World journal of emergency medicine最新文献

Background: Prompt pathogen identification can have a substantial impact on the optimization of antimicrobial treatment. The objective of the study was to assess the diagnostic value of next-generation sequencing (NGS) for identifying pathogen and its clinical impact on antimicrobial intervention in immunocompromised patients with suspected infections.

Methods: This was a retrospective study. Between January and August 2020, 47 adult immunocompromised patients underwent NGS testing under the following clinical conditions: 1) prolonged fever and negative conventional cultures; 2) new-onset fever despite empiric antimicrobial treatment; and 3) afebrile with suspected infections on imaging. Clinical data, including conventional microbial test results and antimicrobial treatment before and after NGS, were collected. Data were analyzed according to documented changes in antimicrobial treatment (escalated, no change, or de-escalated) after the NGS results.

Results: The median time from hospitalization to NGS sampling was 19 d. Clinically relevant pathogens were detected via NGS in 61.7% of patients (29/47), more than half of whom suffered from fungemia (n=17), resulting in an antimicrobial escalation in 53.2% of patients (25/47) and antimicrobial de-escalation in 0.2% of patients (1/47). Antimicrobial changes were mostly due to the identification of fastidious organisms such as Legionella, Pneumocystis jirovecii, and Candida. In the remaining three cases, NGS detected clinically relevant pathogens also detected by conventional cultures a few days later. The antimicrobial treatment was subsequently adjusted according to the susceptibility test results. Overall, NGS changed antimicrobial management in 55.3% (26/47) of patientst, and conventional culture detected clinically relevant pathogens in only 14.9% of patients (7/47).

Conclusion: With its rapid identification and high sensitivity, NGS could be a promising tool for identifying relevant pathogens and enabling rapid appropriate treatment in immunocompromised patients with suspected infections.

Background: There are currently no effective drugs to mitigate the ischemia/reperfusion injury caused by fluid resuscitation after hemorrhagic shock (HS). The aim of this study was to explore the potential of the histone deacetylase 6 (HDAC6)-specific inhibitor tubastatin A (TubA) to suppress nucleotide-binding oligomerization domain-like receptor protein 3 (NLRP3) inflammasome activation in macrophages under hypoxia/reoxygenation (H/R) conditions.

Methods: The viability of RAW264.7 cells subjected to H/R after treatment with different concentrations of TubA was assessed using a cell-counting kit-8 (CCK8) assay. Briefly, 2.5 μmol/L TubA was used with RAW264.7 cells under H/R condition. RAW264.7 cells were divided into three groups, namely the control, H/R, and TubA groups. The levels of reactive oxygen species (ROS) in the cells were detected using fluorescence microscopy. The protein expression of HDAC6, heat shock protein 90 (Hsp90), inducible nitric oxide synthase (iNOS), NLRP3, gasdermin-D (GSDMD), Caspase-1, GSDMD-N, and Caspase-1 p20 was detected by western blotting. The levels of interleukin-1β (IL-1β) and IL-18 in the supernatants were detected using enzyme-linked immunosorbent assay (ELISA).

Results: HDAC6, Hsp90, and iNOS expression levels were significantly higher (P<0.01) in the H/R group than in the control group, but lower in the TubA group than in the H/R group (P<0.05). When comparing the H/R group to the control group, ROS levels were significantly higher (P<0.01), but significantly reduced in the TubA group (P<0.05). The H/R group had higher NLRP3, GSDMD, Caspase-1, GSDMD-N, and Caspase-1 p20 expression levels than the control group (P<0.05), however, the TubA group had significantly lower expression levels than the H/R group (P<0.05). IL-1β and IL-18 levels in the supernatants were significantly higher in the H/R group compared to the control group (P<0.01), but significantly lower in the TubA group compared to the H/R group (P<0.01).

Conclusion: TubA inhibited the expression of HDAC6, Hsp90, and iNOS in macrophages subjected to H/R. This inhibition led to a decrease in the content of ROS in cells, which subsequently inhibited the activation of the NLRP3 inflammasome and the secretion of IL-1β and IL-18.

Background: We aimed to evaluate the utility of point-of-care ultrasound (POCUS) in the assessment of hand infections that present to the emergency department (ED) and its impact on medical decision making and patient management.

Methods: We conducted a retrospective review of patients who presented to two urban academic EDs with clinical presentations concerning for skin and soft tissue infections (SSTI) of the hand between December 2015 and December 2021. Two trained POCUS fellowship physicians reviewed an ED POCUS database for POCUS examinations of the hand. We then reviewed patients' electronic health records (EHR) for demographic characteristics, history, physical examination findings, ED course, additional imaging studies, consultations, impact of POCUS on patient care and final disposition.

Results: We included a total of 50 cases (28 male, 22 female) in the final analysis. The most common presenting symptoms and exam findings were pain (100%), swelling (90%), and erythema (74%). The most common sonographic findings were edema (76%), soft tissue swelling (78%), and fluid surrounding the tendon (57%). POCUS was used in medical decision making 68% of the time (n=34), with the use of POCUS leading to changes in management 38% of the time (n=19). POCUS use led to early antibiotic use (11/19), early consultation (10/19), and led to the performance of a required procedure (8/19). The POCUS diagnosis was consistent with the discharge diagnosis of flexor tenosynovitis 8/12 times, abscess 12/16 times, and cellulitis 14/20 times.

Conclusion: POCUS is beneficial for evaluating of hand infections that present to the ED and can be used as an important part of medical decision making to expedite patient care.

Background: As advocated in advanced trauma life support and prehospital trauma life support protocols, cervical immobilization is applied until cervical spine injury is excluded. This study aimed to show the difference in optic nerve sheath diameter (ONSD) between patients with and without a cervical collar using computed tomography (CT).

Methods: This was a single-center, retrospective study examining trauma patients who presented to the emergency department between January 1, 2021, and December 31, 2021. The ONSD on brain CT of the trauma patients was measured and analyzed to determine whether there was a difference between the ONSD with and without the cervical collar.

Results: The study population consisted of 169 patients. On CT imaging of patients with (n=66) and without (n=103) cervical collars, the mean ONSD in the axial plane were 5.43 ± 0.50 mm and 5.04 ± 0.46 mm respectively for the right eye and 5.50 ± 0.52 mm and 5.11 ± 0.46 mm respectively for the left eye. The results revealed an association between the presence of a cervical collar and the mean ONSD, which was statistically significant (P<0.001) for both the right and left eyes.

Conclusion: A cervical collar may be associated with increased ONSD. The effect of this increase in the ONSD on clinical outcomes needs to be investigated, and the actual need for cervical collar in the emergency department should be evaluated on a case-by-case basis.

Background: Agitation is a common presentation within emergent departments (EDs). Agitation during pregnancy should be treated as an obstetric emergency, as the distress may jeopardize both the patient and fetus. The safety of psychotropic medications in the reproductive age female has not been well established. This review aimed to explore a summary of general agitation recommendations with an emphasis on ED management of agitation during pregnancy.

Methods: A literature review was conducted to explore the pathophysiology of acute agitation and devise a preferred treatment plan for ED management of acute agitation in the reproductive age or pregnant female.

Results: While nonpharmacological management is preferred, ED visits for agitation often require medical management. Medication should be selected based on the etiology of agitation and the clinical setting to avoid major adverse effects. Adverse effects are common in pregnant females. For mild to moderate agitation in pregnancy, diphenhydramine is an effective sedating agent with minimal adverse effects. In moderate to severe agitation, high-potency typical psychotropics are preferred due to their neutral effects on hemodynamics. Haloperidol has become the most frequently utilized psychotropic for agitation during pregnancy. Second generation psychotropics are often utilized as second-line therapy, including risperidone. Benzodiazepines and ketamine have demonstrated adverse fetal outcomes.

Conclusion: While randomized control studies cannot be ethically conducted on pregnant patients requiring sedation, animal models and epidemiologic studies have demonstrated the effects of psychotropic medication exposure in utero. As the fetal risk associated with multiple doses of psychotropic medications remains unknown, weighing the risks and benefits of each agent, while utilizing the lowest effective dose remains critical in the treatment of acute agitation within the EDs.