Hidetada Fukushima

ADAMTS13 gene deletion aggravates ischemic brain damage: a possible neuroprotective role of ADAMTS13 by ameliorating postischemic hypoperfusion.

Reperfusion after brain ischemia causes thrombus formation and microcirculatory disturbances, which are dependent on the platelet glycoprotein Ib-von Willebrand factor (VWF) axis. Because ADAMTS13 cleaves VWF and limits platelet-dependent thrombus growth, ADAMTS13 may ameliorate ischemic brain damage in acute stroke. We investigated the effects of ADAMTS13 on ischemia-reperfusion injury using a 30-minute middle cerebral artery occlusion model in Adamts13(-/-) and wild-type mice. After reperfusion for 0.5 hours, the regional cerebral blood flow in the ischemic cortex was decreased markedly in Adamts13(-/-) mice compared with wild-type mice (P < .05), which also resulted in a larger infarct volume after 24 hours for Adamts13(-/-) compared with wild-type mice (P < .01). Thus, Adamts13 gene deletion aggravated ischemic brain damage, suggesting that ADAMTS13 may protect the brain from ischemia by regulating VWF-platelet interactions after reperfusion. These results indicate that ADAMTS13 may be a useful therapeutic agent for stroke.

Prognostic value of increased plasma levels of brain natriuretic peptide in patients with septic shock.

ABSTRACT Our objective was to investigate the plasma levels of brain and atrial natriuretic peptides (BNP and ANP, respectively) in patients with septic shock/severe sepsis and to study the association of BNP and ANP levels with hemodynamic parameters, severity of the disease, and prognosis of those patients. This is a prospective case series study of 22 patients with septic shock, 11 patients with severe sepsis, and 20 healthy volunteers at the Department of Emergency and Critical Care Medicine, Nara Medical University Hospital, Japan. Blood collection was performed on admission and on days 1, 2, and 4. Plasma BNP and ANP levels were measured by radioimmunoassay. Right atrial pressure, mean pulmonary arterial pressure, pulmonary arterial wedge pressure, and left ventricular stroke work index were determined using a thermodilution catheter. Acute Physiological and Chronic Health Evaluation II scores were calculated. Plasma levels of BNP and ANP were markedly elevated in patients with septic shock/severe sepsis compared with controls (BNP, 7 ± 0.3 pg mL−1; ANP, 13 ± 1 pg mL−1). In patients with septic shock, both BNP and ANP peaked on day 2 (BNP, 987 ± 160 pg mL−1; ANP, 103 ± 17 pg mL−1). Plasma levels of BNP on day 2 in patients with septic shock significantly correlated with right atrial pressure (r = 0.744, P < 0.01), mean pulmonary arterial pressure (r = 0.670, P < 0.01), pulmonary arterial wedge pressure (r = 0.709, P < 0.01), left ventricular stroke work index (r = −0.552, P < 0.05), Acute Physiological and Chronic Health Evaluation II score (r = 0.581, P < 0.01), and poor prognosis (P < 0.05). The optimal cutoff point for predicting mortality in patients with septic shock was a BNP level of 650 pg mL−1 on day 2, in which sensitivity and specificity were 92% and 80%, respectively. Increased plasma levels of BNP may reflect not only the severity of myocardial depression but also the disease severity and could be of prognostic value in patients with septic shock.

Abnormal breathing of sudden cardiac arrest victims described by laypersons and its association with emergency medical service dispatcher-assisted cardiopulmonary resuscitation instruction.

Background Current guidelines for cardiopulmonary resuscitation (CPR) emphasise that emergency medical service (EMS) dispatchers should identify sudden cardiac arrest (CA) with abnormal breathing and assist lay rescuers performing CPR. However, lay rescuers description of abnormal breathing may be inconsistent, and it is unclear how EMS dispatchers provide instruction for CPR based on the breathing status of the CA victims described by laypersons. Methods and results To investigate the incidence of abnormal breathing and the association between the EMS dispatcher-assisted CPR instruction and layperson CPR, we retrospectively analysed 283 witnessed CA cases whose information regarding breathing status of CA victims was available from population-based prospective cohort data. In 169 cases (59.7%), laypersons described that the CA victims were breathing in various ways, and that the victims were ‘not breathing’ in 114 cases (40.3%). Victims described as breathing in various ways were provided EMS dispatch-instruction for CPR less frequently than victims described as ‘not breathing’ (27.8% (47/169) vs 84.2% (96/114); p<0.001). Multivariate logistic regression showed that EMS dispatch-instruction for CPR was associated significantly with layperson CPR (adjusted OR, 11.0; 95% CI, 5.72 to 21.2). Conclusions This population-based study indicates that 60% of CA victims showed agonal respiration, which was described as breathing in various ways at the time of EMS call. Although EMS dispatch-instruction was associated significantly with an increase in layperson CPR, abnormal breathing was associated with a much lower rate of CPR instruction and, in turn, was related to a much lower rate of bystander CPR.

Ratio of von Willebrand factor propeptide to ADAMTS13 is associated with severity of sepsis.

ABSTRACT Von Willebrand factor (VWF)–cleaving protease (ADAMTS13) cleaves ultralarge VWF (ULVWF) secreted from endothelium and by which is regulating its physiologic function. An imbalance between ULVWF secretion and ADAMTS13 level occurs in sepsis and may cause multiple organ dysfunction. We evaluated the association between the VWF-propeptide (VWF-pp)/ADAMTS13 ratio and disease severity in patients with severe sepsis or septic shock. In 27 patients with severe sepsis or septic shock and platelet count less than 120 000/&mgr;L, we measured plasma VWF, VWF-pp, and ADAMTS13 levels on hospital days 1, 3, 5, and 7. The VWF-pp/ADAMTS13 ratio was increased greater than 12-fold in patients with severe sepsis or septic shock on day 1 and remained markedly high on days 3, 5, and 7 compared with normal control subjects. The VWF-pp/ADAMTS13 ratio significantly correlated with Acute Physiology and Chronic Health Evaluation II score on days 1 and 5; Sepsis-related Organ Failure Assessment score on days 1, 3, and 5; maximum Sepsis-related Organ Failure Assessment score and tumor necrosis factor &agr; level on days 1, 3, 5, and 7; and creatinine level on days 1, 5, and 7. Patients with greater than stage 1 acute kidney injury had significantly higher VWF-pp/ADAMTS13 ratio than patients without acute kidney injury. In summary, the VWF-pp/ADAMTS13 ratio was associated with disease severity in patients with severe sepsis or septic shock and may help identify patients at risk for multiple organ dysfunction by detecting severe imbalance between ULVWF secretion and ADAMTS13 level.

Acute pulmonary edema associated with naphazoline ingestion

In published reports of naphazoline ingestion, clinical effects are hypertension, bradycardia, pallor, diaphoresis, and respiratory distress. We report three cases of acute pulmonary edema after the intentional ingestion of naphazoline-containing antiseptic first aid liquid. These cases presented with altered mental status, hypertension, bradycardia, and diaphoresis. Chest x-ray on admission revealed acute pulmonary edema. Two cases required mechanical ventilation. All of these clinical effects resolved within 24 hours and the patients were discharged with no sequelae. Since naphazoline stimulates the peripheral alpha-2 adrenergic receptor, we speculate that intense vasoconstriction may have elevated cardiac afterload and left atrial-ventricular blood volume and caused acute pulmonary edema.

Barriers to telephone cardiopulmonary resuscitation in public and residential locations.

AIM Emergency medical telecommunicators can play a key role in improving outcomes from out-of-hospital cardiac arrest (OHCA) by providing instructions for cardiopulmonary resuscitation (CPR) to callers. Telecommunicators, however, frequently encounter barriers that obstruct the Telephone CPR (TCPR) process. The nature and frequency of these barriers in public and residential locations have not been well investigated. The aim of this study is to identify the barriers to TCPR in public and residential locations. METHODS We conducted a retrospective study of audio recordings of EMS-confirmed OHCAs from eight regional 9-1-1 dispatch centers between January 2012 and December 2013. RESULTS We reviewed 1850 eligible cases (public location OHCAs: N=223 and residential location OHCAs: N=1627). Telecommunicators less frequently encountered barriers such as inability to calm callers in public than in residential locations (2.1% vs 8.5%, p=0.002) or inability to place victims on a hard flat surface (13.9% vs 25.4%, p<0.001). However, the barrier where callers were not with patients was more frequently observed in public than in residential locations (11.8% vs 2.7%, p<0.001). CONCLUSIONS This study revealed that barriers to TCPR are distributed differently across public and residential locations. Understanding these differences can aid in the development of strategies to enhance bystander CPR and improve overall patient outcomes.

Telephone cardiopulmonary resuscitation is independently associated with improved survival and improved functional outcome after out-of-hospital cardiac arrest

AIM OF STUDY This study aims to quantify the relative impact of Dispatcher-Initiated Telephone cardiopulmonary resuscitation (TCPR) on survival and survival with favorable functional outcome after out-of-hospital cardiac arrest (OHCA) in a population of patients served by multiple emergency dispatch centers and more than 130 emergency medical services (EMS) agencies. METHODS We conducted a retrospective, observational study of EMS-treated adult (≥18 years) patients with OHCA of presumed cardiac origin in Arizona, between January 1, 2011, and December 31, 2014. We compared survival and functional outcome among three distinct groups of OHCA patients: those who received no CPR before EMS arrival (no CPR group); those who received BCPR before EMS arrival and prior to or without telephone CPR instructions (BCPR group); and those who received TCPR (TCPR group). RESULTS In this study, 2310 of 4391 patients met the study criteria (median age, 62 years; IQR 50, 74; 1540 male). 32.8% received no CPR, 23.8% received Bystander-Initiated CPR and 43.4% received TCPR. Overall survival was 11.5%. Using no CPR as the reference group, the multivariate adjusted odds ratio for survival at hospital discharge was 1.51 (95% confidence interval [CI], 1.04, 2.18) for BCPR and 1.64 (95% CI, 1.16, 2.30) for TCPR. The multivariate adjusted odds ratio of favorable functional outcome at discharge was 1.58 (95% CI 1.05, 2.39) for BCPR and 1.56 (95% CI, 1.06, 2.31) for TCPR. CONCLUSION TCPR is independently associated with improved survival and improved functional outcome after OHCA.

Implementation of a dispatch-instruction protocol for cardiopulmonary resuscitation according to various abnormal breathing patterns: a population-based study

BackgroundWe modified the dispatch protocol for cardiopulmonary resuscitation (CPR) using results of a retrospective analysis that identified descriptions by laypersons of possible patterns of agonal respiration. The purpose of this study was to assess the effectiveness of this modified protocol by comparing the frequency of dispatch instructions for CPR and bystander CPR before and after protocol implementation. We also identified descriptions of abnormal breathing patterns among ‘Not in cardiac arrest (CA)’ unresponsive cases.MethodsThis study was conducted prospectively using the population-based registry of out-of-hospital cardiac arrests (OHCAs). For 8 months we implemented this modified protocol in cooperation with 4 fire departments that cover regions with a total population of 840,000.ResultsThere were 478 and 427 OHCAs before and after implementation, respectively. Among them, 69 and 71 layperson-witnessed OHCAs for pre- and post-implementation, respectively, were analyzed. Dispatchers provided CPR instructions more frequently after protocol implementation than before (55/71 [77.5 %] vs. 41/69 [59.4 %], p < 0.05). Based on breathing patterns described by emergency callers, dispatchers assessed 143 ‘Not in CA’ unresponsive cases and provided CPR instruction for 45 cases. Sensitivity and specificity of this protocol was 93 % and 50 %, respectively.ConclusionsThis modified protocol based on abnormal breathing described by laypersons significantly increased CPR instructions. Considering high sensitivity and low specificity for abnormal breathing to identify CA and the low risk of chest compression for ‘Not in CA’ cases, our study suggested that dispatchers can provide CPR instruction assertively and safely for those unresponsive individuals with various abnormal breathing patterns.

A case of Vibrio vulnificus infection complicated with fulminant purpura: gene and biotype analysis of the pathogen

Introduction. Vibrio vulnificus (V. vulnificus) causes a severe infection that develops in the compromised host. Its pathophysiology is classified into three types: (1) primary septicaemia, (2) gastrointestinal illness pattern and (3) wound infection pattern. Of these, primary septicaemia is critical. V. vulnificus can be classified into three biotypes and two genotypes and its pathogenicity is type-dependent. Case presentation. A 47-year-old man presented to a local hospital with chief complaints of fever, bilateral lower limb pain and diarrhoea. He had no history of foreign travel or known medical problems. He was in septic shock and developed fulminant purpura within 24 h of the onset. High-dose vasopressor and antibiotic administration failed to alter his status and he died 3 days after the onset of symptoms. V. vulnificus was isolated from blood, skin and nasal discharge cultures. Biotype and gene analysis of the microbe isolated identified it as Biotype 3, mainly reported in Israel in wound infections, and Genotype E, implicating an environmental isolate. These typing analyses indicated that the microbe isolated could be classified as a type with low pathogenicity. Conclusion. This case highlighted that Biotype 3 and Genotype E can also cause primary septicaemia. Although the majority of reports on Biotype 3 have been from the Middle East, this experience with the present case provided evidence that the habitat of Biotype 3 V. vulnificus has been extending to East Asia as well.

Barriers to patient positioning for telephone cardiopulmonary resuscitation in out-of-hospital cardiac arrest

BACKGROUND 9-1-1 callers often face barriers preventing them from starting Telephone CPR (TCPR). The most common problem is getting patients to a hard, flat surface. This study describes barriers callers report when trying to move patients to a hard, flat surface and assesses conditions associated with overcoming these barriers. METHODS We audited 2396 out-of-hospital cardiac arrest (OHCA) audio recordings. A barrier was defined as any statement by the caller that the rescuer could not move the patient to the ground and into a supine position. Barriers were recorded and TCPR process metrics compared across the barrier and non-barrier groups. RESULTS There were 802 OHCAs in the study group. Roughly 26% had a barrier. Telecommunicators were less likely to start TCPR instructions in the barrier group than in the non-barrier group (OR: 0.63, 95% CI: 0.45-0.88; p=0.007). Telecommunicator-directed bystander chest compressions were more than twice as likely to start in the non-barrier group (OR: 2.2, 95% CI: 1.6-3.2; p<0.001). Median time to first compression was longer in the barrier group (276s vs 171s; p<0.001). Rescuers were 3.7 times more likely to overcome a barrier and start compressions (OR: 3.7, 95% CI: 2.0-6.8; p<0.001) when multiple bystanders were present. CONCLUSION Inability to move patients to a hard, flat surface is associated with a reduced rate of TCPR and increased time to first compression. Assessing the conditions under which such barriers are overcome is important for telecommunicator training and can help improve rates and timeliness of TCPR.