Diagnostic value of elevated serum carbohydrate antigen 199 level in acute cholangitis secondary to choledocholithiasis

AIM To investigate the diagnostic value of abnormal serum carbohydrate antigen 199(CA199) level in acute cholangitis secondary to choledocholithiasis.METHODS In this retrospective cohort study, the clinical data of 727 patients with choledocholithiasis admitted to the Third Affiliated Hospital of Zunyi Medical College from June 2011 to June 2017 were collected. Among these patients, 258 patients had secondary acute cholangitis and served as observation group, and the remaining 569 choledocholithiasis patients served as the control group. Serum liver function indexes and tumor markers were detected in both groups, and the receiver operating characteristic(ROC) curves were constructed for markers showing statistical significances. The cutoff value, sensitivity, and specificity of each marker were calculated according to the ROC curves. RESULTS The results of liver function tests showed no significant differences between the two groups(P > 0.05). Tumor markers including serum CA125, CA153, carcinoembryonic antigen, and alpha fetoprotein levels were also not significantly different(P > 0.05); however, the serum CA199 level was significantly higher in the observation group than in the control group(P < 0.05). The ROC curve analysis showed that the area under the curve was 0.885(95%CI: 0.841-0.929) for CA199, and the cutoff value of 52.5 kU/L had the highest diagnostic accuracy, with a sensitivity of 86.8% and a specificity of 81.6%.CONCLUSION Abnormally elevated serum CA199 level has an important value in the diagnosis of acute cholangitis secondary to choledocholithiasis. It may be a specific inflammatory marker for acute cholangitis.

Correlation between the warning symptoms and prognosis of cardiac arrest

BACKGROUND A low survival rate in patients with cardiac arrest is associated with failure to recognize the condition in its initial stage.Therefore,recognizing the warning symptoms of cardiac arrest in the early stage may play an important role in survival.AIM To investigate the warning symptoms of cardiac arrest and to determine the correlation between the symptoms and outcomes.METHODS We included all adult patients with all-cause cardiac arrest who visited Peking University Third Hospital or Beijing Friendship Hospital between January 2012 and December 2014.Data on population,symptoms,resuscitation parameters,and outcomes were analysed.RESULTS Of the 1021 patients in the study,65.9%had symptoms that presented before cardiac arrest,25.2%achieved restoration of spontaneous circulation(ROSC),and 7.2%survived to discharge.The patients with symptoms had higher rates of an initial shockable rhythm(12.2%vs 7.5%,P=0.020),ROSC(29.1%vs 17.5%,P=0.001)and survival(9.2%vs 2.6%,P=0.001)than patients without symptoms.Compared with the out-of-hospital cardiac arrest(OHCA)without symptoms subgroup,the OHCA with symptoms subgroup had a higher rate of calls before arrest(81.6%vs 0.0%,P<0.001),health care provider-witnessed arrest(13.0%vs 1.4%,P=0.001)and bystander cardiopulmonary resuscitation(15.5%vs 4.9%,P=0.002);a shorter no flow time(11.7%vs 2.8%,P=0.002);and a higher ROSC rate(23.8%vs 13.2%,P=0.011).Compared to the in-hospital cardiac arrest(IHCA)without symptoms subgroup,the IHCA with symptoms subgroup had a higher mean age(66.2±15.2 vs 62.5±16.3 years,P=0.005),ROSC(32.0%vs 20.6%,P=0.003),and survival rates(10.6%vs 2.5%,P<0.001).The top five warning symptoms were dyspnea(48.7%),chest pain(18.3%),unconsciousness(15.2%),paralysis(4.3%),and vomiting(4.0%).Chest pain(20.9%vs 12.7%,P=0.011),cardiac etiology(44.3%vs 1.5%,P<0.001)and survival(33.9%vs 16.7%,P=0.001)were more common in males,whereas dyspnea(54.9%vs 45.9%,P=0.029)and a non-cardiac etiology(53.3%vs 41.7%,P=0.003)were more common in females.CONCLUSION Most patients had warning symptoms before cardiac arrest.Dyspnea,chest pain,and unconsciousness were the most common symptoms.Immediately recognizing these symptoms and activating the emergency medical system prevents resuscitation delay and improves the survival rate of OHCA patients in China.

Optimal timing of biliary drainage based on the severity of acute cholangitis:A single-center retrospective cohort study

BACKGROUND Biliary decompression is well known to greatly decrease the risks of mortality in acute cholangitis(AC).Although early biliary drainage is recommended by the treatment guidelines for AC,the best time for performing this procedure is yet to be established.Furthermore,since the clinical outcomes of patients with severe AC vary dramatically,screening for patients that could benefit the most from early drainage would be more beneficial than the drainage performed based on the severity grade criteria.AIM To investigate the optimal drainage timing for AC patients with each disease severity grade and organ dysfunction.METHODS In this retrospective monocenter cohort analysis,we reviewed 1305 patients who were diagnosed with AC according to the Tokyo guidelines 2018 at a Chinese tertiary hospital between July 2016 and December 2020.Demographic characteristics including age and sex,clinical and laboratory characteristics,and imaging findings of each patient were obtained from electronic medical records.We investigated the all-cause in-hospital mortality(IHM),hospital length of stay(LOS),and hospitalization costs associated with the timing of biliary drainage according to the severity grading and different dysfunctioning organs and predictors[age,white blood cell(WBC)count,total bilirubin,albumin,lactate,malignant obstruction,and Charlton comorbidity index(CCI)].RESULTS Biliary drainage within 24 or 48 h in Grade Ⅲ AC patients could dramatically decrease IHM(3.9%vs 9.0%,P=0.041;4%vs 9.9%,P=0.018,respectively),while increasing LOS and hospitalization costs.Multivariate logistic analysis revealed that neurological,respiratory,renal,and cardiovascular dysfunctions,hypoalbuminemia,and malignant obstruction were significantly associated with IHM(odds ratio=5.32,2.541,6.356,4.021,5.655,and 7.522;P<0.001,P=0.016,P<0.001,P=0.012,P<0.001,and P<0.001;respectively).Biliary decompression performed within 12 h of admission significantly decreased the IHM in AC patients with neurological dysfunction(0%vs 17.3%,P=0.041)or with serum lactate>2 mmol/L(0%vs 5.4%,P=0.016).In the subgroup of AC patients with renal dysfunction,abnormal WBC count,hyperbilirubinemia,or hypoalbuminemia,early drainage(<24 h)reduced the IHM(3.6%vs 33.3%,P=0.004;1.9%vs 5.8%,P=0.031;1.7%vs 5.0%,P=0.019;0%vs 27%,P=0.026;respectively).The IHM was lower in patients with AC combined with hepatic dysfunction,malignant obstruction,or a CCI>3 who had undergone biliary drainage within 48 h(2.6%vs 20.5%,P=0.016;3.0%vs 13.5%,P=0.006;3.4%vs 9.6%,P=0.021;respectively).CONCLUSION Biliary drainage within 12 h is beneficial for AC patients with neurological or cardiovascular dysfunction,while complete biliary decompression within 24 h of admission is recommended for treating patients with Grade Ⅲ AC.

Presepsin as a biomarker for risk stratification for acute cholangitis in emergency department: A single-center study

BACKGROUND Acute cholangitis is caused by bacterial infection and has high morbidity and mortality risk.The grade of cholangitis can guide clinical treatment from single antibiotic treatment to biliary drainage.With the introduction of white blood cell(WBC)count,C-reactive protein(CRP),and total bilirubin(T-Bil)into the diagnostic criteria and severity grading for acute cholangitis,the diagnosis rate and grading have significantly improved.However,early risk stratification assessments are challenging in the emergency department.Therefore,we hope to find an ideal predictive biomarker for cholangitis grade.Presepsin is a promising biomarker for the early diagnosis,severity,and prognosis of acute bacterial infections.AIM To assess the grading value of presepsin in patients with acute cholangitis.METHODS This clinical study was conducted at the Beijing Friendship Hospital,a 2000-bed teaching hospital with approximately 200000 emergency admissions per year.In this prospective observational study,336 patients with acute cholangitis meeting the Tokyo Guidelines 2018 diagnostic criteria in the emergency department from May 2019 to December 2020 were analyzed.WBC count,CRP,procalcitonin(PCT),presepsin,T-Bil,and blood culture results were collected.The values were compared using the Pearsonχ2 test,Fisher’s exact test,or Mann-Whitney U test.The area under the receiver operating characteristic curve(AUC)of the value was examined using the Delong test.The correlations among the key research indicators were determined using Pearson correlation.RESULTS In total,336 patients were examined,which included 107,106,and 123 patients classified as having mild,moderate,and severe cholangitis,respectively.WBC count,CRP,PCT,presepsin,T-Bil,direct bilirubin,and sequential organ failure assessment scores of moderate and severe cholangitis patients were higher than those of mild cholangitis patients(P=0.000).The AUC of presepsin in predicting moderate acute cholangitis was 0.728,which was higher than that of CRP(0.631,P=0.043)and PCT(0.585,P=0.002),and same as that of WBC count(0.746,P=0.713)and T-Bil(0.686,P=0.361).The AUC of presepsin in predicting severe acute cholangitis was 0.715,which was higher than that of WBC count(0.571,P=0.008),CRP(0.590,P=0.009),PCT(0.618,P=0.024),and T-Bil(0.559,P=0.006).The presepsin levels in the positive blood culture group were higher(2830.8pg/mLvs1987.8pg/mL,P=0.000),and the AUC of presepsin(0.688)proved that it was a good biomarker for predicting positive bacterial culture.CONCLUSION Presepsin can predict positive blood culture in patients with acute cholangitis.It is superior to WBC count,CRP,PCT,and T-Bil for the risk stratification of acute cholangitis.

Fatal progressive ascending encephalomyelitis caused by herpes B virus infection:first case from China

Dear editor,Herpes B virus(BV),also known as Macacine herpesvirus 1(family:Herpesviridae,subfamily:Alphaherpesvirinae,genus:Simplexvirus),officially designated by the International Committee on the Taxonomy of Viruses,exhibits serologic cross-reactivity with other members of the genus Simplexvirus,namely HSV type 1(HSV-1),the causative agent of oral herpetic ulcers(cold sores)in humans and HSV type 2(HSV-2),the agent of human genital herpes.[1]

Predictive value of presepsin and acylcarnitines for severity and biliary drainage in acute cholangitis

BACKGROUND Bacteremia,which is a major cause of mortality in patients with acute cholangitis,induces hyperactive immune response and mitochondrial dysfunction.Presepsin is responsible for pathogen recognition by innate immunity.Acylcarnitines are established mitochondrial biomarkers.AIM To clarify the early predictive value of presepsin and acylcarnitines as biomarkers of severity of acute cholangitis and the need for biliary drainage.METHODS Of 280 patients with acute cholangitis were included and the severity was stratified according to the Tokyo Guidelines 2018.Blood presepsin and plasma acylcarnitines were tested at enrollment by chemiluminescent enzyme immunoassay and ultra-high-performance liquid chromatography-mass spectrometry,respectively.RESULTS The concentrations of presepsin,procalcitonin,short-and medium-chain acylcarnitines increased,while long-chain acylcarnitines decreased with the severity of acute cholangitis.The areas under the receiver operating characteristic curves(AUC)of presepsin for diagnosing moderate/severe and severe cholangitis(0.823 and 0.801,respectively)were greater than those of conventional markers.The combination of presepsin,direct bilirubin,alanine aminotransferase,temperature,and butyryl-L-carnitine showed good predictive ability for biliary drainage(AUC:0.723).Presepsin,procalcitonin,acetyl-L-carnitine,hydroxydodecenoyl-Lcarnitine,and temperature were independent predictors of bloodstream infection.After adjusting for severity classification,acetyl-L-carnitine was the only acylcarnitine independently associated with 28-d mortality(hazard ratio 14.396;P<0.001)(AUC:0.880).Presepsin concentration showed positive correlation with direct bilirubin or acetyl-L-carnitine.CONCLUSION Presepsin could serve as a specific biomarker to predict the severity of acute cholangitis and need for biliary drainage.Acetyl-L-carnitine is a potential prognostic factor for patients with acute cholangitis.Innate immune response was associated with mitochondrial metabolic dysfunction in acute cholangitis.

Dynamic blood presepsin levels are associated with severity and outcome of acute pancreatitis:A prospective cohort study

BACKGROUND Acute pancreatitis(AP) is an inflammatory disorder of the pancreas with an unpredictable course of illness. A major challenge of AP is the early identification of patients at high-risk for organ failure and death. However, scoring systems are complicated and time consuming, and the predictive values for the clinical course are vague.AIM To determine whether the dynamic changes in presepsin levels can be used to evaluate the severity of disease and outcome of AP.METHODS In this multicentric cohort study, 133 patients with AP were included. Clinical severity was dynamically evaluated using the 2012 revised Atlanta Classification. Blood presepsin levels were measured at days 1, 3, 5 and 7 after admission by chemiluminescent enzyme immunoassay.RESULTS The median concentration of presepsin increased and the clearance rate of presepsin decreased with disease severity and organ failure in AP patients. The presepsin levels on days 3, 5 and 7 were independent predictors of moderately severe and severe AP with time-specific area under the curve(AUC) values of 0.827, 0.848 and 0.867, respectively. The presepsin levels positively correlated with bedside index of severity in AP, Ranson, acute physiology and chronic health evaluation II, computed tomography severity index and Marshall scores. Presepsin levels on days 3, 5 and 7 were independent predictors of 28-d mortality of AP patients with AUC values of 0.781, 0.846 and 0.843, respectively.CONCLUSION Blood presepsin levels within 7 d of admission were associated with and may be useful to dynamically predict the severity of disease course and 28-d mortality in AP patients.

Increasing angiotensin-converting enzyme(ACE)2/ACE axes ratio alleviates early pulmonary vascular remodeling in a porcine model of acute pulmonary embolism with cardiac arrest

BACKGROUND:Acute pulmonary embolism(APE)with cardiac arrest(CA)is characterized by high mortality in emergency due to pulmonary arterial hypertension(PAH).This study aims to determine whether early pulmonary artery remodeling occurs in PAH caused by massive APE with CA and the protective effects of increasing angiotensin-converting enzyme(ACE)2-angiotensin(Ang)(1-7)-Mas receptor axis and ACE-Ang II-Ang II type 1 receptor(AT1)axis(ACE2/ACE axes)ratio on pulmonary artery lesion after return of spontaneous circulation(ROSC).METHODS:To establish a porcine massive APE with CA model,autologous thrombus was injected into the external jugular vein until mean arterial pressure dropped below 30 mmHg(1 mmHg=0.133 kPa).Cardiopulmonary resuscitation and thrombolysis were delivered to regain spontaneous circulation.Pigs were divided into four groups of five pigs each:control group,APE-CA group,ROSC-saline group,and ROSC-captopril group,to examine the endothelial pathological changes and expression of ACE2/ACE axes in pulmonary artery with or without captopril.RESULTS:Histological analysis of samples from the APE-CA and ROSC-saline groups showed that pulmonary arterioles were almost completely occluded by accumulated endothelial cells.Western blotting analysis revealed a decrease in the pulmonary arterial ACE2/ACE axes ratio and increases in angiopoietin-2/angiopoietin-1 ratio and expression of vascular endothelial growth factor(VEGF)in the APE-CA group compared with the control group.Captopril significantly suppressed the activation of angiopoietin-2/angiopoietin-1 and VEGF in plexiform lesions formed by proliferative endothelial cells after ROSC.Captopril also alleviated endothelial cell apoptosis by increasing the B-cell lymphoma-2(Bcl-2)/Bcl-2-associated X(Bax)ratio and decreasing cleaved caspase-3 expression.CONCLUSION:Increasing the ACE2/ACE axes ratio may ameliorate pulmonary arterial remodeling by inhibiting the apoptosis and proliferation of endothelial cells after ROSC induced by APE.

Development and evaluation of a predictive nomogram for survival in heat stroke patients: a retrospective cohort study

BACKGROUND:This study aimed to establish an eff ective nomogram to predict the survival of heat stroke(HS)based on risk factors.METHODS:This was a retrospective,observational multicenter cohort study.We analyzed patients diagnosed with HS,who were treated between May 1 and September 30,2018 at 15 tertiary hospitals from 11 cities in Northern China.RESULTS:Among the 175 patients,32 patients(18.29%)died before hospital discharge.After the univariate analysis,mechanical ventilation,initial mean arterial pressure<70 mmHg,maximum heart rate,lab results on day 1(white blood cell count,alanine aminotransferase,creatinine),and Glasgow admission prediction score were included in multivariate analysis.Multivariate Cox regression showed that invasive ventilation,initial mean arterial pressure<70 mmHg(1 mmHg=0.133 kPa),and Glasgow admission prediction score were independent risk factors for HS.The nomogram was established for predicting 7-d and 14-d survival in the training cohort.The nomogram exhibited a concordance index(C-index)of 0.880(95%confidence interval[95%CI]0.831-0.930)by bootstrapping validation(B=1,000).Furthermore,the nomogram performed better when predicting 14-d survival,compared to 7-d survival.The prognostic index cut-off value was set at 2.085,according to the operating characteristic curve for overall survival prediction.The model showed good calibration ability in the internal and external validation datasets.CONCLUSION:A novel nomogram,integrated with prognostic factors,was proposed;it was highly predictive of the survival in HS patients.

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 dataconcerning 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% wvere women. In patients with AHH coronary heart disease （43.27%） was the most common etiology, andmyocardium 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.

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),(3-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,P-blockers,ACEIs,ARBs,spironolactone,calcium antagonists,nitrates,and digoxin were independently associated with 5-year all-cause mortality.

Effect of Shen-Fu Injection Pretreatment to Myocardial Metabolism During Untreated Ventricular Fibrillation in a Porcine Model

Background： Shen-Fu injection （SFI） can attenuate ischemia-reperfusion injury, protect cardiac function, and improve microcirculation during cardiopulmonary resuscitation. We hypothesized that SFI may also have an influence on myocardial metabolism during ventrictdar fibrillation （VF）. In this study, we used SFI pretreatment prior to VF to discuss the changes of myocardial metabolism and catecholamine （CA） levels during untreated VF, trying to provide new evidence to the protection of SFI to myocardiurn. Methods： Twenty-four pigs were divided into three groups： Saline group （SA group）, SFI group, and SHAM operation group （SHAM group）. Thirty minutes prior to the induction of VF, the SFI group received 0.24 mg/ml SFI through an intravenous injection： the SA group received an equal amount of sodium chloride solution. The interstitial fluid from the left ventricle （LV） wall was collected through the microdialysis tubes during VF. Adenosine diphosphate （ADP）, adenosine triphosphate （ATP）, and Na^＋-K^＋-ATPase and Ca2^＋-ATPase enzyme activities were measured after untreated VF. Peak-to-trough VF amplitude and median frequency were analyzed for each of these 5-s intervals. Results： The levels of glucose and glutamate were lower after VF in both the SA and SFI groups, compared with baseline, and the levels in the SFI group were higher than those in the SA group. Compared with baseline, the levels of lactate and the lactate/pyruvate ratio increased after VF in both SA and SFI groups, and the levels in the SFI group were lower than those in the SA group. In both the SA and SFI groups, the levers of dopamine, norepinephrine, and epinephrine increased significantly. There were no statistical differences between the two groups. The content of ATE ADE and phosphocreatine in the SF1 group was higher than those in the SA group. The activity ofLV Na^＋-K^＋-ATPase was significantly higher in the SFI group than in the SA group. Amplitude mean spectrum area （AMSA） was significantly lower in the SA and SFI groups at 8- and 12-min compared with 4-min. The AMSA in the SFI group was higher than that in the SA group at each time point during untreated VF. Conclusions： SFI pretreatment can improve myocardial metabolism and reduce energy exhaustion during VF, and it does not aggravate the excessive secretion of endogenous CAs.