Treatment strategies for patients with out-of-hospital cardiac arrest associated with traumatic brain injury: A case series.

INTRODUCTION: Collapse after out-of-hospital cardiac arrest (OHCA) can cause severe traumatic brain injury (TBI). We aimed to investigate the clinical characteristics and treatment strategies for patients with OHCA and TBI. METHODS: We analyzed a consecutive cohort of patients with intrinsic OHCA retrospectively treated between January 2011 and December 2021 at a single critical care center, and presented a case series of seven patients. Patients with collapse-related TBI were examined for the causes and situations of cardiac arrest, laboratory data, radiological images, targeted temperature management (TTM), coronary angiography (CAG), percutaneous coronary intervention (PCI), and extracorporeal cardiopulmonary resuscitation (ECPR). RESULTS: Of the 197 patients with intrinsic OHCA, 7 (3.6%) had TBI (age range: 49-70 years; 6 men). All seven patients presented with ventricular fibrillation in the initial electrocardiograms, with four refractory cases treated with ECPR. All patients underwent CAG under heparinization, and four underwent PCI with antiplatelet administration. Initial head computed tomography indicated an intracranial hemorrhage (ICH) in three patients. ICH appeared or was exacerbated in six patients after CAG with or without PCI, except in one who underwent delayed PCI. All patients displayed elevated plasma D-dimer levels, and four underwent neurosurgical procedures. Four patients survived (three with cerebral performance category [CPC] 2, one with CPC 3) and three died; two had hypoxic-ischemic brain injury and one had severe TBI. CONCLUSION: Delayed ICH occurred frequently. Individualized management is required based on the extent of brain and cardiac damage, including optimal TTM, PCI procedures, and antiplatelet medications. Early detection of ICH and emergency treatment are critical for multi-disciplinary collaboration.

Targeted Temperature Management for Severe Subarachnoid Hemorrhage Using Endovascular and Surface Cooling Systems: A Nonrandomized Interventional Study Using Historical Control.

BACKGROUND: Although targeted temperature management (TTM) may mitigate brain injury for severe subarachnoid hemorrhage (SAH), rebound fever correlates with poor outcomes. OBJECTIVE: To study the effect of endovascular TTM after rewarming from initial surface cooling during a high-risk period for delayed cerebral ischemia. METHODS: We studied patients with World Federation of Neurological Surgeons grade V SAH before and after the introduction of endovascular TTM. Both groups (36 patients each) were treated with TTM at 34 °C with conventional surface cooling immediately after SAH diagnosis, together with emergency aneurysm repair. When rewarmed to 36 °C, around 7 days later, the study group underwent TTM at 36 to 38 °C for 7 days with an endovascular cooling system. The control group was treated with antipyretics. RESULTS: Sex, age, Glasgow Coma Scale score, modified Fisher computed tomography classification, aneurysm location, and treatment methods were not different between the study and control groups. Differences were detected in the incidence of fever >38 °C (13 vs 26 patients, P = .0021), duration of fever >38 °C (4.1 vs 18.8 hours, P = .0021), incidence of vasospasm-related cerebral infarction (17% vs 42%, P = .037), and the likelihood of excellent outcomes (0 and 1 on a modified Rankin Scale) at 6 months (42% vs 17%, P = .037). In endovascular TTM, shivering occurred more frequently in patients with better outcomes, requiring aggressive treatment to avoid fever. CONCLUSION: Endovascular TTM at 36 to 38 °C after surface cooling was feasible and safely performed in patients with severe SAH. Combined TTM for 2 weeks was associated with a lower incidence of vasospasm-related infarction and may improve outcomes.

Evaluation of Performance in Colon Capsule Endoscopy Reading by Endoscopy Nurses.

Background: Although there are papers reporting on the accuracy of colon capsule endoscopy (CCE) compared with colonoscopy (CS), there are few reports on the detection rates of significant lesions by endoscopy nurses. We previously reported no significant difference in the detection rates for small bowel capsule endoscopy (SBCE) images among two well-trained physicians and one expert nurse. Objective: To evaluate the reading time and detection rate of the significant lesions of CCE images among novice and trained expert endoscopy nurses and novice physicians. Methods: CCE videos of 20 consecutive patients who performed both CCE and CS with clinically significant localized lesions were selected. Two trained expert endoscopy nurses, untrained two novice physicians, and novice three endoscopy nurses reviewed CCE videos. The detection rate of the lesions and reading time were compared among the three groups and were evaluated by comparison between the first and the second 10 videos. Results: The median reading time was the shortest (19 min) in the trained expert endoscopy nurses and the longest (45 min) in the novice nurses. The number of thumbnails tended to be more in the trained expert endoscopy nurses in the first 10-video reading. Although the detection rates of small polyps (<5 mm) were significantly lower (46.5%, p=0.025) in the novice nurses compared to the others, they were improved (35.2% to 63.5%, p=0.015) in the second 10 videos. The detection rates of tumor lesions by either one of two trained expert endoscopy nurses were higher compared to those by each novice physician. Conclusions: The trained expert endoscopy nurses for CCE reading can reduce physician's time and improve the diagnostic yield.

Continuous amplitude-integrated electroencephalography for prognostication of cardiac arrest patients undergoing extracorporeal cardiopulmonary resuscitation with targeted temperature management.

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR) has been increasingly used for adult cardiac arrest (CA) patients refractory to conventional CPR. However, data on early prognosticators of neurological outcome are lacking. METHODS: CA patients undergoing ECPR were prospectively monitored via amplitude-integrated EEG (aEEG). Targeted temperature management (TTM) was induced using an extracorporeal membrane oxygenation system. aEEG background patterns were classified into continuous normal voltage (CNV), discontinuous normal voltage (DNV), low voltage (LV), flat trace (FT), burst suppression (BS), and status epilepticus (SE). The Cerebral Performance Category (CPC) scale scores at hospital discharge and at 6 months after discharge were assessed, as was wakefulness after TTM. Good neurological outcome was defined as a CPC score of 1 or 2. RESULTS: Twenty-two patients were studied. Six patients who showed CNV within 24 hours after arrival, including one with initial FT and two with initial LV, regained consciousness and had good neurological outcome except for one who died of haemorrhagic complication. Patients with persistent FT or BS at any time did not regain consciousness. Regarding 19 patients in whom aEEG data were obtained within 24 hours, CNV background predicted good outcome at 6 months with 100% sensitivity, 93% specificity, 83% positive predictive values, and 100% negative predictive values. All these indices were 100% concerning wakefulness after TTM. CONCLUSION: aEEG monitoring was feasible and practical in adult CA patients undergoing ECPR and TTM. Evolution of aEEG background within 24 hours provides early accurate information for neurological prognostication.

[Usefulness of tranexamic acid in patients with severe head injury].

UNLABELLED: It is known that patients with severe head injury experience marked hypercoagulability and excessive hyperfibrinolysis due to the release of tissue factors from injured cerebral parenchyma. METHODS: We retrospectively evaluated the usefulness of tranexamic acid (TA) in patients with single, severe head trauma, who showed a Glasgow coma scale (GCS) 8 or D-dime > or = 20 microg ml-1. Twenty-five patients receiving TA [TA (+) ] were given the agent 2 g taking 30 minutes soon after their visit. Those not receiving TA [TA (--)] were 25 consecutive patients who met the criteria before the initiation of treatment with TA. RESULTS: The mortality rate was 4% in TA (+) and 24% in TA (-), significantly lower than in the former. The prognosis showed a tendency to improve in TA (+), but without significant differences between the groups. D-dimer was compared between the groups with a favorable prognosis in TA (+) and those in TA (-), its value was significantly higher in the former (60+/-56 microg ml-1) than the latter (28 +/- 27 microg ml-1) group. In addition, no thrombotic complications occurred in the former. CONCLUSIONS: Patients with severe head injury receiving TA showed a significantly better mortality rate without complications suggesting its usefulness.

Generation of embryonic stem cell lines from immature rabbit ovarian follicles.

In mammalian ovaries, many immature follicles remain after the dominant follicles undergo ovulation. Here we report the successful production of rabbit embryonic stem cells (ESCs) from oocytes produced by in vitro culture of immature follicles and subsequent in vitro maturation treatment. In total, we obtained 53 blastocysts from oocytes that received intracytoplasmic sperm injection followed by in vitro culture. Although only weak expression of POU5f1 was observed in the inner cell masses of in-vitro-cultured follicle-derived embryos, repeated careful cloning enabled establishment of 3 stable ESC lines. These ESC lines displayed the morphological characteristics of primed pluripotent stem cells. The ESC lines also expressed the pluripotent markers Nanog, POU5f1, and Sox2. Further, these ESCs could be differentiated into each of the 3 different germ layers both in vitro and in vivo. These results demonstrate that immature follicles from rabbits can be used to generate ESCs. Moreover, the use of rabbit oocytes as a cell source provides an experimental system that closely matches human reproductive and stem cell physiology.

Analysis of small-bowel capsule endoscopy reading by using Quickview mode: training assistants for reading may produce a high diagnostic yield and save time for physicians.

GOAL: The aim was to investigate the clinical utility of RAPID Access 6.5 Quickview software and to evaluate whether preview of the capsule endoscopy video by a trained nurse could detect significant lesions accurately compared with endoscopists. BACKGROUND: As reading capsule endoscopy is time consuming, one possible cost-effective strategy could be the use of trained nonphysicians or newly available software to preread and identify potentially important capsule images. STUDY: The 100 capsule images of a variety of significant lesions from 87 patients were investigated. The minimum percentages for settings of sensitivity that could pick up the selected images and the detection rate for significant lesions by a well-trained nurse, two endoscopists with limited experience in reading, and one well-trained physician were examined. RESULTS: The frequency of the selected lesions picked up by Quickview mode using percentages for sensitivity settings of 5%, 15%, 25%, and 35% were 61%, 74%, 93%, and 98%, respectively. The percentages for sensitivity significantly correlated (r=0.78, P<0.001) with the reading time. The detection rate by the nurse or the well-trained physician was significantly higher than that by the physician with limited capsule experience (87% and 84.1% vs. 62.7%; P<0.01). The clinical use of Quickview at 25% did not significantly improve the detection rate. CONCLUSIONS: Quickview mode can reduce reading time but has an unacceptably miss rate for potentially important lesions. Use of a trained nonphysician assistant can reduce physician's time and improve diagnostic yield.

Use of an external real-time image viewer coupled with prespecified actions enhanced the complete examinations for capsule endoscopy.

BACKGROUND AND AIM: The clinical utility of capsule endoscopy (CE) is often limited by incomplete small-bowel transit. The aim was to determine whether the use of an external real-time viewer could reduce delays caused by delayed gastric emptying of the capsule or delayed intestinal transit and also improve the rate of positive findings. METHODS: We compared the proportion of completed exams and positive results among a group of patients studied before introduction of real-time viewer and a group in which capsule transit through the esophagus, stomach, and small bowel was regularly monitored and actions (e.g. administration of water or intravenous metoclopramide) were taken if it was delayed. RESULTS: One hundred procedures in the viewer group and 100 control procedures in the age-matched controls were analyzed. In the viewer group, additional water intake (22 cases) and/or administration of metoclopramide (26 cases) were required. Endoscopic-assisted duodenal placement of the capsule was required in three cases. Overall one-third (n=33) of cases required viewer-prompted interventions. The completion rate (86% vs 66%, P=0.002) and the rate of positive findings (80% vs 67%, P=0.04) were significantly higher in the viewer group compared to the no viewer group. CONCLUSIONS: Checking the progress of the capsule with the external real-time viewer improved the diagnostic yield and completion rate of CE.

Evaluation of RAPID(®) 5 Access software for examination of capsule endoscopies and reading of the capsule by an endoscopy nurse.

BACKGROUND: Since capsule endoscopy (CE) is time consuming, one possible cost-effective strategy could be the use of an expert endoscopic assistant and available software to select images. Aims were to examine the clinical utility of RAPID(®) 5 Access software and find the optimum setting mode for reading. We also evaluated whether a nurse could preview the CE video and detect significant lesions accurately. METHODS: The capsule images in 14 volunteers with known mucosal injury induced by low dose aspirin and in 30 patients who were known to have a variety of significant lesions were selected. Using three setting modes of RAPID(®) 5 Access software, the detection rate and reading time for CE images by two well-trained physicians and one expert nurse were compared. RESULTS: There was no significant difference in detection rate among the three readers. The detection rate using Quickview RAPID(®) 5 Access was significantly higher than that using RAPID(®) Reader version 4.1. Comparison among the three modes of RAPID(®) 5 Access showed that auto mode as well as displaying a single image at 12 fps was superior in the detection rate of denuded redness, while its reading time was longer compared to the other modes. Some significant lesions were not detected by using Quickview and Quadview modes. CONCLUSIONS: RAPID(®) 5 Access improves diagnostic yield, reducing reading time; however, it is still unacceptable because of the diagnostic miss rate and may be useful as an ancillary reading tool. Developing further improved software and training expert assistants for reading capsule images are necessary.

Therapeutic hypothermia with immunosuppressive drugs for a comatose renal transplant patient who survived out-of-hospital cardiac arrest.

A 31-year-old man suddenly collapsed at work. His colleagues witnessed the event, applied basic life support, and called for an ambulance. After the ambulance arrived, the initial rhythm was confirmed as ventricular fibrillation (VF) and he was defibrillated with an automated external defibrillator. Spontaneous circulation was regained at 8 min after collapse. He was thought to be a good candidate for therapeutic hypothermia because he was comatose and had survived outside hospital VF cardiac arrest due to cardiac etiology. However, he was taking immunosuppressive drugs after undergoing a kidney transplant. We obtained written, informed consent from the patient's family to start therapeutic hypothermia at 33.5-34.5 °C for 48 h, although he was at high risk for such induction. Serious complications and neurological deficits did not develop and the patient was referred to another hospital on day 42 for implantation with a cardioverter defibrillator.

Location of out-of-hospital cardiac arrests in Takatsuki City: where should automated external defibrillator be placed.

BACKGROUND: Public access defibrillation has been introduced to improve the outcome of patients experiencing out-of-hospital cardiac arrest (OHCA). The aim of this study was to examine the best location for automated external defibrillators (AED). METHODS AND RESULTS: All patients who were resuscitated after OHCA by emergency medical technicians in Takatsuki City over 6 years were enrolled. The annual incidence of OHCA and the number of 1-year survivors with good neurological outcome in each of 21 sub-location categories were investigated, as well as the ratio of ventricular fibrillation (VF) as the initial rhythm to the total OHCA in each of 5 location categories. In total, there were 1,112 patients with OHCA, 62 (5.6%) with VF and 14 (1.3%) with good neurological outcome. The annual incidence of cardiac arrest (CA) per site was the highest in railway stations (0.3000), followed by hospitals (0.1802), homes for the aged (0.1115), playgrounds (0.0769) and golf courses (0.0667). However, none of the patients experiencing CA at railway stations, homes for the aged and golf courses had a good neurological outcome. The ratio of VF to total CA was the highest in the workplace (35.3%). CONCLUSIONS: The 6 locations, including workplace, are recommended as appropriate locations for AED.

Dietary isothiocyanates modify mitochondrial functions through their electrophilic reaction.

We found that both benzyl isothiocyanate (ITC) and phenyl ITC inhibited respiration in the mitochondria in an electrophilic reaction-dependent manner. ITC-induced mitochondrial swelling and cytochrome c release were prevented by cyclosporin A, indicating that they are mediated through the ITC moiety-dependent reaction to critical thiol groups for the opening of membrane permeability transition-dependent pores.

Involvement of the mitochondrial death pathway in chemopreventive benzyl isothiocyanate-induced apoptosis.

In the present study, we studied the molecular mechanism underlying cell death induced by a cancer chemoprotective compound benzyl isothiocyanate (BITC). The cytotoxic effect of BITC was examined in rat liver epithelial RL34 cells. Apoptosis was induced when the cells were treated with 20 mum BITC, characterized by the appearance of phosphatidylserine on the outer surface of the plasma membrane and caspase-3 activation, whereas no caspase activation and propidium iodide incorporation into cell were detected with 50 mum BITC that induced necrosis. The mitochondrial death pathway was suggested to be involved in BITC-induced apoptosis because the treatment of cells with BITC-induced caspase-9-dependent apoptosis and mitochondrial transmembrane potential (Delta Psi m) alteration. We demonstrated here for the first time that BITC directly modifies mitochondrial functions, including inhibition of respiration, mitochondrial swelling, and release of cytochrome c. Moreover, glutathione depletion by diethyl maleate significantly accelerated BITC-triggered apoptosis, suggesting the involvement of a redox-dependent mechanism. This was also implicated by the observations that intracellular accumulation of reactive oxygen species, including superoxide (O(2)) and hydroperoxides (HPOs), was indeed detected in the cells treated with BITC and that the intracellular HPO level was significantly attenuated by pretreatment with N-acetylcysteine. The treatment with a pharmacological scavenger of O(2), Tiron, also diminished the HPO formation by approximately 80%, suggesting that most of the HPOs were H(2)O(2) derived from the dismutation of O(2). These results suggest that BITC induces apoptosis through a mitochondrial redox-sensitive mechanism.