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Barletta JF, Palmieri TL, Toomey SA, Harrod CG, Murthy S, Bailey H. Management of Heat-Related Illness and Injury in the ICU: A Concise Definitive Review. Crit Care Med 2024; 52:362-375. [PMID: 38240487 DOI: 10.1097/ccm.0000000000006170] [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: 02/22/2024]
Abstract
OBJECTIVES The increasing frequency of extreme heat events has led to a growing number of heat-related injuries and illnesses in ICUs. The objective of this review was to summarize and critically appraise evidence for the management of heat-related illnesses and injuries for critical care multiprofessionals. DATA SOURCES Ovid Medline, Embase, Cochrane Clinical Trials Register, Cumulative Index to Nursing and Allied Health Literature, and ClinicalTrials.gov databases were searched from inception through August 2023 for studies reporting on heat-related injury and illness in the setting of the ICU. STUDY SELECTION English-language systematic reviews, narrative reviews, meta-analyses, randomized clinical trials, and observational studies were prioritized for review. Bibliographies from retrieved articles were scanned for articles that may have been missed. DATA EXTRACTION Data regarding study methodology, patient population, management strategy, and clinical outcomes were qualitatively assessed. DATA SYNTHESIS Several risk factors and prognostic indicators for patients diagnosed with heat-related illness and injury have been identified and reported in the literature. Effective management of these patients has included various cooling methods and fluid replenishment. Drug therapy is not effective. Multiple organ dysfunction, neurologic injury, and disseminated intravascular coagulation are common complications of heat stroke and must be managed accordingly. Burn injury from contact with hot surfaces or pavement can occur, requiring careful evaluation and possible excision and grafting in severe cases. CONCLUSIONS The prevalence of heat-related illness and injury is increasing, and rapid initiation of appropriate therapies is necessary to optimize outcomes. Additional research is needed to identify effective methods and strategies to achieve rapid cooling, the role of immunomodulators and anticoagulant medications, the use of biomarkers to identify organ failure, and the role of artificial intelligence and precision medicine.
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Affiliation(s)
- Jeffrey F Barletta
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Glendale Campus, AZ
| | - Tina L Palmieri
- Burn Division, Department of Surgery, Shriners Hospitals for Children Northern California, Sacramento, CA
| | - Shari A Toomey
- Respiratory Department/Sleep Center, Carilion Clinic Children's Hospital, Roanoke, VA
| | | | - Srinivas Murthy
- Department of Pediatrics, BC Children's Hospital, Vancouver, BC, Canada
| | - Heatherlee Bailey
- Department of Emergency Medicine, Durham Veterans Affairs Medical Center, Durham, NC
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Zhong L, Shuai F, Wang C, Han L, Liu Z, Wu M. Serum procalcitonin levels are associated with rhabdomyolysis following exertional heatstroke: an over 10-year intensive care survey. World J Emerg Med 2024; 15:23-27. [PMID: 38188547 PMCID: PMC10765085 DOI: 10.5847/wjem.j.1920-8642.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND Heatstroke has become a common emergency event in hospitals. Procalcitonin (PCT) is used as a biomarker of infection in the emergency department (ED), but its role in rhabdomyolysis (RM) following exertional heatstroke (EHS) remains unclear. METHODS A retrospective cohort study enrolled patients with EHS from the intensive care unit (ICU). We collected RM biomarkers, inflammation markers, critical disease scores at admission, 24 h, 48 h, and discharge, and 90-day mortality. Correlation analysis, linear regression and curve fitting were used to identify the relationship between PCT and RM. RESULTS A total of 162 patients were recruited and divided into RM (n=56) and non-RM (n=106) groups. PCT was positively correlated with myoglobin (Mb), acute hepatic injury, disseminated intravascular coagulation (DIC), Sequential Organ Failure Assessment (SOFA) score, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score, with correlation coefficients of 0.214, 0.237, 0.285, 0.454, and 0.368, respectively (all P<0.05). Interestingly, the results of curve fitting revealed a nonlinear relationship between PCT and RM, and a two-piecewise linear regression model showed that PCT was related to RM with an odds ratio of 1.3 and a cut-off of <4.6 ng/mL. Survival analysis revealed that RM was associated with higher mortality compared to non-RM cases (P=0.0093). CONCLUSION High serum PCT concentrations are associated with RM after EHS in critically ill patients. Elevated PCT concentrations should be interpreted cautiously in patients with EHS in the ED.
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Affiliation(s)
- Li Zhong
- Department of Traditional Chinese Medicine, the First Affiliated Hospital, Guizhou University of Chinese Medicine, Guiyang 550001, China
- Department of Medical Critical Care Medicine, General Hospital of Southern Theatre Command of People’s Liberation Army, Guangzhou 510010, China
| | - Feifei Shuai
- Department of Infection and Critical Care Medicine, Shenzhen Second People’s Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen 518035, China
- Department of Nosocomial Infection Prevention and Control, Shenzhen Second People’s Hospital, Shenzhen 518035, China
| | - Conglin Wang
- Department of Medical Critical Care Medicine, General Hospital of Southern Theatre Command of People’s Liberation Army, Guangzhou 510010, China
- Key Laboratory of Hot Zone Trauma Care and Tissue Repair of People’s Liberation Army, General Hospital of Southern Theatre Command of People’s Liberation Army, Guangzhou 510010, China
| | - Lipeng Han
- Department of Traditional Chinese Medicine, the First Affiliated Hospital, Guizhou University of Chinese Medicine, Guiyang 550001, China
| | - Zhifeng Liu
- Department of Medical Critical Care Medicine, General Hospital of Southern Theatre Command of People’s Liberation Army, Guangzhou 510010, China
- Key Laboratory of Hot Zone Trauma Care and Tissue Repair of People’s Liberation Army, General Hospital of Southern Theatre Command of People’s Liberation Army, Guangzhou 510010, China
| | - Ming Wu
- Department of Infection and Critical Care Medicine, Shenzhen Second People’s Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen 518035, China
- Department of Nosocomial Infection Prevention and Control, Shenzhen Second People’s Hospital, Shenzhen 518035, China
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Pei Y, Ma W, Wang H, Chen F, Xiao W, Fan M, Han X, Cao Y. Mesenchymal stem cell-derived exosomal miR-548x-3p inhibits pyroptosis of vascular endothelial cells through HMGB1 in heat stroke. Genomics 2023; 115:110719. [PMID: 37757977 DOI: 10.1016/j.ygeno.2023.110719] [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: 03/30/2023] [Revised: 09/13/2023] [Accepted: 09/24/2023] [Indexed: 09/29/2023]
Abstract
Heat stroke (HS) is an acute physical illness associated with a higher risk of organ dysfunction. This study is the first to explore exosomal miR-548x-3p derived from human bone marrow mesenchymal stem cells (BMSCs) in the pyroptosis of vascular endothelial cells (VECs) associated with HS. Human BMSCs-derived exosome alleviated the injury of the heart, liver, kidney and ileum tissues, the increase of IL-1β, IL-18 and TNF-α levels, pyroptosis of endothelial cells and the increase of HGMB1, NLRP3, ASC, caspase1 and GSDMD-N protein expression in HS mice and HS-induced human umbilical vein endothelial cells (HUVECs). miR-548x-3p was down-expressed in HS patients, while up-expressed in BMSCs-derived exosome. BMSCs-ExomiR-548x-3p mimics to inhibit pyroptosis, inflammation and HGMB1/NLRP3 activation in HS-induced HUVECs and HS mice, which were blocked by overexpression of HMGB1. In conclusion, human BMSCs-derived exosomes carried miR-548x-3p mimics to inhibit pyroptosis of VECs through HMGB1 in HS mice.
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Affiliation(s)
- Yanfang Pei
- Department of Emergency, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, China
| | - Wenfeng Ma
- Department of Emergency, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, China
| | - Huifang Wang
- Department of Emergency, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, China
| | - Fang Chen
- Institute of Emergency Medicine, Hunan Provincial Key Laboratory of Emergency and Critical Care Metabonomics, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, China
| | - Weiwei Xiao
- Department of Emergency, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, China
| | - Maiying Fan
- Department of Emergency, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, China
| | - Xiaotong Han
- Department of Emergency, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, China
| | - Yan Cao
- Department of Emergency, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, China.
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Iba T, Helms J, Levi M, Levy JH. Inflammation, coagulation, and cellular injury in heat-induced shock. Inflamm Res 2023; 72:463-473. [PMID: 36609608 DOI: 10.1007/s00011-022-01687-8] [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: 09/11/2022] [Revised: 09/29/2022] [Accepted: 12/31/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The number of heatstroke victims hit record numbers in 2022 as global warming continues. In heat-induced injuries, circulatory shock is the most severe and deadly complication. This review aims to examine the mechanisms and potential approaches to heat-induced shock and the life-threatening complications of heatstroke. METHODS A computer-based online search was performed using the PubMed database and Web of Science database for published articles concerning heatstroke, shock, inflammation, coagulopathy, endothelial cell, cell death, and heat shock proteins. RESULTS Dehydration and heat-induced cardiomyopathy were reported as the major causes of heat-induced shock, although other heat-induced injuries are also involved in the pathogenesis of circulatory shock. In addition to dehydration, the blood volume decreases considerably due to the increased vascular permeability as a consequence of endothelial damage. Systemic inflammation is induced by factors that include elevated cytokine and chemokine levels, dysregulated coagulation/fibrinolytic responses, and the release of damage-associated molecular patterns (DAMPs) from necrotic cell death that cause distributive shock. The cytoprotective heat shock proteins can also facilitate circulatory disturbance under excess heat stress. CONCLUSIONS Multiple mechanisms are involved in the pathogenesis of heat-induced shock. In addition to dehydration, heat stress-induced cardiomyopathy due to the thermal damage of mitochondria, upregulated inflammation via damage-associated molecular patterns released from oncotic cells, unbalanced coagulation/fibrinolysis, and endothelial damage are the major factors that are related to circulatory shock.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Julie Helms
- Medical Intensive Care Unit-NHC, Strasbourg University (UNISTRA) Strasbourg University Hospital INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Department of Medicine, University College London Hospitals NHS Foundation Trust, and Cardio-Metabolic Programme-NIHR UCLH/UCL BRC, London, UK
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
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Chen Y, Zhu J, Ji J, Liu Z, Ren G. The role of microglial exosomes in brain injury. Front Cell Neurosci 2022; 16:1003809. [DOI: 10.3389/fncel.2022.1003809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022] Open
Abstract
Microglia are involved in immune responses to central nervous system (CNS) injury. Meanwhile, exosomes derived from microglia are important mediators of information and material exchange in brain, which play an important role in neuroprotective or damaging effects. Microglial exosomes contain a variety of molecular cargos, including microRNAs, soluble proteins, and lipids, which have regulatory effects on other types of cells and microenvironment in brain. In this review, we summarized microglial exosome characteristics, release patterns, pro-proliferative and pro-apoptotic effects on neurons and other glial cells, immunomodulatory effects, and regulation of the extracellular microenvironment. Understanding the relationship between microglia exosomes and brain injury can provide new targets for clinical treatment.
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Schlader ZJ, Davis MS, Bouchama A. Biomarkers of heatstroke-induced organ injury and repair. Exp Physiol 2022; 107:1159-1171. [PMID: 35654394 PMCID: PMC9529995 DOI: 10.1113/ep090142] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 05/19/2022] [Indexed: 11/08/2022]
Abstract
NEW FINDINGS What is the topic of this review? The status and potential role of novel biological markers (biomarkers) that can help identify the patients at risk of organ injury or long-term complications following heatstroke. What advances does it highlight? Numerous biomarkers were identified related to many aspects of generalized heatstroke-induced cellular injury and tissue damage, and heatstroke-provoked cardiovascular, renal, cerebral, intestinal and skeletal muscle injury. No novel biomarkers were identified for liver or lung injury. ABSTRACT Classic and exertional heatstroke cause acute injury and damage across numerous organ systems. Moreover, heatstroke survivors may sustain long-term neurological, cardiovascular and renal complications with a persistent risk of death. In this context, biomarkers, defined as biological samples obtained from heatstroke patients, are needed to detect early organ injury, and predict outcomes to develop novel organ preservation therapeutic strategies. This narrative review provides preliminary insights that will guide the development and future utilization of these biomarkers. To this end, we have identified numerous biomarkers of widespread heatstroke-associated cellular injury, tissue damage and repair (extracellular heat shock proteins 72 and 60, high mobility group box protein 1, histone H3, and interleukin-1α), and other organ-specific biomarkers including those related to the cardiovascular system (cardiac troponin I, endothelium-derived factors, circulation endothelial cells, adhesion molecules, thrombomodulin and von Willebrand factor antigen), the kidneys (plasma and urinary neutrophil gelatinase-associated lipocalin), the intestines (intestinal fatty acid-binding protein 2), the brain (serum S100β and neuron-specific enolase) and skeletal muscle (creatine kinase, myoglobin). No specific biomarkers have been identified so far for liver or lung injury in heatstroke. Before translating the identified biomarkers into clinical practice, additional preclinical and clinical prospective studies are required to further understand their clinical utility, particularly for the biomarkers related to long-term post-heatstroke health outcomes.
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Affiliation(s)
- Zachary J. Schlader
- Department of Kinesiology, School of Public Health, Indiana University, Bloomington, IN, USA
| | - Michael S. Davis
- Department of Physiological Sciences, College of Veterinary Medicine, Oklahoma State University, Stillwater, OK, USA
| | - Abderrezak Bouchama
- Department of Experimental Medicine, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard — Health Affairs, Riyadh, Saudi Arabia
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Ligi D, Maniscalco R, Plebani M, Lippi G, Mannello F. Do Circulating Histones Represent the Missing Link among COVID-19 Infection and Multiorgan Injuries, Microvascular Coagulopathy and Systemic Hyperinflammation? J Clin Med 2022; 11:jcm11071800. [PMID: 35407410 PMCID: PMC8999947 DOI: 10.3390/jcm11071800] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/21/2022] [Accepted: 03/23/2022] [Indexed: 02/07/2023] Open
Abstract
Several studies shed light on the interplay among inflammation, thrombosis, multi-organ failures and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Increasing levels of both free and/or circulating histones have been associated to coronavirus disease 2019 (COVID-19), enhancing the risk of heart attack and stroke with coagulopathy and systemic hyperinflammation. In this view, by considering both the biological and clinical rationale, circulating histones may be relevant as diagnostic biomarkers for stratifying COVID-19 patients at higher risk for viral sepsis, and as predictive laboratory medicine tool for targeted therapies.
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Affiliation(s)
- Daniela Ligi
- Unit of Clinical Biochemistry, Department of Biomolecular Sciences-DISB, University of Urbino Carlo Bo, 61029 Urbino, Italy
| | - Rosanna Maniscalco
- Unit of Clinical Biochemistry, Department of Biomolecular Sciences-DISB, University of Urbino Carlo Bo, 61029 Urbino, Italy
| | - Mario Plebani
- Department of Medicine-DIMED, University of Padua, 35128 Padua, Italy
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University Hospital of Verona, 37134 Verona, Italy
| | - Ferdinando Mannello
- Unit of Clinical Biochemistry, Department of Biomolecular Sciences-DISB, University of Urbino Carlo Bo, 61029 Urbino, Italy
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Neurodegenerative Disease-Associated TDP-43 Fragments Are Extracellularly Secreted with CASA Complex Proteins. Cells 2022; 11:cells11030516. [PMID: 35159325 PMCID: PMC8833957 DOI: 10.3390/cells11030516] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/26/2022] [Accepted: 01/31/2022] [Indexed: 02/04/2023] Open
Abstract
Extracellular vesicles (EVs) play a central role in neurodegenerative diseases (NDs) since they may either spread the pathology or contribute to the intracellular protein quality control (PQC) system for the cellular clearance of NDs-associated proteins. Here, we investigated the crosstalk between large (LVs) and small (SVs) EVs and PQC in the disposal of TDP-43 and its FTLD and ALS-associated C-terminal fragments (TDP-35 and TDP-25). By taking advantage of neuronal cells (NSC-34 cells), we demonstrated that both EVs types, but particularly LVs, contained TDP-43, TDP-35 and TDP-25. When the PQC system was inhibited, as it occurs in NDs, we found that TDP-35 and TDP-25 secretion via EVs increased. In line with this observation, we specifically detected TDP-35 in EVs derived from plasma of FTLD patients. Moreover, we demonstrated that both neuronal and plasma-derived EVs transported components of the chaperone-assisted selective autophagy (CASA) complex (HSP70, BAG3 and HSPB8). Neuronal EVs also contained the autophagy-related MAP1LC3B-II protein. Notably, we found that, under PQC inhibition, HSPB8, BAG3 and MAP1LC3B-II secretion paralleled that of TDP-43 species. Taken together, our data highlight the role of EVs, particularly of LVs, in the disposal of disease-associated TDP-43 species, and suggest a possible new role for the CASA complex in NDs.
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Wu M, Wang C, Zhong L, Liu Z. Serum myoglobin as predictor of acute kidney injury and 90-day mortality in patients with rhabdomyolysis after exertional heatstroke: an over 10-year intensive care survey. Int J Hyperthermia 2022; 39:446-454. [PMID: 35260032 DOI: 10.1080/02656736.2022.2046183] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE Rhabdomyolysis (RM) in exertional heatstroke (EHS) often leads to multiple organ dysfunction including acute kidney injury (AKI). Studies have shown that serum creatine kinase (CK) >1000 U/L as a serological diagnostic criterion for RM does not reflect the risk of AKI or mortality. METHODS This longitudinal cohort study included all patients with EHS who were admitted to intensive care unit between January 2008 and June 2019. Serum myoglobin (sMb) was studied as the serological marker of RM and compared with CK. Outcome events were AKI and 90-day mortality. RESULTS A total of 161 patients were enrolled, of whom 52 (32.3%) had sMb ≥1000 ng/mL. Patients with sMb ≥1000 ng/mL had higher SOFA score, higher APACHE II score, lower GCS score, and higher incidence of disseminated intravascular coagulation, acute myocardial injury, acute liver injury, AKI, and 90-day mortality than patients with sMb <1000 ng/mL. Lymphocytes, neutrophils, D-Dimer were risk factors for AKI in patients with sMb ≥1000 ng/mL. Curve fitting showed a curved relationship between sMb and EHS-induced AKI but not CK. sMb ≥1000 ng/mL showed better predictive ability for AKI (area under curve: 0.786). APACHE II, SOFA, and GCS scores were risk factors for 90-day mortality in patients with sMb ≥1000 ng/mL. CONCLUSION Serum myoglobin is a better predictor of AKI and 90-day mortality than CK in patients with RM after EHS.
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Affiliation(s)
- Ming Wu
- Department of Critical Care Medicine and Hospital Infection Prevention and Control, Shenzhen Second People's Hospital and First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, China
- Shantou University Medical College, Shantou, China
| | - Conglin Wang
- Department of Critical Care Medicine, General Hospital of Southern Theatre Command of Peoples Liberation Army, Guangzhou, China
| | - Li Zhong
- Department of Critical Care Medicine, The First Affiliated Hospital, Guizhou University of Chinese Medicine, Guiyang, China
| | - Zhifeng Liu
- Department of Critical Care Medicine, General Hospital of Southern Theatre Command of Peoples Liberation Army, Guangzhou, China
- Key Laboratory of Hot Zone Trauma Care and Tissue Repair of Peoples Liberation Army, General Hospital of Southern Theatre Command of Peoples Liberation Army, Guangzhou, China
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