mortality was 80.0% in the high-risk group, this rate was only 3.3% in the low-risk group. The SABIHA score also performed well on the validation set.

Conclusion: A simple clinical score consisting of routinely obtained variables can be used to predict short-term outcomes in patients with ACPE.

Objective: We investigated the possible association between lower serum lactate to albumin ratio upon hospital arrival and out-of-hospital cardiac arrest (OHCA) outcome.

Methods: Records from the Japanese Association for Acute Medicine-Out-of-Hospital Cardiac Arrest (JAAM-OHCA) Registry were used for this multicenter observational study. Enrolled patients were ≥18 years old with OHCA of medical etiology who were hospitalized after spontaneous circulation returned between June 1, 2014, and December 31, 2021. We excluded those with missing data or those who failed to meet predefined inclusion criteria. The primary outcome was a cerebral performance category scale of 1 or 2 which indicated 30-day survival with favorable neurological outcome. Patients were divided into quartiles based on serum lactate to albumin ratios. The multivariable logistic regression analysis included adjustment for multiple factors.

Results: Data from 4,413 patients were analyzed. The primary outcome was achieved by 558 of 1,104 patients (50.5%) in the first quartile (lactate to albumin ratio, ≤2.23), 240 of 1,111 patients (21.6%) in the second quartile (lactate to albumin ratio >2.23-3.39), 96 of 1,096 patients (8.8%) in the third quartile (lactate to albumin ratio >3.39-4.70), and 24 of 1,102 patients (2.2%) in the fourth quartile (lactate to albumin ratio, >4.70). Adjusted odds ratios (95% confidence intervals) for the primary outcome in the second, third, and fourth quartile compared with the first quartile were 0.33 (0.26-0.42), 0.19 (0.14-0.26), and 0.07 (0.04-0.11), respectively.

Conclusion: A statistically significant association between categorization in the lower lactate to albumin ratio quartile group and favorable neurological outcome after OHCA was identified.

Objective: N-acetylcysteine as the gold standard antidote may not be sufficient in managing cases of acetaminophen-related poisoning with delayed presentations or with massive ingestions. Existing human reports up until July 2021 have suggested that fomepizole may play a potential role in acetaminophen overdoses through inhibition of CYP2E1-mediated NAPQI production and JNK-mediated oxidative damage. This narrative review aims to build upon the repertoire of literature and case studies summarized by existing systematic and scoping reviews with the latest evidence regarding the use of fomepizole in acetaminophen-poisoning to better understand the hepatoprotective role and safety profile of this medication as well as its practical place in therapy.

Methods: A systematic search was completed through November 2024 in MEDLINE and EMBASE. Studies involving human patients with acetaminophen toxicity who received fomepizole treatment were included. Each patient case was thoroughly summarized in tables from which clinical trends including the risk of hepatotoxicity, quantity of ingestion, time of presentation since ingestion, therapeutic and dosing regimens, and clinical outcomes were identified.

Results: A total of 30 studies and 45 patients across 18 case reports and six case series were included in this review. When used in adjunct with N-acetylcysteine, fomepizole seemed to result in favourable laboratory and clinical outcomes in most patients that were at high risk of hepatotoxicity with late presentations or massive acetaminophen ingestions.

Conclusion: Available data suggests fomepizole may complement N-acetylcysteine in severe acetaminophen toxicity. Though lacking detailed clinical outcome analyses, case studies suggest fomepizole may improve hepatotoxicity, survival, and transplant-free days.

Background and objective: Acute painful conditions are a common reason to emergency department (ED) referral, and a broad variety of analgesic drugs may be used. Among them, ketorolac is a Non-Steroidal Anti-Inflammatory Drug (NSAID) increasingly used in the last two decades. In order to clarify the available evidence about the use of ketorolac in the ED setting, a systematic review and meta-analysis was performed.

Databases and data treatment: A search was performed in PubMed for English written articles updated to February 2023. Only randomized controlled trials regarding adult patients with acute painful conditions treated in the ED were selected. A meta-analysis was performed to evaluate the effectiveness of ketorolac in different pain conditions.

Results: : Forty randomized controlled trials were selected including studies focused on acute renal colic, headache, traumatic and non-traumatic musculoskeletal pain, and biliary colic. In these studies, ketorolac was mainly compared to opioids and in general showed a similar analgesic efficacy. On the other hand, when compared to other NSAIDs, ketorolac does not seem to have a stronger analgesic effect.

Conclusion: s: This systematic review indicates that ketorolac is a valuable option, alternative to opioids, to induce analgesia in adult ED patients, as our meta-analysis showed no significant difference in efficacy compared to opioids or other NSAIDs. Nevertheless, the evidence regarding its efficacy compared to other commonly NSAIDs is still limited and should be further explored in future studies.

Objectives: To identify the association between skull fracture (SF) and hyperfibrinolysis (HF) among patients with isolated traumatic brain injury.

Methods: This study was the retrospective cohort study based on the nationwide neurotrauma database in Japan. Adult patients with isolated traumatic brain injury (head abbreviated injury scale (AIS) >2, any other AIS <3) registered in the JNTDB from 2015 to 2017 were included. To examine the association between SF and HF, we conducted multivariable logistic regression analyses to calculate the adjusted odds ratios (ORs) of SF with their 95% confidence intervals (CIs) for HF. HF was defined as a D-dimer level ≥ 38 mg/L on arrival based on the previous study.

Results: A total of 335 patients were enrolled and the median age of the cohort was 64 years (interquartile range, 44-76 years). HF was observed in 161 patients (48.1%). The association of SF with HF yielded an adjusted odds ratio (OR) of 4.78 (95% CI: 2.71-8.42) compared to non-SF in multivariable logistic regression analysis. In addition, the association of skull base fracture, skull vault fracture, and combination of skull base and vault fracture with HF yielded the corresponding adjusted ORs of 3.60 (95% CI: 1.20-10.81), 4.99 (95% CI: 2.63-9.44), and 4.84 (95% CI: 2.41-9.72), respectively, relative to non-SF.

Conclusion: This multicenter observational study demonstrated the association of SF with HF in patients with isolated TBI.

Objective: We previously developed and validated an artificial intelligence-based electrocardiogram (ECG) analysis tool (ECG Buddy) in a Korean population. This study investigated the performance of this tool in a US population, specifically assessing the left ventricular (LV) dysfunction score and LV ejection fraction (LVEF)-ECG feature for predicting LVEF <40%. The study used N-terminal pro-B-type natriuretic peptide (NT-ProBNP) as a comparator.

Methods: We identified emergency department (ED) visits from the MIMIC-IV dataset with information on LVEF <40% or ≥40% and matched 12-lead ECG data recorded within 48 hours of the ED visit. The performance of ECG Buddy's LV dysfunction score and the LVEF-ECG feature was compared with those of NT-ProBNP using area under the receiver operating characteristic curve (AUC) analysis.

Results: A total of 22,599 ED visits was analyzed. The LV dysfunction score had an AUC of 0.905 (95% confidence interval [CI], 0.899-0.910), with a sensitivity of 85.4% and specificity of 80.8%. The LVEF-ECG feature had an AUC of 0.908 (95% CI, 0.902-0.913), sensitivity of 83.5%, and specificity of 83.0%. NT-ProBNP had an AUC of 0.740 (95% CI, 0.727-0.752), with a sensitivity of 74.8% and specificity of 62.0%. The ECG-based predictors demonstrated superior diagnostic performance compared to NT-ProBNP (all P<0.001). In the sinus rhythm subgroup, the LV dysfunction score achieved an AUC of 0.913 and LVEF-ECG had an AUC of 0.917, both outperforming NT-ProBNP (AUC, 0.748; 95% CI, 0.732-0.763; all P<0.001).

Conclusion: ECG Buddy demonstrated superior accuracy compared with NT-ProBNP in predicting LV systolic dysfunction, validating its utility in a US ED population.

Objective: Deep vein thrombosis (DVT) is a significant cause of morbidity and mortality worldwide, accounting for substantial healthcare utilization. However, management strategies have evolved, and current data on the incidence, admission rates, and medical management of DVT in the emergency department (ED) setting are needed.

Methods: This cross-sectional study analyzed ED presentations for DVT from 2016 to 2023 using the Cosmos database. Inclusion criteria were patients aged ≥18 years with an ICD-10 code for acute extremity DVT. The outcomes were incidence rates, admission rates, and anticoagulant prescriptions. Data were analyzed using descriptive statistics, and subgroup analyses were performed for upper and lower extremity DVTs.

Results: Of 190,144,463 total ED encounters, 368,044 (0.2%) were due to DVT. Among the DVT cases, 119,986 patients (32.6%) were admitted, at a stable rate during the study period. Apixaban was the most prescribed anticoagulant (40.3%), followed by rivaroxaban (28.3%), enoxaparin (7.9%), warfarin (3.6%), and dabigatran (0.3%). Use of apixaban increased from 12.4% in 2016 to 56.2% in 2023. Lower extremity DVTs accounted for 88.5% of cases, with a 32.1% admission rate, whereas upper extremity DVTs accounted for 11.7% of cases, with a 37.0% admission rate.

Conclusion: This study provides a summary of DVT presentation and management in US EDs during an 8-year period. The findings highlight stable incidence rates, reduced admission rates compared with historical data, and a significant shift toward the use of direct oral anticoagulants, particularly apixaban, for outpatient management. These trends underscore the importance of evidence-based practices and ongoing research to optimize DVT management and improve patient outcomes.