Tatsuro Kai

An analysis of time factors in out-of-hospital cardiac arrest in Osaka Prefecture

OBJECTIVE To ascertain important factors in the improvement of out-of-hospital cardiac arrest survival rates through analysis of data for Osaka Prefecture with the focus on time factors. DESIGN Prospective cohort study according to the Utstein style. SETTING Osaka Prefecture (population 8,830,000) served by a single emergency medical services system. PATIENTS Consecutive prehospital cardiac arrests occurring between May 1998 and April 1999. MAIN OUTCOME MEASURES One-year survival from cardiac arrest, and time factors. RESULT Of the 5047 cases of confirmed cardiac arrests, resuscitation was attempted in 4871 subjects. Of the 982 cases of cardiac origin and witnessed by bystanders, 31 (3.2%) were still alive, and of the 576 cases of non-cardiac origin and witnessed by bystanders, ten (1.7%) were still alive at the 1 year follow-up. The median time from receipt of the emergency call until ambulance arrival was 5 min and that from receipt of the call until the start of cardiopulmonary resuscitation (CPR) was 7 min. For the 214 patients for whom defibrillation was attempted, the median time from receipt of the call until the first shock was 15 min. The median time from receipt of the call until departure of the ambulance from the scene was 16 min and that until arrival of the ambulance at a hospital was 22 min. CONCLUSIONS This study using the standardized format according to the Utstein style clearly elucidates the specific delay of the start of defibrillation by paramedics and also indicates the inappropriate rule for this procedure in Japan.

C-arm-guided reduction of zygomatic fractures revisited.

BACKGROUND Anatomic reduction of the zygomatic arch, a key surgical landmark for midfacial width and projection, is essential for the treatment of combined fractures of the zygomaticomaxillary complex and zygomatic arch. Reduction control in surgery for this common facial fracture would be facilitated by intraoperative real-time assessment using widely available and reliable equipment. Although C-arm fluoroscopy is routinely used in the repair of orthopedic fractures, its use in the maxillofacial region, particularly for combined zygomatic fractures, has been scarcely reported. METHODS We prospectively evaluated C-arm-guided reduction in 38 patients of combined zygomatic fracture without concurrent craniofacial fractures. Patients were classified according to the presence or absence of bone contact in the displaced zygomatic arch, namely as conserved (C) and loss (L) types, respectively. Reduction status was determined by the degree of recovery of the malar prominence and arch shape. RESULTS In all cases, C-arm imaging clearly displayed the displaced zygomatic arch and body in a single image. Cumulative fluoroscopic time was a few minutes in all cases. Total reduction status was excellent in 21 patients and good in 17. No case was classified as fair or poor. Repair was significantly more favorable in type C than in type L cases (p = 0.0016). CONCLUSIONS In combined zygomatic fractures, the C-arm technique provides easy, flexible, and time-efficient adjustment. Its comprehensive imaging for zygomatic arch shape and body contour markedly facilitates the control of fracture reduction and protects against unexpected, unsatisfactory outcomes.

Resistance to conventional cardiopulmonary resuscitation in witnessed out-of-hospital cardiac arrest patients with shockable initial cardiac rhythm.

BACKGROUND Shockable initial cardiac rhythm is a key predictor of survival after out-of-hospital cardiac arrest (OHCA). However, not all patients with shockable OHCA achieve return of spontaneous circulation (ROSC) via conventional cardiopulmonary resuscitation (CPR). Therefore, we retrospectively analyzed patients with witnessed OHCA and shockable initial cardiac rhythm to identify the resistance factors for conventional CPR. METHODS We retrospectively analyzed consecutive patients with witnessed OHCA and shockable initial cardiac rhythm who were admitted to our hospital between October 2009 and October 2014. We then compared the baseline characteristics, pre-hospital clinical course, and causes of the cardiopulmonary arrest among patients who achieved ROSC via conventional CPR and patients who did not achieve ROSC via conventional CPR and underwent extracorporeal CPR (ECPR). RESULTS A total of 85 patients achieved ROSC via conventional CPR (non-ECPR group) and 40 patients did not achieve ROSC via conventional CPR and underwent ECPR (ECPR group). Among these 125 patients, 113 had known causes for their cardiopulmonary arrest, including 66 cases (53%) of acute myocardial infarction (AMI). There were no significant differences in the causes of arrest between the non-ECPR and ECPR cases. However, among the 66 cases of AMI (43 non-ECPR and 23 ECPR), the rate of non-recanalization during the initial coronary angiography was significantly higher among the ECPR cases (non-ECPR: 58% vs. ECPR: 87%; p=0.03). CONCLUSIONS The major cause of witnessed OHCA with shockable initial cardiac rhythm was AMI, and resistance to conventional CPR was related to continuous myocardial ischemia.

Closed reduction of mandibular condyle fractures using C-arm fluoroscopy: a technical note

We describe a C-arm technique for mandibular condylar fractures in an anatomic study using a model skull and show its feasibility in a clinical case. The C-arm allowed posterior-anterior visualization of the condylar process. The X-ray axis was canted ∼15 degrees cranially to the Frankfort horizontal line. The skulls sagittal plane was rotated ∼15 degrees ipsilaterally to the X-ray axis. This technique facilitates clear visualization of the condylar neck with easy, flexible, and timely adjustments. In selected cases, this method would convert the clinical settings of the condylar fracture pattern to that which would not be amenable to an open approach, making possible minimally invasive surgical procedures.

Significant Association of Serum Adiponectin and Creatine Kinase-MB Levels in ST-Segment Elevation Myocardial Infarction.

Aims: Adiponectin, an adipocyte-specific secretory protein, abundantly exists in the blood stream while its concentration paradoxically decreases in obesity. Hypoadiponectinemia is one of risks of cardiovascular diseases. However, impact of serum adiponectin concentration on acute ischemic myocardial damages has not been fully clarified. The present study investigated the association of serum adiponectin and creatine kinase (CK)-MB levels in subjects with ST-segment elevation myocardial infarction (STEMI). Methods: This study is a physician-initiated observational study and is also registered with the University Hospital Medical Information Network (Number: UMIN 000014418). Patients were admitted to Senri Critical Care Medical Center, given a diagnosis of STEMI, and treated by primary percutaneous coronary intervention (PCI). Finally, 49 patients were enrolled and the association of serum adiponectin, CK-MB, and clinical features were mainly analyzed. Results: Serum adiponectin levels decreased rapidly and reached the bottom at 24 hours after recanalization. Such reduction of serum adiponectin was inversely correlated with the area under the curve (AUC) of serum CK-MB (p = 0.013). Serum adiponectin concentrations were inversely correlated with AUC of serum CK-MB. In multivariate analysis, serum adiponectin concentration on admission (p = 0.002) and collateral (p = 0.037) were significantly and independently correlated with serum AUC of CK-MB. Conclusion: Serum AUC of CK-MB in STEMI subjects was significantly associated with serum adiponectin concentration on admission and reduction of serum adiponectin levels from baseline to bottom. The present study may provide a possibility that serum adiponectin levels at acute phase are useful in the prediction for prognosis after PCI-treated STEMI subjects.

Impact of extracorporeal cardiopulmonary resuscitation on outcomes of elderly patients who had out-of-hospital cardiac arrests: a single-centre retrospective analysis

Objectives Little is known about the effectiveness of extracorporeal cardiopulmonary resuscitation (ECPR) for elderly patients who had out-of-hospital cardiac arrest (OHCA). The aim of this study was to examine the impact of age on outcomes among patients who had OHCA treated with ECPR. Design Single-centre retrospective cohort study. Setting A critical care centre that covers a population of approximately 1 million residents. Participants Patients who had consecutive OHCA aged ≥18 years who underwent ECPR from 2005 to 2013. Primary and secondary outcome measures Primary outcomes were 1 month neurologically favourable outcomes and survival. To determine the association between advanced age and each outcome, we fitted multivariable logistic regression models using: (1) age as a continuous variable and (2) age as a categorical variable (<50 years, 50–59 years, 60–69 years and ≥70 years). Results Overall, 144 patients who had OHCA who underwent ECPR were eligible for our analyses. The proportion of neurologically favourable outcomes was 7%, while survival was 19% in patients who had OHCA. After the adjustment for potential confounders, while advanced age was non-significantly associated with neurologically favourable outcomes (adjusted OR 0.96 (95% CI 0.91 to 1.01), p=0.08), the association between advanced age and the poor survival rate was significant (adjusted OR 0.96 (95% CI 0.93 to 0.99), p=0.04). Additionally, compared with age <50 years, age ≥70 years was non-significantly associated with poor neurological outcomes (adjusted OR 0.08 (95% CI 0.01 to 1.00), p=0.051), whereas age ≥70 years was significantly associated with worse survival in the adjusted model (adjusted OR 0.14 (95% CI 0.03 to 0.80), p=0.03). Conclusions In our analysis of consecutive OHCA data from a critical care hospital in an urban area of Japan, we found that advanced age was associated with the lower rate of 1-month survival in patients who had OHCA who underwent ECPR. Although larger studies are required to confirm these results, our findings suggest that ECPR may not be beneficial for patients who had OHCA aged ≥70 years.

Successfully treated life-threatening upper gastrointestinal bleeding from fistula between gastroduodenal artery pseudoaneurysm and duodenum

An 85‐year‐old man was admitted to the hospital, underwent laparotomy, and was diagnosed with diffuse peritonitis due to perforation of gastric ulcer. Omental patch repair was carried out. After surgery, he suddenly vomited blood and manifested hypovolemic shock. An emergency upper gastrointestinal endoscopy was carried out immediately. However, the bleeding source was not visible. Dynamic‐enhanced abdominal computed tomography showed a pseudoaneurysm of the gastroduodenal artery‐communicating duodenal lumen with extravasation. Next, the patient underwent angiography for embolization. However, selective arterial embolization was not successful.

IMPACT OF SINGLE INTRACORONARY NICORANDIL ADMINISTRATION ON MICROCIRCULATORY DISTURBANCE AFTER SUCCESSFUL PRIMARY PERCUTANEOUS INTERVENTION IN ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION

Background: Index of Microcirculatory Resistance (IMR) is an on-site parameter for the assessment of microcirculatory disturbance after primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). High IMR has been shown to be a predictor of poor left ventricular (LV) function recovery. We sought to investigate the effects of intracoronary nicorandil administration after primary PCI on microvascular injury and chronic phase LV function.

DISTAL PROTECTION CAN PRESERVE INDEX OF MICROCIRCULATORY RESISTANCE IN PATIENTS WITH ST-SEGMENT ELEVATION ANTERIOR WALL MYOCARDIAL INFARCTION

Authors: Noritoshi Ito, Shinsuke Nanto, Yasuji Doi, Hirotaka Sawano, Daisaku Masuda, Shizuya Yamashita, Mai Hatano, Daisuke Tonomura, Yuma Kurozumi, Tomoaki Natsukawa, Yusuke Ito, Kazuyuki Oka, Jiro Ooba, Taizo Hasegawa, Makoto Kobayashi, Hiroshi Ichiyanagi, Koji Akashi, Koichi Otsuya, Shoji Kaibe, Ken-ichiro Okada, Yasuyuki Hayashi, Tatsuro Kai, Toru Hayashi, Osaka Saiseikai Senri Hospital, Suita, Japan, Osaka University Graduate School of Medicine, Suita, Japan