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Purpose: The predominant symptom of pheochromocytomas and paragangliomas (PPGLs) is variable hypertension (HTN); however, not all patients with PPGLs develop HTN. Studies of the clinical characteristics of normotensive patients and which patients are more likely to develop HTN in PPGLs are rare. This study was performed to identify the clinical features to better understand this clinical entity. Methods: All consecutive adult patients with PPGLs were retrospectively enrolled from January 2018 to June 2020. The clinical characteristics of the patients were investigated. Multivariate logistic regression analysis was used to identify risk factors and receiver operating characteristic curves were used to evaluate the diagnostic performance of the variables. Results: There were 203 patients in the analysis, including 115 patients with normotension. Fewer patients with normotensive PPGLs had diabetes (p< 0.001) and clinical symptoms (p< 0.001). The 24-h urinary epinephrine (p= 0.002) and 24-h urinary norepinephrine (24hU-NE) concentrations (p< 0.001) were lower, and tumor diameter (p< 0.001) was smaller in patients with normotensive PPGLs. Multivariate logistic regression analysis showed that diabetes and 24hU-NE concentration were independent and negative risk factors for normotensive PPGLs. The area under the curve of 24hU-NE concentration and diabetes for predicting normotensive PPGLs was 0.788 and 0.634, respectively. Combining diabetes and 24hU-NE concentration into one model, the area under the curve of the model for predicting normotensive PPGLs was 0.817. Conclusions: Normal blood pressure could not exclude PPGLs. Identifying the clinical characteristics of normotensive and hypertensive patients in PPGLs is helpful for risk stratification and individualized assessment and treatment.

Background:Sepsis-associated encephalopathy (SAE) is a dysfunction of the central nervous system experienced during sepsis with variable clinical and pathophysiologic features. We sought to identify distinct SAE phenotypes in relation to clinical outcomes. Methods:The Medical Information Mart for Intensive Care IV (MIMIC-IV) database and the eICU database were used to conduct a retrospective cohort study. Adult sepsis patients were included and SAE was defined as having a Glasgow Coma Scale (GCS) score ˂15 or delirium. The following our clinical phenotypes were defined as: ischemic-hypoxic, metabolic, mixed (ischemic-hypoxic and metabolic), and unclassified. The primary outcome was in-hospital mortality. Results:The study enrolled 4,120 sepsis patients, 2,239 from MIMIC-IV (including 1,489 patients with SAE, 67%), and 1,881 from eICU (1,291, 69%). For the SAE cohort, 2,780 patients in total were enrolled (median age, 67 years; interquartile range, 56–76.8; 1,589 (57%) were male; median GCS score was 12 [8–14]; median Sequential Organ Failure Assessment score was 6 [4–9]). The SAE phenotype distributions between the MIMIC-IV and eICU cohorts were as follows (39% vs. 35% ischemic-hypoxic, P= 0.043; 38% vs.40% metabolic, P= 0.239; 15% vs. 15% mixed, P= 0.972; 38% vs. 40% unclassified, P= 0.471). For the overall cohort, the in-hospital mortality for patients with ischemic-hypoxic, metabolic, mixed, or unclassified phenotypes was 33.9% (95% confidence interval, 0.3–0.37), 28.4% (0.26–0.31), 41.5% (0.37–0.46), and 14.2% (0.12–0.16), respectively. In the multivariable logistic analysis, the mixed phenotype was associated with the highest risk of in-hospital mortality after adjusting for age, sex, GCS, and modified Sequential Organ Failure Assessment score (adjusted odds ratio, 2.11; 95% confidence interval, 1.67–2.67; P< 0.001). Conclusions:Four SAE phenotypes had different clinical outcomes. The mixed phenotype had the worst outcomes. Further understanding of these phenotypes in sepsis may improve trial design and targeted SAE management.

Background: Appropriate lessons and formalized training concerning emergency medicine is becoming increasingly important in undergraduate medical education. There is an urgent need to evaluate undergraduate emergency medicine education of students enrolled on the 8-year Doctor of Medicine degree programs nationwide in China with the aim that the data extracted could ultimately be used to help develop a standardized emergency medicine curriculum in China.Objectives: The aim of the study is to accurately describe emergency medicine education of 8-year Doctor of Medicine program in China, including emergency medicine classes, clinical practice in emergency medicine department, and expectations toward emergency medicine education.Methods: An online questionnaire was distributed to all the medical students of 8-year Doctor of Medicine program who have attended emergency medicine education in 14 medical schools in China. Participation in the survey was voluntary and anonymized.Results: In total, 529 valid responses were collected. There was a clear difference between students with a career aspiration in emergency medicine and those without. Comparing to countries that have an established emergency medicine curriculum, shortage of classroom hours and clinical practice time is a major cause of unsatisfactory educational outcomes in China. A detailed uniform emergency medicine curriculum that outlines exact requirements for medical students is required as well.Conclusion: A consolidated syllabus and curriculum should be compiled by all the medical schools with the 8-year integrated Doctor of Medicine degree program in China. The specific diseases and skills that should be covered in emergency medical education remain up to debate.

Appropriate lessons and formalized training concerning emergency medicine is becoming increasingly important in undergraduate medical education. There is an urgent need to evaluate undergraduate emergency medicine education of students enrolled on the 8-year Doctor of Medicine degree programs nationwide in China with the aim that the data extracted could ultimately be used to help develop a standardized emergency medicine curriculum in China. The aim of the study is to accurately describe emergency medicine education of 8-year Doctor of Medicine program in China, including emergency medicine classes, clinical practice in emergency medicine department, and expectations toward emergency medicine education. An online questionnaire was distributed to all the medical students of 8-year Doctor of Medicine program who have attended emergency medicine education in 14 medical schools in China. Participation in the survey was voluntary and anonymized. In total, 529 valid responses were collected. There was a clear difference between students with a career aspiration in emergency medicine and those without. Comparing to countries that have an established emergency medicine curriculum, shortage of classroom hours and clinical practice time is a major cause of unsatisfactory educational outcomes in China. A detailed uniform emergency medicine curriculum that outlines exact requirements for medical students is required as well. A consolidated syllabus and curriculum should be compiled by all the medical schools with the 8-year integrated Doctor of Medicine degree program in China. The specific diseases and skills that should be covered in emergency medical education remain up to debate.

The development of growth factor-free biomaterials for bone tissue regeneration with anti-infection and anti-inflammatory activities remains challenging. Black phosphorus nanosheets (BPNs), with distinctive attributes, including photothermal conversion and calcium ion chelation, offer potential for use in bone tissue engineering and infection prevention. However, BPNs are prone to oxidation and degradation in aqueous environments, and methods to stabilize BPNs for long-term bone repair remain insufficient. Herein, zeolitic imidazolate framework-8 (ZIF-8) was used to stabilize BPNs via in situ crystallization onto the surface of BPNs (BP@ZIF-8 nanocomposite). A novel injectable dual-component hydrogel comprising gelatin methacryloyl (GelMA) and methacrylate-modified hyaluronic acid (HAMA) was used as a BP@ZIF-8 nanocomposite carrier (GelMA/HAMA/BP@ZIF-8). The BP@ZIF-8 nanocomposite could effectively protect internal BPNs from oxidation and enhance the long-term photothermal performance of the hydrogel in both in vitro and in vivo settings. The GelMA/HAMA/BP@ZIF-8 hydrogel was injectable and exhibited outstanding performance for photothermal conversion, mechanical strength, and biodegradability, as well as excellent photothermal antibacterial activity against Staphylococcus aureusand Escherichia coliin vitro and in an in vivo rat model. The GelMA/HAMA/BP@ZIF-8 hydrogel also provided a microenvironment conducive to osteogenic differentiation, promoting the transformation of M2 macrophages and inhibiting inflammatory responses. Furthermore, the hydrogel promoted bone regeneration and had a synergistic effect with near-infrared irradiation in a rat skull-defect model. Transcriptome sequencing analysis revealed that the PI3K-AKT- and calcium-signaling pathways may be involved in promoting osteogenic differentiation induced by the GH-BZ hydrogel. This study presents an innovative, multifaceted solution to the challenges of bone tissue regeneration with antibacterial and anti-inflammatory effects, providing insights into the design of smart biomaterials with dual therapeutic capabilities.

Background: The inflammatory immune response is involved in the pathophysiology of the post-cardiac arrest syndrome and leads to high mortality. The admission (neutrophil + monocyte) to lymphocyte ratio (NMLR) can help us to assess the immune inflammatory status of patients. We aimed to identify factors that affect the prognosis and explore the association between NMLR and the prognosis of patients after cardiopulmonary resuscitation (CPR). Methods: This is a retrospective study based on the MIMIC-IV database. We assessed patients admitted to the ICU after cardiopulmonary resuscitation, included demographic characteristics, peripheral blood cell count and blood gas indicators for the first time after admission to the ICU, developed a multivariate COX proportional-hazards model to explore prognostic factors, and divided patients into High NMLR and Low NMLR groups by cutoff values of NMLR. Propensity score matching (PSM) was used to adjust confounding factors. Results: A total of 955 patients were included in the analysis, with 497 surviving and 458 dying during the follow-up period. In a multivariate Cox proportional-hazards model, age (RR 1.007, p= 0.0411), NMLR levels (RR 1.003, p= 0.0381), lactate (RR 1.097, p&lt; 0.001) and hematocrit (RR 1.101, p&lt; 0.001) were independent risk factors for patient death following CPR. Patients were divided into a high NMLR group (> 14.2) and a low NMLR group (≤ 14.2) based on the optimal threshold for NMLR. Compared to low NMLR group, high NMLR group had higher total vasoactive drugs and lower 28-day survival. After PSM, there were no differences in baseline characteristics. The high NMLR group still had a higher mortality rate (p= 0.001), lower 28-day survival (p= 0.001) and shorter length of stay (p= 0.005) compared to the low NMLR group. Conclusions: Age, NMLR levels, lactate levels and hematocrit were independent risk factors for death in patients after CPR. NMLR > 14.2 was associated with higher mortality and was a potential predictor of clinical outcome in patients after CPR.

Acute respiratory distress syndrome is regarded as a formidable clinical challenge due to its high prevalence and mortality. The treatment of acute respiratory distress syndrome is very complex and difficult. As an adjuvant therapy, the antioxidant N-acetylcysteine has been investigated for several years but the benefit is controversial. We performed the systematic review and meta-analysis of randomized controlled trials to evaluate the efficacy of N-acetylcysteine on patients with acute respiratory distress syndrome. We searched PubMed, CENTRAL, and CBM databases. Randomized controlled trials comparing the effects of N-acetylcysteine and control were included. Overall mortality was the primary outcome; length of intensive care unit stay, duration of mechanical ventilation, glutathione levels, and PaO2/FiO2were the secondary outcomes. Eight trials with a total of 289 patients were included. Compared to the control group, the N-acetylcysteine group did not lower the overall mortality (risk ratio: 0.83; 95% confidence interval: 0.62 to 1.11; P?=?0.21; I2?=?0%). However, N-acetylcysteine significantly shortened intensive care unit stay in the random-effects model (mean difference: –4.47?days; 95% confidence interval: –8.79 to -0.14; P?=?0.04; I2?=?46%). Due to substantial heterogeneity and limited number of studies, the data of duration of mechanical ventilation, glutathione levels, and PaO2/FiO2could not be pooled in the meta-analysis. N-acetylcysteine is ineffective in reducing mortality but beneficial for intensive care unit stay. Nonetheless, the effectiveness of N-acetylcysteine for acute respiratory distress syndrome is limited and further research is required before strong recommendations can be made.

Background: Acute respiratory distress syndrome is regarded as a formidable clinical challenge due to its high prevalence and mortality. The treatment of acute respiratory distress syndrome is very complex and difficult. As an adjuvant therapy, the antioxidant N-acetylcysteine has been investigated for several years but the benefit is controversial.Objectives: We performed the systematic review and meta-analysis of randomized controlled trials to evaluate the efficacy of N-acetylcysteine on patients with acute respiratory distress syndrome.Methods: We searched PubMed, CENTRAL, and CBM databases. Randomized controlled trials comparing the effects of N-acetylcysteine and control were included. Overall mortality was the primary outcome; length of intensive care unit stay, duration of mechanical ventilation, glutathione levels, and PaO2/FiO2were the secondary outcomes.Results: Eight trials with a total of 289 patients were included. Compared to the control group, the N-acetylcysteine group did not lower the overall mortality (risk ratio: 0.83; 95% confidence interval: 0.62 to 1.11; P = 0.21; I2= 0%). However, N-acetylcysteine significantly shortened intensive care unit stay in the random-effects model (mean difference: –4.47 days; 95% confidence interval: –8.79 to −0.14; P = 0.04; I2= 46%). Due to substantial heterogeneity and limited number of studies, the data of duration of mechanical ventilation, glutathione levels, and PaO2/FiO2could not be pooled in the meta-analysis.Conclusion: N-acetylcysteine is ineffective in reducing mortality but beneficial for intensive care unit stay. Nonetheless, the effectiveness of N-acetylcysteine for acute respiratory distress syndrome is limited and further research is required before strong recommendations can be made.

Echocardiography is an essential tool in emergency medicine, and its training is the most challenging of all types of bedside ultrasound (US) training. This study investigated the effectiveness of the Sectra Table (Sectra AB, Linköping, Sweden), an anatomy visualization and collaboration tool, in improving the quality of echocardiography training for emergency medicine physicians. We conducted an exploratory prospective observational study from 2015 to 2017 and enrolled 66 trainees who participated in a 2.5‐day bedside US course organized by the emergency department (ED) of Peking Union Medical College Hospital. The study participants underwent 2 different training programs: the first group received standard training, and the second group was trained with Sectra Table experiences integrated into the echocardiography training curriculum. After the training sessions, both groups were evaluated for their hands‐on echocardiography performance. The new training program with the Sectra Table significantly increased trainees' self‐confidence in performing bedside echocardiography. The Sectra Table trainees had a higher performance rating than the trainees in the traditional program, with a mean total assessment score of 40.5 versus 26.5 for traditional training (P< .01). The improved performance was evident for all subcategories of echocardiography. The higher performance rating of the Sectra Table trainees was also statistically significant after adjusting for confounders, including prior training experiences, baseline confidence in independently performing ED US examinations, the number of ED US examinations performed, years in ED practice, and physician seniority. Our analysis suggests that integrating the Sectra Table into echocardiography training may improve the effectiveness of training programs.

To prospectively assess the utility of multidetector row computed tomography angiography (MDCTA) in the diagnosis of active gastrointestinal bleeding (GIB).

The protein homeostasis (proteostasis) network (PN) encompasses mechanisms that maintain proteome integrity by controlling various biological functions. Loss of proteostasis leads to toxic protein aggregation (proteotoxicity), which underlies the manifestation of neurodegeneration. How the PN responds to dissimilar proteotoxic challenges and how these responses are regulated at the organismal level are largely unknown. Here, we report that, while torsin chaperones protect from the toxicity of neurodegeneration-causing polyglutamine stretches, they exacerbate the toxicity of the Alzheimer’s disease-causing Aβ peptide in neurons and muscles. These opposing effects are accompanied by differential modulations of gene expression, including that of three neuropeptides that are involved in tailoring the organismal response to dissimilar proteotoxic insults. This mechanism is regulated by insulin/IGF signaling and the transcription factor SKN-1/NRF. Our work delineates a mechanism by which the PN orchestrates differential responses to dissimilar proteotoxic challenges and points at potential targets for therapeutic interventions.