Beneficial effects of intracoronary nicorandil on microvascular dysfunction after primary percutaneous coronary intervention: demonstration of its superiority to nitroglycerin in a cross-over study.

PURPOSE: In patients undergoing primary percutaneous coronary intervention (PCI) for the treatment of ST-segment elevation myocardial infarction (STEMI), coronary microvascular dysfunction is associated with poor prognosis. Coronary microvascular resistance is predominantly regulated by ATP-sensitive potassium (KATP) channels. The aim of this study was to clarify whether nicorandil, a hybrid KATP channel opener and nitric oxide donor, may be a good candidate for improving microvascular dysfunction even when administered after primary PCI. METHODS: We compared the beneficial effects of nicorandil and nitroglycerin on microvascular function in 60 consecutive patients with STEMI. After primary PCI, all patients received single intracoronary administrations of nitroglycerin (250 µg) and nicorandil (2 mg) in a randomized order; 30 received nicorandil first, while the other 30 received nitroglycerin first. Microvascular dysfunction was evaluated with the index of microcirculatory resistance (IMR), defined as the distal coronary pressure multiplied by the hyperemic mean transit time. RESULTS: As a first administration, nicorandil decreased IMR significantly more than did nitroglycerin (median [interquartile ranges]: 10.8[5.2-20.7] U vs. 2.1[1.0-6.0] U, p=0.0002).As a second administration, nicorandil further decreased IMR, while nitroglycerin did not (median [interquartile ranges]: 6.0[1.3-12.7] U vs. -1.4[-2.6 to 1.3] U, p<0.0001). The IMR after the second administration was significantly associated with myocardial blush grade, angiographic TIMI frame count after the procedure, and peak creatine kinase level. CONCLUSION: Intracoronary nicorandil reduced microvascular dysfunction after primary PCI more effectively than did nitroglycerin in patients with STEMI, probably via its KATP channel-opening effect.

Impact of early intravenous epinephrine administration on outcomes following out-of-hospital cardiac arrest.

BACKGROUND: The effectiveness of epinephrine administration for cardiac arrests has been shown in animal models, but the clinical effect is still controversial. METHODS AND RESULTS: A prospective, population-based, observational study in Osaka involved consecutive out-of-hospital cardiac arrest (OHCA) patients from January 2007 through December 2009. We evaluated the outcomes among adult non-traumatic bystander-witnessed OHCA patients for whom the local protocol directed the emergency medical service personnel to administer epinephrine. After stratifying by first documented cardiac rhythm, outcomes were compared among the following groups: non-administration, ≤10, 11-20 and ≥21 min as the time from emergency call to epinephrine administration. A total of 3,161 patients were eligible for our analyses, among whom 1,013 (32.0%) actually received epinephrine. The epinephrine group had a significantly lower rate of neurologically intact 1-month survival than the non-epinephrine group (4.1% vs. 6.1%, P=0.028). In cases of ventricular fibrillation (VF) arrest, patients in the early epinephrine group who received epinephrine administration within 10 min had a significantly higher rate of neurologically intact 1-month survival compared with the non-epinephrine group (66.7% vs. 24.9%), though other epinephrine groups did not. In cases of non-VF arrest, the rate of neurologically intact 1-month survival was low, irrespective of epinephrine administration. CONCLUSIONS: The effectiveness of epinephrine after OHCA depends on the time of administration. When epinephrine is administered in the early phase, there is an improvement in neurological outcome from OHCA with VF.

Distal protection during primary coronary intervention can preserve the index of microcirculatory resistance in patients with acute anterior ST-segment elevation myocardial infarction.

BACKGROUND: The objective of this study was to investigate whether a distal protection (DP) device can preserve the index of microcirculatory resistance (IMR) after primary percutaneous coronary intervention (PCI) in patients with anterior ST-segment elevation myocardial infarction (STEMI). METHODS AND RESULTS: The study group of 36 consecutive patients with anterior STEMI were randomized into 2 groups of primary PCI with or without DP: stenting without DP (non-DP group, n = 17) and with DP (DP group, n = 19). The DP in all cases was Filtrap (Nipro, Japan). Following final coronary angiography after successful PCI, IMR was measured using PressureWire™ Certus (St Jude Medical, USA) at maximal hyperemia. The averaged IMR of the 36 patients with STEMI after primary PCI was 31.6U. The IMR in the DP group was significantly lower than that in the non-DP group (26.6 ± 25.8U vs. 37.2 ± 23.2U, P = 0.03242). CONCLUSIONS: DP as an adjunctive therapy of PCI for acute anterior STEMI may have beneficial effects on myocardial microcirculation because of preservation of IMR.

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.

High index of microcirculatory resistance level after successful primary percutaneous coronary intervention can be improved by intracoronary administration of nicorandil.

BACKGROUND: Although microvascular dysfunction following percutaneous coronary intervention (PCI) can be evaluated with the index of microcirculatory resistance (IMR), no method of treatment has been established. We hypothesized that intracoronary administration of nicorandil can improve IMR after successful primary PCI in patients with ST-segment elevation myocardial infarction (STEMI). METHODS AND RESULTS: In 40 patients with first STEMI after successful primary PCI, IMR was measured using PressureWire(TM) Certus (St. Jude Medical, MN, USA). In 20 of the patients (Group N), IMR was measured at baseline and after intracoronary nicorandil (2 mg/10 ml). In the other 20 patients (Control), IMR was measured at baseline, after intracoronary saline (10 ml) and after intracoronary nicorandil (2 mg/10 ml). In Group N, IMR significantly decreased after intracoronary nicorandil (median IMR, 27.7-18.7 U, P<0.0001). In the Control group, IMR did not change after saline administration (median IMR, 24.3-23.8 U, P=0.8193), but was significantly decreased after intracoronary nicorandil (median IMR, 23.8-14.9 U, P<0.0001). Next, all 40 patients were divided into subgroups by tertile of baseline IMR. In those with intermediate to high IMR (baseline IMR > or =21), intracoronary nicorandil significantly decreased IMR, although it did not change IMR in those with low IMR (baseline IMR <21). CONCLUSIONS: High IMR levels in patients with STEMI after successful primary PCI can be improved by intracoronary administration of nicorandil.

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.

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.

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

Case: 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. Outcome: Finally, duodenotomy was carried out. The fistula between the pseudoaneurysm and duodenal lumen was directly ligated. An aneurysm could be clearly identified by previous findings. Conclusions: Gastroduodenal artery aneurysms are very uncommon but possibly lethal if they rupture. This life-threatening condition requires rapid diagnosis and treatment. Minimally invasive treatment is the preferred therapy for gastroduodenal artery aneurysm; however, acute care surgery should be considered without hesitation when conditions are critical.

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.

At what level of unconsciousness is mild therapeutic hypothermia indicated for out-of-hospital cardiac arrest: a retrospective, historical cohort study.

BACKGROUND: Appropriate patient selection is very important when initiating mild therapeutic hypothermia (MTH) for patients following out-of-hospital cardiac arrest, and the extent of unconsciousness at implementation must be defined in such cases. However, there are no clear standards regarding the level of unconsciousness at which MTH would be beneficial. The effects of MTH in patients with different degrees of unconsciousness according to the motor response score of the Glasgow Coma Scale (GCS) were investigated. METHODS: The subjects consisted of witnessed non-traumatic adult out-of-hospital cardiac arrest patients admitted to our institute from April 2002 to August 2011. The patients were divided into six groups according to the GCS motor response score: 1 (GCS M1), 2 (GCS M2), 3 (GCS M3), 4 (GCS M4), 5 (GCS M5), and 6 (GCS M6). The neurological outcome was evaluated at 30 days after hospital admission using the Cerebral Performance Category. Chi-squared Automatic Interaction Detection (CHAID) analysis was performed to estimate the threshold GCS M level where therapeutic hypothermia is indicated. Odds ratios were then calculated by multiple logistic-regression analysis using factors including GCS M5-6 and MTH. RESULTS: A total of 289 patients were enrolled in this study. CHAID analysis demonstrated two points of significant increase in percentage of good recovery at 30 days after admission, dividing the GCS M categories into three groups. Patients classified with a GCS motor response score of 5 or higher had the highest percentage of good recovery. The odds ratio for good recovery (CPC1-2) was 2.901 (95 % CI 1.460-5.763, P = 0.002) for MTH, and that for GCS M5-6 was 159.835 (95 % CI 33.592-760.513, P < 0.001). CONCLUSIONS: MTH may be unnecessary in patients with a GCS motor response score of 5 or higher. Consequently, because there are post cardiac arrest patients with a GCS motor response score of 4 or lower who benefit from MTH, MTH may be limited to patients with a GCS motor response score of 4 or lower.

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.

Three year longitudinal study for out-of-hospital cardiac arrest in Osaka Prefecture.

OBJECTIVE: To analyze the longitudinal changes in the treatment of out-of-hospital cardiac arrests. These analyses have focused on the time interval from the receipt of call until defibrillation of patients with ventricular fibrillation. DESIGN: Population-based, prospective longitudinal study according to the Utstein style. SETTING: Osaka Prefecture (population 8, 800, 000), served by 36 municipal fire and emergency departments. PATIENTS: Consecutive, out-of-hospital cardiac arrests occurring between May 1998 and April 2001. MAIN OUTCOME MEASURES: Change in the interval to defibrillation, and one-year survival from cardiac arrest. RESULTS: Of the 15,211 cases of confirmed cardiac arrests during the three years, resuscitation was attempted in 14,609 subjects. Of the 2957 cases of cardiac origin and witnessed by bystanders, 90 cases (3.0%) were alive 1 year following the episode. In 383 cases of defibrillation, the interval from receipt of call to defibrillation was evaluated annually. This interval decreased significantly during the three year course (14.5, 13.0, and 11.5 min expressed by the median), suggesting that this project to report the data of out-of-hospital arrests was an effective campaign for EMT. However, the outcome did not improve significantly during this period (3.0%, 2.6%, and 3.6% alive 1 year in witnessed arrests with cardiac etiology). This may be because the third year median duration of 11.5 min, is still insufficient to indicate a significant improvement in the outcome. CONCLUSIONS: This project to report the data of out-of-hospital cardiac arrest might have contributed to the reduction of the interval for defibrillation, as a campaign for the EMTs; although the decrease in this interval was still insufficient to result in a significant increase in the number of cases who are alive one year later.

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 skull's 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.

Regional cerebral oxygen saturation on hospital arrival is a potential novel predictor of neurological outcomes at hospital discharge in patients with out-of-hospital cardiac arrest.

AIM: To investigate the association between regional brain oxygen saturation (rSO(2)) on hospital arrival and neurological outcomes at hospital discharge in patients with out-of-hospital cardiac arrest (OHCA). METHODS: A prospective cohort study was conducted, registering 179 patients with OHCA who were referred to Senri Critical Care Medical Centre between April 2009 and June 2010. Of these patients, 92 met the inclusion criteria. The primary end point was "neurological outcomes" at hospital discharge according to the "Utstein style" guidelines. RESULTS: The overall rate of good neurological outcome at hospital discharge was 14% (n=13). Sixty-one patients with rSO(2) ≤25% showed poor neurological outcome in the receiver operating curve analysis (optimal cut-off point, 25%; sensitivity, 0.772; specificity, 1.000; positive predictive value, 1.000; area under the curve (AUC), 0.919; p<0.0001). The AUC for rSO(2) was greater than that for base excess (p=0.0461) or lactate (p=0.0128) measured on hospital arrival. Since rSO(2) >40% was previously collated with good neurological outcome after cardiovascular surgery, we categorised our patients into three groups in a post hoc analysis: patients with rSO(2) ≤25% (n=61); patients with rSO(2) 26-40% (n=9) and patients with rSO(2) >40% (n=22). Patients with good neurological outcome were as follows: 0 (0%)/61 with rSO(2) ≤25%; two (22.2%)/9 with rSO(2) 26-40% and 11 (50.0%)/22 with rSO(2) >40% (p<0.0001). CONCLUSION: rSO(2) on hospital arrival may help predict neurological outcomes at hospital discharge in patients with OHCA.