Hong Zhan

Out-of-hospital cardiac arrest without return of spontaneous circulation in the field: Who are the survivors?☆

BACKGROUNDnReturn of spontaneous circulation (ROSC) in the field is a vital determinant contributing to survival from out-of-hospital cardiac arrest (OHCA). However, nearly one third of survivors at the Dallas-Fort Worth (DFW) Resuscitation Outcomes Consortium (ROC) site did not obtain ROSC in the field.nnnMETHODSnA retrospective, observational analysis was performed on all adult patients with non-traumatic OHCA treated on scene and transported to hospital, who did not gain ROSC in the field at DFW ROC site between 2006 through 2011.We described the demographics, pre-hospital characteristics and outcomes of all enrolled cases. Those patients without ROSC in the field, who did and did not meet Termination of Resuscitation (TOR) criteria in the field, were also compared.nnnRESULTSnAmong a total of 5099 treated and transported non-traumatic OHCA cases, 83.2% (4243) were included in this study as patients without ROSC gained in the field, of which 66.6% (2827) met TOR criteria but still were treated and transported; 1.9% (79) survived to hospital discharge. Further analysis showed that 39.2% (31) of survivors met TOR rule, accounting for 1.1% of those patients who should have been declared dead in the field. Shockable initial rhythms, EMS-witnessed arrest, bystander CPR and age were factors significant to predict survival from OHCA without ROSC in the field. Of concern, 1.7% (47) of patients who met TOR presented initially shockable rhythms but no shocks were delivered in the field.nnnCONCLUSIONSnWe suggest that all treated non-traumatic OHCA patients should be transported to hospital.

Conversion to shockable rhythms is associated with better outcomes in out-of-hospital cardiac arrest patients with initial asystole but not in those with pulseless electrical activity

BACKGROUNDnThe prognostic implication of conversion from initially non-shockable to shockable rhythms in patients with out-of-hospital cardiac arrest (OHCA) remains unclear. Our objective is to determine whether the conversion to shockable rhythms is a reliable predictor of short- and long-term outcomes both in patients who initially presented with pulseless electrical activity (PEA) and in those with asystole.nnnMETHODSnA secondary analysis was performed on non-traumatic OHCA cases ≥18 years old with PEA or asystole as initial rhythms, who were treated in the field and enrolled in the Resuscitation Outcomes Consortium (ROC) PRIMED study (clinicaltrials.gov/ct2/show/NCT00394706). We reported the characteristics and outcomes for those patients with or without shocks delivered in the field. Logistic regression analysis assessed the association of shock delivery with pre-hospital return of spontaneous circulation (ROSC), survival to hospital discharge and favorable neurological outcome as well.nnnRESULTSnOf the 9902 included cases, 3415 (34.5%) were initially in PEA and 6487 (65.5%) were in asystole. 744 (21.8%) PEA and 1134 (17.5%) asystolic patients underwent rhythm conversions and received subsequent shocks. For asystolic patients, the adjusted odds ratios (ORs) of shock delivery for pre-hospital ROSC, survival to discharge and favorable neurological outcome were 1.862 (95%CI 1.590-2.180), 3.778 (95%CI 2.374-6.014) and 4.154 (95%CI 2.192-7.871) respectively, while for PEA patients they were 0.951 (95%CI 0.796-1.137), 1.115 (95%CI 0.720-1.726) and 1.373 (95%CI 0.790-2.385) respectively.nnnCONCLUSIONSnConversion to shockable rhythms was associated with better outcomes in initially asystolic OHCA patients, whereas such associations were not observed in patients initially in PEA.

A case report of acute myocardial infarction concomitant with Standford type B aortic dissection.

BACKGROUNDnAcute myocardial infarction (AMI) concomitant with aortic dissection (AD) is rare but a devastating situation if misdiagnosed as simply AMI, followed by anticoagulant or thrombolytic therapy. In such cases, Standford type B AD was extremely infrequent.nnnOBJECTIVESnTo present a case with apparent concordance with the patients history, symptoms, cardiac enzymes that lead to diagnostic error.nnnCASE REPORTnAn 85-year-old man with chronic hypertension and coronary atherosclerotic heart disease presented in our emergency department with squeezing retrosternal chest pain and dyspnea. Elevated cardiac enzymes and electrocardiography result suggested acute non-ST-segment elevation myocardial infarction. Emergency coronary angiography demonstrated a 50-90% diffuse stenosis of the proximal and mid right coronary artery also confirmed the diagnosis. Stents were deployed thereafter. However, the patient was found to be concomitant with Standford type B AD by computed tomography angiography due to unrelieved chest pain and new onset of abdominal pain after the operation. The patient refused to have endovascular operation and died of hemorrhagic shock one week later.nnnCONCLUSIONSnAD may cause AMI due to some indirect mechanisms, and it is of utmost importance to search for the existence of AD before reperfusion therapy in AMI patients. Aortic dissection detection risk score, transthoracic echocardiography and D-dimer help early identification of AD.

Elevation in circulating YKL-40 concentration in patients with cerebrovascular disease

YKL-40 is a novel inflammatory protein. Elevated serum levels of YKL-40 have been reported in patients with atherosclerosis and other cardiovascular diseases, but the circulating profile of YKL-40 in patients with cerebrovascular disease has been less investigated. This prospective observational study aimed to determine serum levels of YKL-40 in patients with different subtypes and severities of cerebrovascular disease. Eighty patients with acute ischemic stroke, 30 patients with acute hemorrhagic stroke, 15 patients with transient ischemic attack (TIA) and 18 age- and gender-matched healthy control subjects were recruited. Blood was sampled. Serum levels of YKL-40 were measured by ELISA. In healthy control subjects, serum levels of YKL-40 were 45.09 ± 31.41 ng/ml, significantly lower than those in patients with acute ischemic stroke (178.58 ± 127.78 ng/ml), hemorrhagic stroke (105.32 ± 87.35 ng/ml) and TIA (148.09 ± 108 ng/ml) respectively (P<0.05). When the 80 acute ischemic stroke cases were stratified into four Oxfordshire Community Stroke subtypes, serum levels of YKL-40 were significantly higher in patients with total anterior (n=16), partial anterior (n=25) and posterior (n=12) circulation infarctions respectively than those with lacunar (n=27) infarction (P<0.05). Moreover, 63 of 80 patients with acute ischemic stroke survived. Circulating levels of YKL-40 in these stroke survivors were associated with the United States National Institutes of Health Stroke Scale (NIHSS) scores of neurological deficit. In summary, serum levels of YKL-40 were elevated in patients with cerebrovascular disease in lesion subtype- and severity-dependent manners. These observations suggest a potential for YKL-40 as a diagnostic/prognostic biomarker for cerebrovascular disease.

Gastrin attenuates ischemia-reperfusion-induced intestinal injury in rats

Intestinal ischemia-reperfusion (I/R) injury is a devastating complication when the blood supply is reflowed in ischemic organs. Gastrin has critical function in regulating acid secretion, proliferation, and differentiation in the gastric mucosa. We aimed to determine whether gastrin has an effect on intestinal I/R damage. Intestinal I/R injury was induced by 60-min occlusion of the superior mesenteric artery followed by 60-min reperfusion, and the rats were induced to be hypergastrinemic by pretreated with omeprazole or directly injected with gastrin. Some hypergastrinemic rats were injected with cholecystokinin-2 (CCK-2) receptor antagonist prior to I/R operation. After the animal surgery, the intestine was collected for histological analysis. Isolated intestinal epithelial cells or crypts were harvested for RNA and protein analysis. CCK-2 receptor expression, intestinal mucosal damage, cell apoptosis, and apoptotic protein caspase-3 activity were measured. We found that high gastrin in serum significantly reduced intestinal hemorrhage, alleviated extensive epithelial disruption, decreased disintegration of lamina propria, downregulated myeloperoxidase activity, tumor necrosis factor-α, and caspase-3 activity, and lead to low mortality in response to I/R injury. On the contrary, CCK-2 receptor antagonist L365260 could markedly impair intestinal protection by gastrin on intestinal I/R. Severe edema of mucosal villi with severe intestinal crypt injury and numerous intestinal villi disintegrated were observed again in the hypergastrinemic rats with L365260. The survival in the hypergastrinemic rats after intestinal I/R injury was shortened by L365260. Finally, gastrin could remarkably upregulated intestinal CCK-2 receptor expression. Our data suggest that gastrin by omeprazole remarkably attenuated I/R induced intestinal injury by enhancing CCK-2 receptor expression and gastrin could be a potential mitigator for intestinal I/R damage in the clinical setting.

THE EFFECTS OF TEAM-BASED LEARNING (TBL) TEACHING USED IN CARDIOPULMONARY RESUSCITATION SKILLS TRAINING FOR THE PUBLICS

Objectives Most cardiac arrests occur outside the hospital, so it is really necessary to begin cardiopulmonary resuscitation skills training for the publics. The publics can participate in the rescue at once as the first witnesses of the cardiac arrest to improve the survival rate of the sufferer. The purpose of this research is to explore the teaching effectiveness of team-based learning teaching in cardiopulmonary resuscitation skills training for the publics. Methods Between 15 September 2011 to 30 October 2011, 160 college students that are not medical profession participated in this research. They were trained for cardiopulmonary resuscitation skills based on 2010 CPR guidelines. Eighty students assigned into the experimental group, were trained with TBL teaching. Another 80 students assigned into the control group, were trained with traditional lecture teaching. Theory, skill-practice and cardiac arrest scene simulation, three tests were employed to evaluate the training effectiveness before the training course started and after the training course finished in two groups. Results After training, both groups got higher scores than before training in all the tests (p<0.05). College students in experimental group acted better than those in contol group in skill-practice and cardiac arrest scene simulation tests (p<0.05). Better group cooperation, superior quality and higher rates of chest compression, as well as more prompt initiation of chest compression, are obtained in the experimental group (p<0.05). However, there was no difference in theory test between them (p>0.05). The experimental group to teaching satisfaction was also higher than those in the control group (p<0.05). Conclusions Teaching with team-based learning seems more helpful than traditional lecture teaching in training of the cardiopulmonary resuscitation skills for the publics.