Effect of Agkistrodon halys antivenom in patients bit by green pit viper and the prognostic role of the disease - a retrospective cohort study

BACKGROUND AND AIMS

In Mainland China and Hong Kong, health authorities utilize Agkistrodon halys antivenom in the treatment of patients who sustained bites from green pit vipers. However, the treatment benefit of Agkistrodon halys antivenom among such patients is still controversial. The purpose of this study is to evaluate the coagulation parameters normalization time of Agkistrodon halys antivenom in patients who sustained green pit viper bites and explore independent risk factors of patient prognosis.

METHODS

Data were extracted from the Donghua Hospital Information System. Comparison of the two groups of patients - who used antivenom (GPUA) and who did not use antivenom (GPNUA) were performed using stratified analysis, univariate and multivariate ordered logistic regression models to evaluate the coagulation parameters normalization time. Univariate and multivariate ordered logistic regression models were used to explore independent risk factors of patient prognosis.

RESULTS

Between the GPUA and GPNUA groups, there is no significant difference in the coagulation parameters normalization time with the treatment of Agkistrodon halys antivenom. GPNUA consumed more cryoprecipitate and platelets and had a lower cost. The patient's severity of the bite, first coagulation profile, and dosages of fresh frozen plasma, platelet, and red cell suspension was found to be risk factors for the normalization time of coagulation parameters.

CONCLUSIONS

The therapeutic effect of Agkistrodon halys antivenom in green pit vipers bite patients is not quite satisfying. In addition, more attention should be paid to the first coagulation profile, blood clotting factors indices, platelet count (PLT), and hemoglobin when treating such patients.

Development of an intensive simulating training program in emergency medicine for medical students in China

BACKGROUND

A national standardized emergency medicine (EM) curriculum for medical students, including specific competencies in procedural skills, are absent in many countries. The development of an intensive simulating training program in EM, based on a tight schedule, is anticipated to enhance the competency of medical students.

METHODS

A 3-day intensive EM training program, consisting of four procedural skills and 8-hour case-based learning (CBL), was developed by experienced physicians from the EM department in Peking Union Medical College Hospital (PUMCH). Medical students from Peking Union Medical College (PUMC) and Tsinghua University (THU) participated in the training. Three written tests were cautiously designed to examine the short-term (immediately after the program) and long-term (6 months after the program) efficacy of the training. After completion of the training program, an online personal appraisal questionnaire was distributed to the students on WeChat (a mobile messaging App commonly used in China) to achieve anonymous self-evaluation.

RESULTS

Ninety-seven out of 101 students completed the intensive training and took all required tests. There was a significant increase in the average score after the intensive simulating training program (pre-training 13.84 vs. 15.57 post-training, P<0.001). Compared with the pre-training test, 63 (64.9%) students made progress. There was no significant difference in scores between the tests taken immediately after the program and 6 months later (15.57±2.22 vs. 15.38±2.37, P=0.157). Students rated a higher score in all diseases and procedural skills, and felt that their learning was fruitful.

CONCLUSIONS

The introduction of a standardized intensive training program in EM focusing on key competencies can improve clinical confidence, knowledge, and skills of medical students toward the specialty. In addition, having such a program can also enhance student's interest in EM as a career choice which may enhance recruitment into the specialty and workplace planning.

Efficacy and safety of corticosteroids in immunocompetent patients with septic shock

BACKGROUND

The use of corticosteroids in septic shock has been studied for many decades but yielded conflicting results. We conducted a systematic review to evaluate the efficacy and the safety of corticosteroids in immunocompetent patients with septic shock.

METHODS

Medline via PubMed, Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, and EMBASE were searched from inception to March 2020. Two reviewers independently identified randomized controlled trials (RCTs) comparing corticosteroids with a control group for immunocompetent patients with septic shock. Data were abstracted and reported following the Cochrane Handbook for Systematic Review of Intervention and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The efficacy outcome included mortality and shock reversal. The safety outcomes were infection, gastrointestinal bleeding, and hyperglycemia.

RESULTS

Nine RCTs with a total of 1,298 patients were included. Compared with the control group, corticosteroid group did not lower the short-term (28 or 30 days) mortality (risk ratio [RR] 0.95, 95% confidence interval (CI) 0.85 to 1.06, inconsistency [I ²]=0%, trial sequential analysis [TSA]-adjusted CI 0.83 to 1.09, moderate-certainty evidence). Corticosteroids significantly shortened the time to shock reversal compared with the control group (mean difference [MD] -21.56 hours; 95% CI -32.95 to -10.16, I ²=0%; TSA-adjusted CI -33.33 to -9.78, moderate-certainty evidence). The corticosteroid treatment was associated with an increased risk of hyperglycemia but not the infection or gastrointestinal bleeding.

CONCLUSIONS

The corticosteroid treatment is not associated with lower short- or long- term mortality compared with placebo in immunocompetent patients with septic shock. However, corticosteroids significantly shorten the time to shock reversal without increasing the risk of infection. The patient's immune status should also be considered during clinical treatment and clinical trials in future.

Comparison of the anterior and posterior approach in treating four-level cervical spondylotic myelopathy

BACKGROUND

The optimal surgical approach for four-level cervical spondylotic myelopathy remains controversial. The purpose of this study was to compare clinical and radiological outcomes and complications between the anterior and posterior approaches for four-level cervical spondylotic myelopathy.

METHODS

A total of 19 patients underwent anterior decompression and fusion and 25 patients underwent posterior laminoplasty and instrumentation in this study. Perioperative information, intraoperative blood loss, clinical and radiological outcomes, and complications were recorded. Japanese Orthopedic Association (JOA) score, 36-item short form survey (SF-36) score and cervical alignment were assessed.

RESULTS

There were no significant differences in JOA scores between the anterior and posterior group preoperatively (11.6 ± 1.6 vs. 12.1 ± 1.5), immediately postoperatively (14.4 ± 1.1 vs. 13.8 ± 1.3), or at the last follow-up (14.6 ± 1.0 vs. 14.2 ± 1.1) (P > 0.05). The JOA scores significantly improved immediately postoperatively and at the last follow-up in both groups compared with their preoperative values. The recovery rate was significantly higher in the anterior group both immediately postoperatively and at the last follow-up. The SF-36 score was significantly higher in the anterior group at the last follow-up compared with the preoperative value (69.4 vs. 61.7). Imaging revealed that there was no significant difference in the Cobb angle at C2-C7 between the two groups preoperatively (-2.0° ± 7.3° vs. -1.4° ± 7.5°). The Cobb angle significantly improved immediately postoperatively (12.3° ± 4.2° vs. 9.2° ± 3.6°) and at the last follow-up (12.4° ± 3.5° vs. 9.0° ± 2.6°) in both groups compared with their preoperative values (P = 0.00). Three patients had temporary dysphagia in the anterior group and four patients had persistent axial symptoms in the posterior group.

CONCLUSIONS

Both the anterior and posterior approaches were effective in treating four-level cervical spondylotic myelopathy in terms of neurological clinical outcomes and radiological features. However, the JOA score recovery rate and SF-36 score in the anterior group were significantly higher. Persistent axial pain could be a major concern when undertaking the posterior approach.

Venous thromboembolism in the emergency department: A survey of current best practice awareness in physicians and nurses in China

BACKGROUND

For emergency department (ED) patients, risk assessment, prophylaxis, early diagnosis and appropriate treatment of venous thromboembolism (VTE) are essential for preventing morbidity and mortality. This study aimes to investigate knowledge amongst emergency medical staff in the management of VTE.

METHODS

We designed a questionnaire based on multiple scales. The questionnaire was distributed to the medical and nursing clinical staff in the large urban ED of a medical center in Northern China. Data was described with percentages and the Kruskal-Wallis test was used to compare ranked data between different groups. The statistical analysis was done using the SPSS 22.0 software.

RESULTS

In this survey, 180 questionnaires were distributed and 174 valid responses (response rate of 96.67%) were collected and analyzed. In scores of VTE knowledge, no significant differences were found with respect to job (doctor vs. nurse), the number of years working in clinical medicine, education level, and current position, previous hospital experience and nurses' current work location within the ED. However, in pair wise comparison, we found participants who worked in ED for more than 5 years (n=83) scored significantly higher on the questionnaire than those under 5 years (n=91) (95.75 vs. 79.97, P=0.039). There was a significant difference in some questions based on gender, age, job, and nurse work location, number of working years, education level, and different ED working lifetime.

CONCLUSION

Our survey has shown deficiencies among ED medical staff in knowledge and awareness of the management of VTE. We recommend several changes be considered, such as the introduction of an interdisciplinary workshop for medical staff; the introduction of a standardized VTE protocol; a mandatory study module on VTE for new physicians and nurses; the introduction of a mandatory reporting system for adverse events (including VTE).

Effect of Resveratrol on Preventing Steroid-induced Osteonecrosis in a Rabbit Model

Background:

Prevention of osteonecrosis (ON) has seldom been addressed. The purpose of this study was to evaluate the effect of resveratrol on preventing steroid-induced ON in rabbits.

Methods:

Seventy-two rabbits were divided into four groups: (1) NEC (ON) group: thirty rabbits were treated with lipopolysaccharide (LPS) once, then with methylprednisolone (MPS) daily for 3 days; (2) PRE (prevention) group: thirty rabbits were given one dose of LPS, then MPS daily for 3 days, and resveratrol on day 0 and daily for 2 weeks; (3) RES (resveratrol) group: six rabbits were given resveratrol for 2 weeks but without LPS/MPS; (4) CON (control) group: six rabbits were given alcohol for 2 weeks but without LPS/MPS. Levels of plasma tissue-type plasminogen activator (t-PA), plasminogen activator inhibitor 1 (PAI-1), thrombomodulin (TM), vascular endothelial growth factor (VEGF), maximum enhancement (ME) by magnetic resonance imaging, and ON incidence were evaluated.

Results:

The PRE group had a lower ON incidence than the NEC group, but with no significant differences at 2 weeks and 12 weeks. The RES and CON groups did not develop ON. TM and VEGF were significantly higher in the NEC group compared with the PRE group at weeks 1, 2, and 4 (TM: 1 week, P = 0.029; 2 weeks, P = 0.005; and 4 weeks, P = 0.047; VEGF: 1 week, P = 0.039; 2 weeks, P = 0.021; 4 weeks, P = 0.014), but the difference disappeared at 12 weeks. The levels of t-PA and PAI-1 were not significantly different between the NEC and PRE groups. The TM, t-PA, PAI-1, and VEGF concentrations in the RES and CON groups did not change over time. Compared to the baseline, ME in the NEC group decreased significantly (P = 0.025) at week 1, increased significantly (P = 0.021) at week 2, and was decreased at week 12. The variance was insignificant in the PRE group.

Conclusions:

Resveratrol may improve blood supply to bone in a rabbit model of ON of the femoral head via anti-inflammatory effects to protect the vascular endothelium and reduce thrombosis.

Surgical Fixation of Fourth and Fifth Metacarpal Shaft Fractures with Flexible Intramedullary Absorbable Rods: Early Clinical Outcomes and Implications

Background:

To avoid the irritation of tendons and soft tissues as well as hardware-related problems, we designed an intramedullary fixation with bioabsorbable rods for the treatment of the metacarpal shaft fractures.

Methods:

Five patients with nine shaft fractures of the fourth and fifth metacarpi were treated with intramedullary absorbable implants and followed up with an average of 4.2 months postoperatively.

Results:

At final follow-up, all patients achieved fracture union with no signs of inflammatory or subcutaneous effusion. There was no shortening, angulatory, or rotatory deformity. There was almost full active extension range of motion (ROM) of the metacarpophalangeal joints while the active flexion ROM of these joints was 80.7 ± 9.6°. Compared with the contralateral hand, the grip strength of the injured hand was 94.0 ± 9.6%. X-rays showed that the arch of the second to fifth metacarpal heads was smooth. There were no intramedullary lytic changes and soft tissue swellings.

Conclusion:

The intramedullary absorbable implants are a safe, simple, and practical treatment for fourth and fifth metacarpal fractures with good early clinical outcomes and no significant complications.

TRANSPLANTATION OF HYPERTHERMIC PRECONDITIONING OLFACTORY ENSHEATHING CELLS COMBINED WITH NEURAL STEM CELLS IN THE TREATMENT OF CENTRAL NERVE INJURY

This study aims to observe the effect of the transplantation of hyperthermic preconditioning (HPC) olfactory ensheathing cells (OECs) at 40°C combined with neural stem cells (NSCs) in the treatment of spinal cord injury (SCI), based on the OECs and NSCs taken from the olfactory bulbs and cerebral cortex of newborn rats. Forty-two female Sprague Dawley (SD) rats were randomly divided into: control group, NSCs+OECs without HPC group and NSCs+HPC OECs group. Firstly, hemisected spinal cord injury model was established; the motor function recovery of the right lower limb of the rats was compared by Basso-Beatie-Bresnahan rating (BBB rating), climbing score and running time on a rotating platform during the whole experiment. At one day, two weeks and four weeks after transplantation, two rats were randomly selected from each group for section preparation. Hematoxylin and eosin (HE) staining was performed on the sections to observe and analyze the pathological changes of the spinal cord tissue, and bromodeoxyuridine (BrdU) labeling was used to observe the distribution of transplanted cells. The results demonstrated that, BBB score of the rats that were treated by transplantation of NSCs combined with HPC OCEs was distinctly improved; a rapid increase of BBB score was found two weeks after transplantation, while BBB score had slightly increased six weeks later. BBB score of the control group and the NSCs+OECs without HPC group was found with a slight increase, especially in the control group. BBB score of NSCs+HPC OECs was significantly higher than in the control group and the NSCs+OECs without HPC group at the 2nd, 4th, 6th, 8th and 12th week after treatment (P<0.05). Climbing tests and detection of running time after 4 weeks and 6 weeks demonstrated that, the recovery of limb function of the NSCs+HPC OECs group was better than the other groups (P<0.05). HE staining results of NSCs+HPC OECs indicated that, cells of the spinal cord were neatly arranged, close to normal. BrdU labeling results revealed that, transplanted cells were found in injury tissue, indicating that they were involved in the spinal cord repair. This study proves that, the effect of NSCs combined with HPC OECs in the treatment of SCI is better than NSCs combined with OECs without HPC, and the ratio of NSCs differentiating to neuron after inducing HPC OECs supernate is higher than that after inducing OECs supernate without HPC.

Clinical research of persimmon leaf extract and ginkgo biloba extract in the treatment of vertebrobasilar insufficiency

This paper aims to compare the curative effects of persimmon leaf extract and ginkgo biloba extract in the treatment of headache and dizziness caused by vertebrobasilar insufficiency. Sixty patients were observed, who underwent therapy with persimmon leaf extract and ginkgo biloba extract based on the treatment of nimodipine and aspirin. After 30 days, 30 patients treated with persimmon leaf extract and 30 patients with ginkgo biloba extract were examined for changes in hemodynamic indexes and symptoms, such as headache and dizziness. The results showed statistically significant differences of 88.3% for the persimmon leaf extract and 73.1% for the ginkgo biloba extract, P < 0.05. Compared to the group of ginkgo biloba extract, the group of persimmon leaf extract had more apparent improvement in the whole blood viscosity, plasma viscosity, fibrinogen, hematokrit, and platelet adhesion rate, and the difference was statistically significant (P < 0.05 or P < 0.01). Based on these analyses, it can be concluded that persimmon leaf extract is better than ginkgo biloba extract in many aspects, such as cerebral circulation improvement, cerebral vascular expansion, hypercoagulable state lowering and vertebrobasilar insufficiency-induced headache and dizziness relief.

Full-valve annuloplasty in treatment of primary deep venous valvular incompetence of the lower extremities

Full-valve annuloplasty of superficial femoral venous valves was performed successfully in 139 extremities affected with primary deep venous incompetence of the lower limb. Chronic ulcerations in 43 affected extremities healed after operation. Postoperative venography showed that the recovery rate of valvular function was 97%, and no serious complication was noted. Follow-up for a mean of 3.5 years showed no varicosed vein and no recurrence of ulceration. The principles of operation, the optimum site, number and degree of annuloplasty, indications and results of the operation were discussed.