Neurological outcome of cardiac arrest patients in mountain areas: An analysis of the Northern French Alps Emergency Network.

BACKGROUND: Mountainous areas pose a challenge for the out-of-hospital cardiac arrest (OHCA) chain of survival. Survival rates for OHCAs in mountainous areas may differ depending on the location. Increased survival has been observed compared to standard location when OHCA occurred on ski slopes. Limited data is available about OHCA in other mountainous areas. The objective was to compare the survival rates with a good neurological outcome of OHCAs occurring on ski slopes (On-S) and off the ski slopes (OffS) compared to other locations (OL). METHODS: Analysis of prospectively collected data from the cardiac arrest registry of the Northern French Alps Emergency Network (RENAU) from 2015 to 2021. The RENAU corresponding to an Emergency Medicine Network between all Emergency Medical Services and hospitals of 3 counties (Isère, Savoie, Haute-Savoie). The primary outcome was survival at 30 days with a Cerebral Performance Category scale (CPC) of 1 or 2 (1: Good Cerebral Performance, 2: Moderate Cerebral Disability). RESULTS: A total of 9589 OHCAs were included: 213 in the On-S group, 141 in the Off-S group, and 9235 in the OL group. Cardiac etiology was more common in On-S conditions (On-S: 68.9% vs OffS: 51.1% vs OL: 66.7%, p < 0.001), while Off-S cardiac arrests were more often due to traumatic circumstances (OffS: 39.7% vs On-S: 21.7% vs OL: 7.7%, p < 0.001). Automated external defibrillator (AED) use before rescuers' arrival was lower in the Off-S group than in the other two groups (On-S: 15.2% vs OL: 4.5% vs OffS: 3.7%; p < 0.002). The first AED shock was longer in the Off-S group (median time in minutes: OffS: 22.0 (9.5-35.5) vs On-S: 10.0 (3.0-19.5) vs OL: 16.0 (11.0-27.0), p = 0.03). In multivariate analysis, on-slope OHCA remained a positive factor for 30-day survival with a CPC score of 1 or 2 with a 1.96 adjusted odds ratio (95% confidence interval (CI), 1.02-3.75, p = 0.04), whereas off-slope OHCA had an 0.88 adjusted odds ratio (95% CI, 0.28-2.72, p = 0.82). CONCLUSIONS: OHCAs in ski-slopes conditions were associated with an improvement in neurological outcomes at 30 days, whereas off-slopes OHCAs were not. Ski-slopes rescue patrols are efficient in improving outcomes.

Supraglottic Airway Device to Improve Ventilation Success and Reduce Pulmonary Aspiration during Cardio-Pulmonary Resuscitation by Basic Life Support Rescuers: A Randomized Cross-over Human Cadaver Study.

OBJECTIVES: Early airway management during cardiopulmonary resuscitation (CPR) prevents aspiration of gastric contents. Endotracheal intubation is the gold standard to protect airways, but supraglottic airway devices (SGA) may provide some protection with less training. Bag-mask ventilation (BMV) is the most common method used by rescuers. We hypothesized that SGA use by first rescuers during CPR could increase ventilation success rate and also decrease intragastric pressure and pulmonary aspiration. METHODS: We performed a randomized cross-over experimental trial on human cadavers. Protocol A: we assessed the rate of successful ventilation (chest rise), intragastric pressure, and CPR key time metrics. Protocol B: cadaver stomachs were randomized to be filled with 300 mL of either blue or green serum saline solution through a Foley catheter. Each rescuer was randomly assigned to use SGA or BMV during a 5-minute standard CPR period. Then, in a crossover design, the stomach was filled with the second color solution and another 5-minute CPR period was performed using the other airway method. Pulmonary aspiration, defined as the presence of colored solution below the vocal cords, was assessed by a blinded operator using bronchoscopy. A generalized linear mixed model was used for statistical analysis. RESULTS: Protocol A: Forty-eight rescuers performed CPR on 11 cadavers. Median ventilation success was higher with SGA than BMV: 75.0% (IQR: 59.8-87.3) vs. 34.7% (IQR: 25.0-50.0), (p = 0.003). Gastric pressure and differential (maximum minus minimum) gastric pressure were lower in the SGA group: 2.21 mmHg (IQR: 1.66; 2.68) vs. 3.02 mmHg (IQR: 2.02; 4.22) (p = 0.02) and 5.70 mmHg (IQR: 4.10; 7.60) vs. 8.05 mmHg (IQR: 5.40; 11.60) (p = 0.05). CPR key times were not different between groups. Protocol B: Ten cadavers were included with 20 CPR periods. Aspiration occurred in 2 (20%) SGA procedures and 5 (50%) BMV procedures (p = 0.44). CONCLUSION: Use of SGA by rescuers improved the ventilation success rate, decreased intragastric pressure, and did not affect key CPR metrics. SGA use by basic life support rescuers appears feasible and efficient.

Mechanical ventilation during cardiopulmonary resuscitation: influence of positive end-expiratory pressure and head-torso elevation.

BACKGROUND: Efficient ventilation is important during cardiopulmonary resuscitation (CPR). Nevertheless, there is insufficient knowledge on how the patient's position affects ventilatory parameters during mechanically assisted CPR. We studied ventilatory parameters at different positive end-expiratory pressure (PEEP) levels and when using an inspiratory impedance valve (ITD) during horizontal and head-up CPR (HUP-CPR). METHODS: In this human cadaver experimental study, we measured tidal volume (VT) and pressure during CPR at different randomized PEEP levels (0, 5 or 10 cmH2O) or with an ITD. CPR was performed, in the following order: horizontal (FLAT), at 18° and then at 35° head-thorax elevation. During the inspiratory phase we measured the net tidal volume (VT) adjusted to predicted body weight (VTPBW), reversed airflow (RAF), and maximum and minimum airway pressure (Pmax and Pmin). RESULTS: Using ten thawed fresh-frozen cadavers we analyzed the inspiratory phase of 1843 respiratory cycles, 229 without CPR and 1614 with CPR. In a mixed linear model, thoracic position and PEEP significantly impacted VTPBW (p < 0.001 for each), and the insufflation time, thoracic position and PEEP significantly affected the RAF (p < 0.001 for each) and Pmax (p < 0.001). For Pmin, only PEEP was significant (p < 0.001). In subgroup analysis, at 35° VTPBW and Pmax were significantly reduced compared with the flat or 18° position. CONCLUSION: When using mechanical ventilation during CPR, it seems that the PEEP level and patient position are important determinants of respiratory parameters. Moreover, tidal volume seems to be lower when the thorax is positioned at 35°.

Comparative expression of hCG ß-genes in human trophoblast from early and late first-trimester placentas.

Human chorionic gonadotropin (hCG) displays a major role in pregnancy initiation and progression and is involved in trophoblast differentiation and fusion. However, the site and the type of dimeric hCG production during the first trimester of pregnancy is poorly known. At that time, trophoblastic plugs present in the uterine arteries disappear, allowing unrestricted flow of maternal blood to the intervillous space. The consequence is an important modification of the trophoblast environment, including a rise of oxygen levels from about 2.5% before 10 wk of amenorrhea (WA) to ∼8% after 12 WA. Two specific ß-hCG proteins that differ from three amino acids have been described: type 1 (CGB7) and type 2 (CGB3, -5, and -8). Here, we demonstrated in situ and ex vivo on placental villi and in vitro in primary cultures of human cytotrophoblasts that type 1 and 2 ß-hCG RNAs and proteins were expressed by trophoblasts and that these expressions were higher before blood enters in the intervillous space (8-9 vs. 12-14 WA). hCG was immunodetected in villous mononucleated cytotrophoblasts (VCT) and syncytiotrophoblast (ST) at 8-9 WA but only in ST at 12-14 WA. Furthermore, hCG secretion was fourfold higher in VCT cultures from 8-9 WA compared with 12-14 WA. Interestingly, VCT from 8-9 WA placentas were found to exhibit more fusion features. Taken together, we showed that type 1 and type 2 ß-hCG are highly expressed by VCT in the early first trimester, contributing to the high levels of hCG found in maternal serum at this term.

Drug transporter expression during in vitro differentiation of first-trimester and term human villous trophoblasts.

Drug transporters interfere with drug disposition during pregnancy by actively transporting drugs from mother to fetus, and vice versa. Data on their placental expression are scarce, especially during the first trimester of pregnancy. The aim of our study was to assess mRNA expression of more than 80 drug transporters by using an RT-qPCR array in primary cytotrophoblastic cells isolated from first-trimester and term human placentas and cultured for 72 h to form syncytiotrophoblasts. This original expression panel of human placental drug transporters should help to understand transplacental drug transfer and to ensure more rational drug use during pregnancy.

Calcitonin and calcitonin gene-related peptide are chemotactic for F9 embryonal carcinoma cells.

The chemotactic effect of calcitonin (CT) gene products was tested on F9 teratocarcinoma cells, which are an in vitro model of early embryonic development. CT and CT gene-related peptide (CGRP) induce a significant chemotactic response (chemotactic index, 40-50). The order of potency is: chicken CGRP greater than or equal to salmon CT greater than or equal to human CGRP. Human CT is a less potent chemotactic agent (chemotactic index, 15). Compared to other well known peptides with chemotactic activity, such as platelet-derived growth factor (no activity) and transforming growth factor-beta (chemotactic index, 5), CGRP and CT appear to be very active in attracting F9 cells in the Boyden chamber assay. Interestingly, CT and CGRP exhibit little chemotactic effect toward differentiated teratocarcinoma cells (i.e. retinoic acid-treated F9 cells or parietal endodermal PYS cells). While salmon CT and chicken CGRP activate adenylate cyclase activity in F9 cell membranes by 7- to 8-fold, higher concentrations (greater than 10(-10) M) of these peptides are required to stimulate cAMP formation than are required to mediate the chemotactic effect of these peptides. These data imply the possible involvement of CT gene products in regulating cell migration during early embryonic development.

Calcitonin mRNA activity in young obese (fa/fa) Zucker rats.

Alterations in both calcitonin (CT) secretion and plasma calcium were recently described in adult obese Zucker rats. We have investigated the CT biosynthetic activity of thyroid glands in 30-day-old obese Zucker rats (fa/fa), and their controls (Lean). Plasma calcium level was significantly increased (+0.6 mg/dl) in obese animals, but plasma phosphate was unchanged. Plasma CT levels measured by radioimmunoassay (RIA) were significantly decreased in fatty (0.50 +/- 0.03 vs 0.68 +/- 0.03 ng/ml in Leans; P less than 0.001), but thyroidal hormone content was not different between Lean and fatty rats (68.7 +/- 5.1 in Leans vs 60.5 +/- 3.6 ng/gland in fatty rats). mRNA was extracted from 10 thyroids, and translated in a rabbit reticulocyte lysate (NEN) in the presence of [35S]methionine. After polyacrylamide gel electrophoresis, specific immunoprecipitates were autoradiographed and quantified by integration. A 50% decrease in translatable CT mRNA was observed in fatty rats. In basal conditions, the biosynthetic activity of C cells in obese rats correlates with the secretion rate of the hormone in the face of unchanged thyroidal CT contents.

Cell free translation of chicken calcitonin messenger RNA.

The primary step of calcitonin biosynthesis was studied in a normal organ: chicken ultimobranchial gland, a tissue particularly rich in calcitonin secretory cells. Poly(A)-rich RNA was extracted and purified from ultimobranchial organs and translated in a reticulocyte lysate in the presence of labelled methionine. Polyacrylamide gel electrophoresis of specific immunoprecipitates revealed a major band of Mr 14 500 and a band of Mr 13 300. Thus, in chicken the precursor of calcitonin is a Mr 14 500 polypeptide. The minor component of Mr 13 300 could represent limited processing by the reticulocyte lysate.

Sequence and expression of the chicken calcitonin gene.

The avian calcitonin gene was isolated and sequenced; two mRNAs are expressed by tissue-specific alternate splicing. The peptides encoded by the mRNAs are the protein precursors of either calcitonin or calcitonin gene-related peptide (CGRP). Calcitonin is expressed predominantly in ultimobranchial bodies and CGRP in brain.

Increased level of calcitonin mRNA after 1,25-dihydroxyvitamin D3 injection in the rat.

Vitamin D metabolites are able to change plasma calcitonin (CT) levels, but nothing is known about a possible effect at the CT gene level. Here we have investigated the acute effects of 1,25-dihydroxyvitamin D3 (1,25-(OH)2D3) on the CT biosynthetic activity of thyroid glands from adult rats. Plasma CT levels were significantly increased (X2) 1 and 2 h after 1,25-(OH)2D3 injection in the face of unchanged plasma calcium values. The thyroidal CT content also was unchanged. A 2-fold increase in CT mRNA level measured by dot-blot hybridization occurred 1 and 2 h after 1,25-(OH)2D3 administration. Expression of CT gene products was examined in the rabbit reticulocyte lysate cell-free translation assay. After polyacrylamide gel electrophoresis, specific immunoprecipitates were autoradiographed and quantified by integration. A single precursor of Mr approximately equal to 15 000 could be specifically immunoprecipitated with CT antisera. A 3-4-fold rise in translatable CT mRNA activity was observed 1 and 2 h after 1,25-(OH)2D3 injection. Thus, parallel changes in CT mRNA level, CT mRNA activity and plasma CT levels were observed in adult female rats after administration of 1,25-(OH)2D3. These findings demonstrate for the first time that 1,25-(OH)2D3 enhanced CT gene expression in the face of unchanged plasma calcium levels.

PCR amplification of CGRP II mRNA. Variable expression in tumoral and non-tumoral human thyroid.

Two genes code for calcitonin gene-related peptides (CGRPs). One expresses by tissue-specific alternate splicing calcitonin and CGRP I mRNAs, the other CGRP II mRNA. Calcitonin is the marker of sporadic or hereditary human medullary thyroid carcinoma (MTC). CGRP II expression is not well established in normal or tumoral thyroid. After amplification by polymerase chain reaction, CGRP I and II mRNAs were detected in six cases of MTC associated with other endocrine neoplasia (MEN IIa) and in two cases of isolated MTC. CGRP I was detected in all non-C cell tumoral thyroids (6 samples), CGRP II was barely detectable in three out of six cases. CGRP II could be a specific tumoral marker of MTC.

An isoform of the human calcitonin receptor is expressed in TT cells and in medullary carcinoma of the thyroid.

We amplified, using the polymerase chain reaction and calcitonin receptor (CTR) specific primers, RNA extracted from medullary thyroid carcinoma (MTC) and the derived TT cell line. Both secrete large amounts of calcitonin. Electrophoresis of amplification products revealed, in both cases, an ethidium bromide-stained band that hybridized to a CTR probe. Sequencing the band amplified from TT cells revealed an open reading frame identical to the sequence of H-CTR but lacking 16 amino acids in the first intracellular loop. This demonstrates the existence of an mRNA coding for a subtype of H-CTR which is expressed in TT cells and MTC.

Specific immunostaining for CCP II, a novel calcitonin carboxyl terminal peptide encoded by the calcitonin/CGRP gene.

Alternative splicing of the primary transcript of the CALC I gene in thyroid C-cells results predominantly in calcitonin (CT) mRNA (exons 1-4), whereas CGRP mRNA (exons 1, 2, 3, 5, and 6) is mainly produced in neuronal cells. The CT mRNA encodes for a protein precursor containing an amino terminal peptide, CT, and a carboxyl terminal peptide (CCP I). CGRP precursor is composed of the same amino terminal peptide and CGRP. Recently we reported the presence of a third mature transcript of the CALC I gene in human medullary thyroid carcinoma (MTC) tissues. This transcript encodes for a precursor containing the amino terminal peptide CT and a novel carboxyl terminal peptide, CCP II. This finding was further confirmed in the TT-cell line derived from a human MTC. We produced monoclonal antibodies against CCP II and developed a rapid and specific immunofluorescence method for this peptide. We demonstrated CCP II-specific immunoreactivity in TT-cells and in MTC tissues. CCP II labeling was relatively homogeneous in contrast to CT and CGRP, which presented striking heterogeneity for intensity of labeling. Therefore, CCP II mRNA is translated in tumor cells in an apparently constitutive way.

Circadian rhythms of calcitonin gene expression in the rat.

The daily changes in rat thyroid calcitonin and its specific mRNA concentrations, and the relationship between their dynamics and the plasma levels of calcitonin, calcium and phosphate over a 24-h period were investigated. The circulating calcitonin concentration rose during the daily dark period when plasma calcium and phosphate levels were minimal, indicating that plasma calcitonin rhythm cannot be generated directly by a linear effect of calcium on hormone secretion. Moreover, we established that the expression of the calcitonin gene also exhibited periodic dynamics observable at the pretranslational level: the gland content of hybridizable specific calcitonin RNA displayed daily rhythms; specific RNA levels peaked during the light period and were minimal during the first part of the dark period. Significant changes in thyroid calcitonin concentrations also occurred over a 24-h period. Statistical analyses which distinguished between variations over the 24-h period and residual variations were performed to test the relationships between the various parameters. The daily rhythms of hybridizable RNA, thyroid calcitonin and plasma minerals appeared to be in phase, while the plasma calcitonin concentration displayed variations out of phase with these rhythms. The implication of the correlations observed on the residual variations is discussed in comparison with the temporal relationship between the daily variations. The results fit the hypothesis that hormone production and secretion are self-oscillating processes. Plasma concentrations of calcium and phosphate might play a role in the synchronization of the calcitonin metabolism periodicity.

Potassium administration and calcitonin mRNA level in the rat.

We have investigated the acute effects of elevated plasma potassium concentrations on the calcitonin (CT) mRNA level measured by dot-blot hybridization. Plasma CT levels were significantly increased (X2) 30 min after potassium administration (1.2 mmol, KCl/100 g body weight) in adult female rats; a trend towards increased values was observed 10 min after treatment. No change in plasma calcium concentration was induced by the elevated extracellular potassium levels. The amount of CT mRNA measured by dot-blot hybridization was statistically significantly increased 10 min and 30 min (around 47-55%) after potassium treatment. This finding was confirmed by a Northern blot analysis. It is suggested for the first time that the potassium-induced CT release is associated with a slight increase in CT mRNA level. The increased CT secretion was probably mediated through a rise in the ionized calcium concentration of the C-cell.

Effects of calcitonin on human trophoblastic cells in culture: absence of autocrine control.

The purpose of this work was to investigate the effects of calcitonin (CT) on trophoblastic cells with respect to cAMP levels and human chorionic gonadotrophin (hCG) secretion in cultured cells from first-trimester and term placentas and in a choriocarcinoma cell line (JEG-3). The expression of the CT gene was investigated to elucidate a putative autocrine control of CT during pregnancy. The addition of salmon CT (10(-10) M and above) resulted in concentration-dependent increases in cAMP secretion by normal trophoblastic cells from term and first-trimester placentas. Moreover, CT was found to increase cAMP secretion preferentially in completely differentiated cells, i.e. after 4-7 days in culture. Addition to the culture medium of JEG-3 cells slightly increased cAMP secretion only at a concentration of 10(-8) M. The basal level of hCG in the medium was found to be higher in the first-trimester than in the term trophoblast culture, but salmon CT induced an increase in hCG secretion by term placenta cells only. CT gene expression in our experimental model was investigated to elucidate a putative autocrine control of CT action during pregnancy. It was not found to be expressed in syncytiotrophoblast cells from either first-trimester or term placenta cells by the method used. Our data demonstrate the absence of autocrine control of CT effects in trophoblastic cells, and suggest that CT is likely to exert its effect preferentially on differentiated cells.

Influence of laminin substratum on cell proliferation and CALC I gene expression in medullary thyroid carcinoma C cell lines.

Medullary thyroid carcinoma (MTC) originates from C cells, which secrete calcitonin (CT) and CT gene-related peptide (CGRP), the two splice peptide products of the CALC I gene. Normal and hyperplastic C cells are intrafollicular, in contact with the basement membrane (BM) that is maintained around the differentiated tumors. To investigate the relationships between MTC evolution and BM constituents, we examined the modifications induced by laminin-1 and -2 (merosin), two isoforms colocalized in the follicular BM, on three MTC cell lines: murine rMTC 6-23 and CA-77 cells, and human TT cells. Laminin exerted a mitogenic activity on rMTC 6-23 and on TT cells, causing a concurrent decrease in both CT and CGRP mRNA levels and production of the peptides. Conversely, laminin reduced the proliferation rate and enhanced CGRP synthesis and secretion in CA-77 cells. This antiproliferative response, which coincides with an increase in differentiation markers, is comparable to that reported in normal cells and also in the neoplastic Caco-2 cell line. This suggests that laminin could exert opposite effects depending on the stage of tumor evolution.

Indomethacin increases 15-PGDH mRNA expression in HL60 cells differentiated by PMA.

We previously reported an induction of 15-hydroxyprostaglandin dehydrogenase type I mRNA (15-PGDH) expression accompanied by a decrease in prostaglandin E2(PGE2) levels during cord blood monocytes differentiation into preosteoclastic cells by 1,25 dihydroxyvitamin D3 (1,25 (OH)2D3). These results suggested a role of prostaglandin (PG) enzymes in adhesion and/or differentiation of monocytes. In the present work, we studied modulation of gene expression of PG metabolism enzymes mRNAs in HL60 cells differentiated by phorbol myristate acetate (PMA) into the monocyte/macrophage lineage. We showed that adhesion of HL60 induced by PMA causes an increase of cyclooxygenase 2 (COX 2) and 15-PGDH mRNAs. When adding indomethacin, a non steroidal antiinflammatory drug known to inhibit COX activity, the cells remained attached and expressed large amounts of 15-PGDH mRNA while COX 2 mRNA expression remained unchanged. Indomethacin, in association with PMA can consequently exert a dual control on key enzymes of PGE2 metabolism without modifying adhesion of the cells.

Indomethacin, a cox inhibitor, enhances 15-PGDH and decreases human tumoral C cells proliferation.

High levels of prostaglandins (PGs) are currently found in tumoral cells, due to expression of the inducible PGs synthesis enzyme, the cyclooxygenase 2 (COX 2). Non Steroidal Anti Inflammatory Drugs (NSAIDs) possess an antitumoral effect related, in a large extend, to the inhibition of this enzyme. It was recently suggested that the decreased activity of 15-hydroxyprostaglandin dehydrogenase (15-PGDH), the key enzyme catabolysing PGs, may be responsible too for experimentally induced colon tumor enhancement. We report here, for the first time, that indomethacin, an NSAID, decreased TT cell proliferation, derived from a human Medullary Thyroid Carcinoma (MTC). This effect is time and concentration-dependent. Moreover, indomethacin enhanced expression and activity of 15-PGDH. The 15-PGDH levels were negatively correlated with TT cell proliferation (r = -0.52, p < 0.001). Indomethacin, known to decrease COX levels and activity, could also act in modifying catabolism of PGs. This suggests that 15-PGDH is involved in tumoral development, and could therefore be considered as a target for NSAIDs.

Study of calcitonin and thyroglobulin gene expression in human mixed follicular and medullary thyroid carcinoma.

mRNAs were isolated from 2 patients suffering from a familial form of a rare variant of medullary carcinoma of the thyroid (MTC), called mixed follicular and medullary carcinoma. The presence of calcitonin (CT) and thyroglobulin (Tg) mRNAs was checked by northern and in situ hybridization and compared with immunohistochemical results. In each case, mRNAs hybridizing to probes specific for CT and Tg were detected. Both proteins were quantified by radioimmunoassay determination in tissue extracts. Patient 1 had 20 ng Tg and 68 ng CT per micrograms total protein, and patient 2 had 0.4 ng Tg and 1.7 ng CT per micrograms total protein. Northern analysis showed that mixed carcinoma expressed several species of both CT mRNAs and Tg mRNAs. The main Tg transcripts present in neoplastic cells (8.5 and 4.8 kb for patient 1 and patient 2) were identical to or smaller than those of normal thyroid tissue (8.5 kb). The tumor CT mRNA (1 kb) was identical to that of normal tissue. In situ hybridization confirmed the presence of CT and Tg mRNA in the great majority of tumor cells. Furthermore, the presence of small amounts of organified iodine was evidenced by analytical ion microscopy in 35% of these cells. This raises an important question regarding the histogenesis of this tumor.