Women With Acute Aortic Dissection Have Higher Prehospital Mortality Than Men.

Background: Acute aortic dissection (AAD) often leads to out-of-hospital cardiac arrest (OHCA) and death before hospital arrival. Objectives: The purpose of this study was to investigate differences in AAD incidence by sex. Methods: A population-based study in a city with 121,180 residents was conducted using postmortem computed tomography data to identify patients with AAD who died before hospital arrival in 2008-2020. The incidence rate ratio and odds ratio were estimated using Poisson regression and univariable logistic regression, respectively. Results: A total of 266 patients with incident AAD were enrolled: 84 patients with OHCA, 137 women [n = 137], and 164 patients with type A AAD. The crude and age-adjusted incidence of AAD was 16.2 and 14.3/100,000 person-years, respectively. The incidence of AAD was comparable by sex (men, 16.7/100,000 person-years; women, 15.7/100,000 person-years; incidence rate ratio: 0.94; 95% CI: 0.74-1.20; P = 0.64). Compared with men with AAD, women with AAD were older (77 ± 11 years vs 70 ± 14 years; P < 0.001), and a higher proportion had type A AAD (76% vs 47%; P < 0.001). Women with AAD had higher prehospital mortality than men with AAD (37% vs 21%; P = 0.004; OR: 2.24; 95% CI: 1.30-3.87; P = 0.004). Among 1,373 patients with OHCA, the proportion of women with AAD was significantly higher than the proportion of men with AAD (11% vs 3.9%; P < 0.001; OR: 2.90; 95% CI: 1.86-4.53; P < 0.001). AAD was most common in women aged 60 to 69 years (16.4%). Conclusions: Women had a higher incidence of AAD presenting as prehospital death than men.

Prediction of intracerebral hemorrhage in patients with out-of-hospital cardiac arrest using post-resuscitation electrocardiogram: An observational cohort study.

Aim: We evaluated the characteristics of patients with intracerebral hemorrhage in nontraumatic out-of-hospital cardiac arrests (OHCA) after return of spontaneous circulation (ROSC) to identify patients who required brain computed tomography as the next diagnostic workup. Methods: We conducted a retrospective cohort study on 1303 consecutive patients with nontraumatic OHCA who were admitted to Miyazaki Prefectural Nobeoka Hospital between 2008 and 2020. Among these, 454 patients achieved sustained ROSC. We excluded 126 patients with obvious extracardiac causes. Clinical and demographic characteristics of patients and post-resuscitation 12-lead electrocardiogram were compared. Patients were categorized into the intracerebral hemorrhage (n = 32, 10%) and no intracerebral hemorrhage group (n = 296). All causes of intracerebral hemorrhage were diagnosed based on brain computed tomography images by board-certified radiologists. Results: We included 328 patients (mean age, 74 years; women, 36%) who achieved ROSC. Logistic regression analyses showed that female sex, younger age (<75 years), no shockable rhythm changes, tachycardia (≥100 bpm), lateral ST-segment elevation, and inferior ST-segment depression on post-resuscitation electrocardiogram were independently associated with intracerebral hemorrhage. We developed a new predictive model for intracerebral hemorrhage by considering 1 point for each of the six factors. The odds ratio for intracerebral hemorrhage increased 2.36 for each 1-point increase (P < 0.001). A score ≥ 4 had 43.7% sensitivity, 90.8% specificity, 34.1% positive predictive value, and 93.7% negative predictive value. Conclusion: Our new predictive model might be useful for risk stratification of intracerebral hemorrhage in patients with OHCA who achieved ROSC.

Factors associated with the progression of traumatic intracranial hematoma during interventional radiology to establish hemostasis of extracranial hemorrhagic injury in severe multiple trauma patients.

AIM: To identify factors affecting the progression of traumatic intracranial hemorrhagic injury (t-ICH) during interventional radiology (IVR) for the hemostasis of extracranial hemorrhagic injury. METHODS: This was a retrospective comparative study. Fifty-two patients with t-ICH who underwent hemostasis using IVR for extracranial trauma at our institute were included. Clinical and computed tomography scan data were collected to investigate factors associated with t-ICH progression. RESULTS: Fifty-two subjects (36 men/16 women) with a mean age of 70.9 ± 19.2 years were analyzed. The mean Injury Severity Score was 34.9 ± 11.2. In 29 patients (55.7%), t-ICH progressed during IVR. Hematoma progression frequently occurred in patients with acute subdural hematoma (56.2%) and traumatic intracerebral hematoma/hemorrhagic brain contusion (66.6%). Factors associated with t-ICH progression included age (P = 0.029), consciousness level at admission (P = 0.001), Revised Trauma Scale (P = 0.036), probability of survival (P = 0.043), platelet count (P = 0.005), fibrinogen level (P = 0.016), hemoglobin level (P = 0.003), D-dimer level (P = 0.046), and red blood cell transfusion volume (P = 0.023). CONCLUSION: Aggressive correction of anemia, thrombocytopenia, and low fibrinogen levels in severe consciousness disturbance patients with acute subdural hematoma and traumatic intracerebral hematoma/hemorrhagic brain contusion could improve the prognosis after IVR for hemostasis of extracranial hemorrhagic injuries.

Prognostic impact of the presence of on-duty cardiologist on patients with acute myocardial infarction admitted during off-hours.

BACKGROUND: Owing to reduced staffing, patients hospitalized for acute myocardial infarction (AMI) during off-hours (nights, weekends, and holidays) have poorer outcomes than those admitted during regular hours. Whether the presence of an on-duty cardiologist in a hospital during off-hours is related to better outcomes for patients with AMI remains unclear. The Miyazaki Prefectural Nobeoka Hospital had a unique medical care system in that cardiologists were on call for half of the week and on duty for the other half during off-hours, thus providing an opportunity to assess the relationship between the presence of an on-duty cardiologist and patient outcomes. We examined clinical outcomes of patients admitted for AMI during off-hours according to the presence of an on-duty cardiologist. METHODS: We recruited 225 consecutive patients with AMI hospitalized during off-hours, who underwent stent implantation at Miyazaki Prefecture Nobeoka Hospital from 2013 to 2017. The endpoints were in-hospital death or long-term major adverse cardiac events (MACE) including cardiovascular death, non-fatal MI, non-fatal stroke, stent thrombosis, ischemia-driven target-lesion revascularization, admission owing to unstable angina, or admission owing to heart failure. RESULTS: Based on the presence of an on-call cardiologist at admission, we divided patients into the cardiologist on-call group (n = 112) or cardiologist on-duty group (n = 113). The presence of an on-duty cardiologist did not affect door-to-reperfusion time (p = 0.776), level of peak creatine kinase (p = 0.971), or in-hospital death (p = 0.776). The Kaplan-Meier curve analysis showed similar prognosis for the cardiologist on-duty and cardiologist on-call groups (p = 0.843), and multivariable Cox regression analysis showed that the presence of an on-duty cardiologist was not associated with MACE. CONCLUSIONS: The presence of an on-duty cardiologist is not a prognostic factor for patients hospitalized for AMI during off-hours in our medical system. Further prospective multicenter studies should confirm our results.

The Additive Effect of Atropine Sulfate during Cardiopulmonary Resuscitation in Out-of-hospital Non-traumatic Cardiac Arrest Patients with Non-shockable Rhythm.

Objective The updated guidelines of 2015 for cardiopulmonary resuscitation (CPR) do not recommend the routine use of atropine for cardiopulmonary arrest. Methods The study population included out-of-hospital cardiac arrest (OHCA) patients with non-shockable rhythm who were encountered at a Japanese community hospital between October 1, 2012 and April 30, 2017. Results At the outcome, the epinephrine with atropine and epinephrine-only groups had a similar survival rate to that at hospital admission (28.7% vs. 26.7%: p=0.723). The odds ratio (OR) for the survival to hospital admission after the administration of atropine with epinephrine was 1.33 (95% CI 1.09-1.62; p<0.01), while that after the administration of epinephrine was 0.64 (95% CI: 0.55-0.74, p<0.01). The ORs for the survival to hospital admission for patients with pulseless electrical activity in the epinephrine-alone group and the atropine with epinephrine group were 0.62 (95% CI 0.49-0.78; p<0.01) and 1.35 (95% CI 0.99-1.83; p=0.06), respectively, and those for such patients with asystole in the epinephrine-alone group and the atropine with epinephrine group were 0.64 (95% CI 0.53-0.76; p<0.01) and 1.39 (95% CI 1.10-1.77; p<0.01), respectively. The OR for the survival to hospital admission after the administration of atropine sulfate (1 mg) was 2.91 (95% CI 1.49-5.67; p<0.01), while that for the survival to hospital admission after the administration of 0, 2 and ≥3 mg atropine sulfate was 0.38 (95% CI 0.29-0.50; p<0.01), 1.54 (95% CI 0.58-4.08; p=0.38) and 0.23 (95% CI 0.09-0.60; p<0.01), respectively. Conclusion The addition of atropine (within 2 mg) following epinephrine was a comprehensive independent predictor of the survival to hospital admission for non-shockable (especially asystole) OHCA adults.

Modulation of two types of jaw-opening reflex by stimulation of the red nucleus.

The red nucleus (RN) is divided cytoarchitecturally into two parts, the parvicellular part (RPC) and the magnocellular part (RMC). The present study aims, first, to compare the effects of RN stimulation between low- and high-threshold afferents-evoked jaw opening reflexes (JORs), and secondly to compare the size of these effects in the RPC and RMC. Experiments were performed on rats anesthetized with urethane-chloralose. The JOR was evoked by electrical stimulation of the inferior alveolar nerve and was recorded as the electromyographic response of the anterior belly of the digastric muscle. The stimulus intensity was either 1.2 (low-threshold) or 4.0 (high-threshold) times that necessary to elicit the JOR. Conditioning electrical stimulation of the RN significantly facilitated the JOR evoked by the low-threshold afferents. On the other hand, conditioning electrical stimulation of the RN significantly suppressed the JOR evoked by the high-threshold afferents. Microinjection of monosodium glutamate into the RN also facilitated the JOR evoked by the low-threshold afferents, but suppressed that evoked by high-threshold afferents. Facilitation did not differ between the RMC and the RPC. Suppression by the RMC stimulation was significantly greater than that by the RPC stimulation. These results suggest that the RN has distinct functional roles in the control of the JOR.

Relationship between masticatory rhythm, body mass and mandibular morphology in primates.

OBJECTIVE: It has been proposed that rhythmic movements such as locomotion and respiration have a period proportional to body mass(1/4). Mastication basically consists of rhythmic alternation of jaw-closing and jaw-opening movements. We studied the relation between masticatory rhythm and body mass in primates, and masticatory rhythm and mandible morphology. METHODS: We measured the chewing cycle duration (CCD), mandibular length, mandible height, mandible width and distance from the condylar process of mandible to the centre of gravity of the mandible. Body mass was quoted from the literature. RESULTS: The CCD is related to mandible morphology and was found to be proportional to body mass(1/6). CONCLUSION: These findings suggest that masticatory rhythm is correlated with body mass and mandibular morphology, and that scaling rate of masticatory rhythm to body mass is slower than for the other rhythms.

Neuronal activities of the vestibular nuclear complex during mechanically induced rhythmic jaw movements in rats.

We studied the neuronal activities of the vestibular nuclear complex (VN) neurons during rhythmic jaw movements in rats anesthetized with urethane. Rhythmic jaw movements were induced by mechanical stimulation of the palate mucosa. The firing rate of approximately 25% of VN neurons increased significantly, and that of 10% of VN neurons decreased significantly, during these rhythmic jaw movements. There was no correlation between the change in the firing rate and the phase of the rhythmic jaw movements (jaw-opening and jaw-closing phases). The neurons that were affected were intermingled in the VN. These results suggest that the VN neurons are involved in controlling jaw movements.

Effects of neck muscle activities during rhythmic jaw movements by stimulation of the medial vestibular nucleus in rats.

This study first examines whether there is rhythmic activity of the neck muscles during cortically induced rhythmic jaw movements in rats anesthetized by urethane. Rhythmic jaw movements were induced by repetitive electrical stimulation of the orofacial motor cortex. An electromyogram in the splenius muscles (spEMG) showed rhythmic bursts during the jaw-opening phase, or during the transition from the jaw-opening phase to the jaw-closing phase. In the sternomastoid (stEMG), however, the electromyogram did not show any bursts during rhythmic jaw movements. A further study then examines whether stimulation of the medial vestibular nucleus (MVN) modulates the rhythmic activity of the neck muscles. Stimuli applied in the jaw-closing phase induced a transient burst in the stEMG, and the duration of activity in the spEMG was increased. Stimuli applied in the jaw-opening phase induced a transient burst in the stEMG and an inhibitory period in the spEMG. These results imply that the MVN is involved in the modulation of neck muscle activities during rhythmic jaw movements induced by stimulating the orofacial motor cortex.

Spinal epidural hematoma after stretch exercise: a case report.

Spinal epidural hematoma (SEH) is a rare but serious condition. Common causes of SEH include spinal fracture, spinal trauma, and invasive spinal procedures such as lumbar puncture, epidural anesthesia, or myelography. A few previous reports have suggested that SEH could be caused by minor triggers such as spinal manipulation therapy or spontaneously in rare cases. A 60-year-old man, immediately after stretch exercise, developed severe back cervicodynia and rapidly progressive weakness of left arm from SEH. He was treated by decompression laminectomy and evacuation of the hematoma. However, the upper extremity weakness did not completely resolve. The standard treatment remains timely surgical decompression and evacuation of the hematoma. Thus, early diagnosis and treatment can confer a significant prognostic advantage to patients with SEH. Based on the finding that SEH was caused by a mild mechanical trigger and neurologic deficits remained in this patient, this report highlights its diagnostic difficulty as well as the importance of rapid treatment. Emergency physicians should consider SEH among the differential diagnosis in patients with sudden-onset back pain with symptoms and signs of spinal cord compression.