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Wang H, Wang W, Xue Z, Gong H. SIRT3 MEDIATES THE CARDIOPROTECTIVE EFFECT OF THERAPEUTIC HYPOTHERMIA AFTER CARDIAC ARREST AND RESUSCITATION BY RESTORING AUTOPHAGIC FLUX VIA THE PI3K/AKT/MTOR PATHWAY. Shock 2024; 62:127-138. [PMID: 38526135 DOI: 10.1097/shk.0000000000002366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
ABSTRACT Background : Postresuscitation cardiac dysfunction is a significant contributor to early death following cardiopulmonary resuscitation (CPR). Therapeutic hypothermia (TH) mitigates myocardial dysfunction due to cardiac arrest (CA); however, the underlying mechanism remains unclear. Sirtuin 3 (Sirt3) was found to affect autophagic activity in recent research, motivating us to investigate its role in the cardioprotective effects of TH in the treatment of CA. Methods : Sprague-Dawley rats were used to establish an in vivo CA/CPR model and treated with a selective Sirt3 inhibitor or vehicle. Survival rate, myocardial function, autophagic flux, and Sirt3 expression and activity were evaluated. H9C2 cells were subjected to oxygen-glucose deprivation/reoxygenation (OGD/R) injury in vitro . The cells were transfected with Sirt3-siRNA and treated with the autophagy inhibitor chloroquine or the PI3K inhibitor LY294002, and cell viability and autophagic flux were assessed. Results : Rats exhibited decreased survival and impaired cardiac function after CA/CPR, which were alleviated by TH. Mechanistically, TH restored Sirt3 expression and autophagic flux, which were impaired by CA/CPR. Sirt3 inactivation diminished the capacity of TH to restore autophagic flux and partially abolished the improvements in myocardial function and survival. An in vitro study further showed that TH-induced restoration of disrupted autophagic flux by OGD/R was attenuated by pretreatment with Sirt3-siRNA, and this attenuation was partially rescued by the inhibition of PI3K/Akt/mTOR signaling cascades. Conclusions : Sirt3 mediates the cardioprotective effect of TH by restoring autophagic flux via the PI3K/Akt/mTOR pathway. These findings suggest the potential of Sirt3 as a therapeutic target for CA.
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Affiliation(s)
- Hui Wang
- Department of Geriatric Medicine, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wenwen Wang
- Department of Emergency, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Zhiwei Xue
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
| | - Huiping Gong
- Department of Emergency, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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Vammen L, Munch Johannsen C, Magnussen A, Povlsen A, Riis Petersen S, Azizi A, Løfgren B, Andersen LW, Granfeldt A. Cardiac Arrest in Pigs With 48 hours of Post-Resuscitation Care Induced by 2 Methods of Myocardial Infarction: A Methodological Description. J Am Heart Assoc 2021; 10:e022679. [PMID: 34854307 PMCID: PMC9075364 DOI: 10.1161/jaha.121.022679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Systematic reviews have disclosed a lack of clinically relevant cardiac arrest animal models. The aim of this study was to develop a cardiac arrest model in pigs encompassing relevant cardiac arrest characteristics and clinically relevant post‐resuscitation care. Methods and Results We used 2 methods of myocardial infarction in conjunction with cardiac arrest. One group (n=7) had a continuous coronary occlusion, while another group (n=11) underwent balloon‐deflation during arrest and resuscitation with re‐inflation after return of spontaneous circulation. A sham group was included (n=6). All groups underwent 48 hours of intensive care including 24 hours of targeted temperature management. Pigs underwent invasive hemodynamic monitoring. Left ventricular function was assessed by pressure‐volume measurements. The proportion of pigs with return of spontaneous circulation was 43% in the continuous infarction group and 64% in the deflation‐reinflation group. In the continuous infarction group 29% survived the entire protocol while 55% survived in the deflation‐reinflation group. Both cardiac arrest groups needed vasopressor and inotropic support and pressure‐volume measurements showed cardiac dysfunction. During rewarming, systemic vascular resistance decreased in both cardiac arrest groups. Median [25%;75%] troponin‐I 48 hours after return of spontaneous circulation, was 88 973 ng/L [53 124;99 740] in the continuous infarction group, 19 661 ng/L [10 871;23 209] in the deflation‐reinflation group, and 1973 ng/L [1117;1995] in the sham group. Conclusions This article describes a cardiac arrest pig model with myocardial infarction, targeted temperature management, and clinically relevant post‐cardiac arrest care. We demonstrate 2 methods of inducing myocardial ischemia with cardiac arrest resulting in post‐cardiac arrest organ injury including cardiac dysfunction and cerebral injury.
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Affiliation(s)
- Lauge Vammen
- Department of Anesthesiology and Intensive Care Aarhus University Hospital Aarhus Denmark.,Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Cecilie Munch Johannsen
- Department of Anesthesiology and Intensive Care Aarhus University Hospital Aarhus Denmark.,Department of Clinical Medicine Aarhus University Aarhus Denmark
| | | | - Amalie Povlsen
- Department of Clinical Medicine Aarhus University Aarhus Denmark.,Department of Cardiothoracic Anesthesia Copenhagen University HospitalRigshospitalet Denmark Copenhagen Denmark
| | | | - Arezo Azizi
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Bo Løfgren
- Department of Clinical Medicine Aarhus University Aarhus Denmark.,Research Center for Emergency Medicine Aarhus University Hospital Aarhus Denmark.,Department of Internal Medicine Randers Regional Hospital Randers Denmark
| | - Lars W Andersen
- Department of Anesthesiology and Intensive Care Aarhus University Hospital Aarhus Denmark.,Department of Clinical Medicine Aarhus University Aarhus Denmark.,Research Center for Emergency Medicine Aarhus University Hospital Aarhus Denmark.,Prehospital Emergency Medical Services Central Denmark Region Aarhus Denmark
| | - Asger Granfeldt
- Department of Anesthesiology and Intensive Care Aarhus University Hospital Aarhus Denmark.,Department of Clinical Medicine Aarhus University Aarhus Denmark
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Resolvin D1 Improves Post-Resuscitation Cardiac and Cerebral Outcomes in A Porcine Model of Cardiac Arrest. Shock 2021; 54:548-554. [PMID: 32080063 DOI: 10.1097/shk.0000000000001528] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Following global ischemia reperfusion injury triggered by cardiac arrest (CA) and resuscitation, the ensuing cardiac and cerebral damage would result in high mortality and morbidity. Recently, resolvin D1 has been proven to have a protective effect on regional cardiac and cerebral ischemia reperfusion injury. In this study, we investigated the effects of resolvin D1 on cardiac and cerebral outcomes after cardiopulmonary resuscitation (CPR) in a porcine model.Twenty-eight male domestic pigs weighing between 33 and 41 kg were randomly divided into one of the four groups: sham, CPR, low-dose resolvin D1 (LRD), and high-dose resolvin D1 (HRD). Sham animals underwent the surgical preparation only. Other animals were subjected to 8 min of untreated ventricular fibrillation and then 5 min of CPR. At 5 min after resuscitation, resolvin D1 was intravenously administered with the doses of 0.3 and 0.6 μg/kg in the LRD and HRD groups, respectively. The resuscitated animals were monitored for 6 h and observed for an additional 18 h.After resuscitation, myocardial and neurological function were significantly impaired, and their serum levels of injury biomarkers were markedly increased in the CPR, LRD, and HRD groups compared with the sham group. In addition, tissue inflammation and oxidative stress in the heart and brain were observed in the three groups. However, myocardial function was significantly improved and its injury biomarker was significantly decreased starting 3 h after resuscitation in the LRD and HRD groups compared with the CPR group. Similarly, neurological function was significantly better at 24 h post-resuscitation and its injury biomarkers were significantly lower at 6 and 24 h post-resuscitation in the LRD and HRD groups than in the CPR group. In addition, myocardial, cerebral inflammation, and oxidative stress were significantly milder in the two resolvin D1-treated groups. Especially, HRD produced significantly greater post-resuscitation cardiac and cerebral protection compared with the LRD group.In conclusion, resolvin D1 significantly improved post-resuscitation cardiac and cerebral outcomes in a porcine model of CA, in which the protective effects may be in a dose-dependent manner.
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Chen S, Lachance BB, Gao L, Jia X. Targeted temperature management and early neuro-prognostication after cardiac arrest. J Cereb Blood Flow Metab 2021; 41:1193-1209. [PMID: 33444088 PMCID: PMC8142127 DOI: 10.1177/0271678x20970059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Targeted temperature management (TTM) is a recommended neuroprotective intervention for coma after out-of-hospital cardiac arrest (OHCA). However, controversies exist concerning the proper implementation and overall efficacy of post-CA TTM, particularly related to optimal timing and depth of TTM and cooling methods. A review of the literature finds that optimizing and individualizing TTM remains an open question requiring further clinical investigation. This paper will summarize the preclinical and clinical trial data to-date, current recommendations, and future directions of this therapy, including new cooling methods under investigation. For now, early induction, maintenance for at least 24 hours, and slow rewarming utilizing endovascular methods may be preferred. Moreover, timely and accurate neuro-prognostication is valuable for guiding ethical and cost-effective management of post-CA coma. Current evidence for early neuro-prognostication after TTM suggests that a combination of initial prediction models, biomarkers, neuroimaging, and electrophysiological methods is the optimal strategy in predicting neurological functional outcomes.
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Affiliation(s)
- Songyu Chen
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Brittany Bolduc Lachance
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Liang Gao
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaofeng Jia
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Orthopedics, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Wang J, Shi L, Xu J, Zhou W, Zhang M, Wu C, Chen Q, Jin X, Zhang J. Fast hypothermia induced by extracorporeal circuit cooling alleviates renal and intestinal injury after cardiac arrest in swine. Am J Emerg Med 2021; 47:231-238. [PMID: 33932856 DOI: 10.1016/j.ajem.2021.04.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/12/2021] [Accepted: 04/19/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) was currently demonstrated to be an effective way to induce fast hypothermia and had proective effects on cardiac dysfunction and brain damage after cardiac pulmonary resuscitation (CPR). In the present study, we aimed to investigate the influence of extracorporeal circuit cooling using CRRT on renal and intestinal damage after CPR based on a porcine model. METHODS 32 pigs were subjected to ventricular fibrillation for 8 min, followed by CPR for 5 min before defibrillation. All were randomized to receive extracorporeal circuit cooling using CRRT (CRRT, n = 9), surface cooling (SC, n = 9), normothermia (NT, n = 9) or sham control (n = 5) at 5 min post resuscitation. Pigs in the CRRT group were cooled by 8-h CRRT cooling with the infusion line initially submerged in 4 °C of ice water and 16-h SC, while in the SC group by a 24-h SC. Temperatures were maintained at a normal range in the other two groups. Biomarkers in serum were measured at baseline and 1, 3, 6, 12, 24 and 30 h post resuscitation to assess organ functions. Additionally, tissues of kidney and intestine were harvested, from which the degree of tissue inflammation, oxidative stress, and apoptosis levels were analyzed. RESULTS The blood temperature decreased faster by extracorporeal circuit cooling using CRRT than SC (9.8 ± 1.6 vs. 1.5 ± 0.4 °C/h, P < 0.01). Post-resuscitation renal and intestinal injury were significantly improved in the 2 hypothermic groups compared to the NT group. And the improvement was significantly greater in animals received extracorporeal circuit cooling than those received surface cooling, from both the results of biomarkers in serum and pathological evidence. CONCLUSION Fast hypothermia induced by extracorporeal circuit cooling was superior to. surface cooling in mitigating renal and intestinal injury post resuscitation.
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Affiliation(s)
- Jiangang Wang
- Hangzhou Emergency Medical Center of Zhejiang Province, Zhejiang, Hangzhou, China
| | - Lin Shi
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China; Institute of Emergency Medicine, Zhejiang University, Zhejiang, Hangzhou, China.
| | - Jiefeng Xu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China; Institute of Emergency Medicine, Zhejiang University, Zhejiang, Hangzhou, China.
| | - Wen Zhou
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China; Institute of Emergency Medicine, Zhejiang University, Zhejiang, Hangzhou, China
| | - Mao Zhang
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China; Institute of Emergency Medicine, Zhejiang University, Zhejiang, Hangzhou, China.
| | - Chunshuang Wu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China; Institute of Emergency Medicine, Zhejiang University, Zhejiang, Hangzhou, China
| | - Qijiang Chen
- Department of Intensive Care Medicine, The First Hospital of Ninghai, Zhejiang, Ningbo, China
| | - Xiaohong Jin
- Department of Emergency Medicine, The First People's Hospital of Wenling, Zhejiang, Taizhou, China
| | - Jungen Zhang
- Hangzhou Emergency Medical Center of Zhejiang Province, Zhejiang, Hangzhou, China.
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Wu C, Xu J, Jin X, Chen Q, Lu X, Qian A, Wang M, Li Z, Zhang M. Effects of therapeutic hypothermia on cerebral tissue oxygen saturation in a swine model of post-cardiac arrest. Exp Ther Med 2020; 19:1189-1196. [PMID: 32010288 PMCID: PMC6966162 DOI: 10.3892/etm.2019.8316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 11/01/2019] [Indexed: 11/08/2022] Open
Abstract
Since the introduction of therapeutic hypothermia (TH), trends have changed in the monitoring indicators used during and after cardiac arrest. During hypothermia, the cerebral metabolic rate of oxygen is reduced, which leads to uncertainty in regional cerebral tissue oxygen saturation (SctO2). The aim of the present study was to evaluate the effect of TH on changes in SctO2 using near-infrared spectroscopy. A total of 23 male domestic pigs were randomized into three groups: TH (n=9), normothermia (NT; n=9) and control (n=5). Animals in the control group underwent surgical preparation only. The animal models were established using 8 min of ventricular fibrillation and 5 min of cardiopulmonary resuscitation. In the TH group, at 5 min after resuscitation, the animals were cooled with a cooling blanket and ice packs for 24 h. SctO2 was recorded throughout the experiment. In all groups, The mean arterial pressure, arterial carbon dioxide partial pressure, arterial oxygen partial pressure, lactate, neuron-specific enolase (NSE) and S100B were measured at baseline and at 1, 3, 6, 12, 24 and 30 h after resuscitation. SctO2 significantly decreased after ventricular fibrillation, compared with the baseline. Following resuscitation, the SctO2 values gradually increased to 55.6±3.8% of baseline in the TH group and 51.2±3.5% in the NT group (P=0.039). Significant differences between the two groups were observed, starting at 6 h after cardiac arrest. Throughout the hypothermic period, NSE and S100B showed an increasing trend, then decreased during rewarming in the TH and NT groups. NSE and S100B showed greater improvement in the TH group compared with the NT group at 6 and 24 h after resuscitation. Following cardiac arrest, therapeutic hypothermia could increase SctO2 after resuscitation and could improve neurological outcome. In conclusion, SctO2 may be a feasible marker for use in the early assessment of brain damage during and after cardiac arrest.
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Affiliation(s)
- Chunshuang Wu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine and Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, P.R. China
| | - Jiefeng Xu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine and Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, P.R. China.,Department of Emergency Medicine, Yuyao People's Hospital, Ningbo, Zhejiang 315400, P.R. China
| | - Xiaohong Jin
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine and Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, P.R. China.,Department of Emergency Medicine, Wenling People's Hospital, Taizhou, Zhejiang 317500, P.R. China
| | - Qijiang Chen
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine and Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, P.R. China.,Department of Emergency Medicine, Ninghai People's Hospital, Ningbo, Zhejiang 315500, P.R. China
| | - Xiao Lu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine and Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, P.R. China
| | - Anyu Qian
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine and Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, P.R. China
| | - Moli Wang
- Department of Emergency Medicine, Yuyao People's Hospital, Ningbo, Zhejiang 315400, P.R. China
| | - Zilong Li
- Department of Emergency Medicine, Yuyao People's Hospital, Ningbo, Zhejiang 315400, P.R. China
| | - Mao Zhang
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine and Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, P.R. China
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Wu C, Xu J, Jin X, Chen Q, Li Z, Zhang M. Effect of mild hypothermia on lung injury after cardiac arrest in swine based on lung ultrasound. BMC Pulm Med 2019; 19:198. [PMID: 31690318 PMCID: PMC6833209 DOI: 10.1186/s12890-019-0958-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 10/14/2019] [Indexed: 12/16/2022] Open
Abstract
Background Lung injury is common in post-cardiac arrest syndrome, and is associated with increased morbidity and mortality. The aim of this study was to evaluate the effect of mild hypothermia on lung injury after cardiac arrest in swine based on lung ultrasound. Methods Twenty-three male domestic swine weighing 36 ± 2 kg were randomly assigned to three groups: therapeutic hypothermia (TH, n = 9), normothermia (NT, n = 9), and sham control (control, n = 5) groups. Sham animals only underwent surgical preparation. The animal model was established with 8 min of ventricular fibrillation followed by 5 min of cardiopulmonary resuscitation. Therapeutic hypothermia was induced and maintained until 24 h post-resuscitation in the TH group by surface blanket cooling, followed by rewarming at a rate of 1 °C/h for 5 h. The extravascular lung water index (ELWI), pulmonary vascular permeability index (PVPI), PO2/FiO2, and lung ultrasound score (LUS) were measured at baseline and at 1, 3, 6, 12, 24, and 30 h after resuscitation. After euthanizing the swine, their lung tissues were quickly obtained to evaluate inflammation. Results After resuscitation, ELWI and PVPI in the NT group were higher, and PO2/FiO2 was lower, than in the sham group. However, those measures were significantly better in the TH group than the NT group. The LUS was higher in the NT group than in the sham group at 1, 3, 6, 12, 24, and 30 h after resuscitation. The LUS was significantly better in the TH group compared to the NT group. The lung tissue biopsy revealed that lung injury was more severe in the NT group than in the TH group. Increases in LUS were highly correlated with increases in ELWI (r = 0.613; p < 0.001) and PVPI (r = 0.683; p < 0.001), and decreases in PO2/FiO2 (r = − 0.468; p < 0.001). Conclusions Mild hypothermia protected against post-resuscitation lung injury in a swine model of cardiac arrest. Lung ultrasound was useful to dynamically evaluate the role of TH in lung protection.
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Affiliation(s)
- Chunshuang Wu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Institute of Emergency Medicine, Zhejiang University, Hangzhou, China
| | - Jiefeng Xu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Institute of Emergency Medicine, Zhejiang University, Hangzhou, China
| | - Xiaohong Jin
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Institute of Emergency Medicine, Zhejiang University, Hangzhou, China.,Research fellow, from Department of Emergency Medicine, Wenling People's Hospital, Taizhou, China
| | - Qijiang Chen
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Institute of Emergency Medicine, Zhejiang University, Hangzhou, China.,Research fellow, from Department of Emergency Medicine, Ninghai People's Hospital, Ningbo, China
| | - Zilong Li
- Research fellow, from Department of Emergency Medicine, Yuyao People's Hospital, Ningbo, China
| | - Mao Zhang
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Institute of Emergency Medicine, Zhejiang University, Hangzhou, China.
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What's New in Shock, October 2019? Shock 2019; 52:397-399. [PMID: 31524815 DOI: 10.1097/shk.0000000000001398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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